The Concept of Elimination

The nurse is caring for a patient with a history of heart failure, poor mobility, and urinary incontinence. The patient has a prescription for a diuretic, but the nurse notes that the patient has pitting edema in the lower extremities. Which question should the nurse ask first?

"Are you taking your diuretics as prescribed?" It is common for some older people to avoid taking their prescribed diuretics, especially when they have difficulty ambulating, because they are afraid of having an accident or having to get up to use the bathroom frequently. The patient's pitting edema is an indication that the patient is still retaining fluid. Fluid intake and dietary habits are important but are not the priority. Elevating the legs may be a useful intervention, but the nurse must assess the situation first.

The nurse is admitting a patient in the emergency department for acute diarrhea. Which is the priority assessment question the nurse should ask?

"How often are you having diarrhea?" It is most important for the nurse to ask about the symptoms of diarrhea, including when and how often the symptoms occur. Questions about incontinence, normal bowel movement patterns, and regular fluid intake are important but are not the priority for this patient.

The mother of a 2-month-old infant is concerned about the frequency of her infant's bowel movements. Which response by the nurse addresses the mother's concern?

"Infant bowel movement patterns change at this age." An infant's defecation pattern changes at the age of 1 to 2 months, but it is not similar to adult habits. Infants may have from one or more bowel movements per day to one bowel movement every 1-2 weeks. Breastfed infants usually have a higher frequency of bowel movements, and formula-fed infants are more prone to constipation. Infants cannot control defecation at 2 months and pass meconium only in the first day of life.

An older adult patient asks why they are having difficulty making it to the bathroom on time lately. Which response by the nurse is accurate?

"The muscles under your bladder become weakened with age, making it difficult to control urine flow."

A male patient is experiencing urinary issues and the healthcare provider has ordered a digital rectal exam. The patient asks the nurse what to expect from the test. How should the nurse reply?

"The physician will insert a single gloved and lubricated finger into the rectum to feel the prostate gland." During a digital rectal examination (DRE), the physician will insert a single gloved and lubricated finger into the rectum in order to palpate, or feel, the prostate gland. An ultrasound probe is not used during a DRE. Only the prostate gland is felt, not the bladder. A needle biopsy is not part of a DRE

The nurse is caring for an older male with urinary problems. The patient has been ordered to have an ultrasonic bladder scan. The patient asks, "What is the purpose of the test?" How should the nurse reply?

"To see how much you empty your bladder" An ultrasonic bladder scan looks at residual volume to determine the degree of bladder emptying. An uroflowmetry test is performed to measure the volume of urine passed per second. Cystometrography can be used to evaluate urethral pressures. A urinalysis can look for signs of a bladder infection.

At 5 feet 10 inches and 320 pounds, a female patient has been advised to lose weight for her overall health and to help with a recent problem of incontinence. The patient asks, "How will this help with my incontinence?" Which explanation by the nurse is appropriate?

"Weight loss can reduce stress incontinence caused by increased pressure on the bladder as a result of obesity." Obesity is a risk factor for urinary incontinence, especially stress incontinence. This is most likely because of the excess force placed on the bladder. Not all patients with diabetes are obese and not all obese patients have diabetes. Reflex incontinence causes the bladder to empty at a predictable volume. Overflow incontinence is the lack of normal detrusor muscle function causing bladder overfilling and increased bladder pressure.

The nurse is caring for a group of patients on the medical-surgical unit. The nurse delegates some duties to the unlicensed assistive personnel (UAP). Which patient should the nurse instruct the UAP to provide care for first?

A 75-year-old bedbound man with an episode of urinary incontinence Urinary incontinence can cause skin irritation and breakdown, especially in a patient who is bedbound. This patient should receive care first to minimize skin exposure to urine and the risk for pressure ulcers. The other patients who need routine oral care, morning hygiene, and assistance with ambulation are not the priority in this case

The nurse is caring for a patient with major fecal incontinence. Which collaborative intervention should the nurse be prepared to implement?

Administer an antibiotic. An antimicrobial agent may be prescribed for major fecal incontinence because it may be caused by infection. Also, the nurse should expect that an antidiarrheal agent will also be prescribed. The cause of this condition is not behavioral. Digital stimulation and administering a suppository would be implemented for constipation.

The nurse is caring for a patient who reports frequent urination. The nurse asks about dietary intake during the focused assessment. Which product consumed by the patient should concern the nurse?

Alcohol Alcohol is an example of a fluid that decreases production of antidiuretic hormone (ADH), which will increase urine output. Pickles, pretzels, and canned soup are all high in sodium and cause fluid retention.

A patient is experiencing increased urinary urgency and incontinence. Which medication should the nurse anticipate to be prescribed for this patient?

Anticholinergic agent Anticholinergic agents affect the autonomic nervous system and are used to relieve symptoms associated with voiding in patients who have urge incontinence. Cholinergic agents are used to promote urination and simulate bladder contractions. Antiflatulents are used to reduce and treat excess gas. Diuretics promote removal of excess water and increase urination.

The nurse is caring for a group of clients on a​ medical-surgical unit. Which client does the nurse anticipate to be at the greatest risk for alterations in urinary​ elimination?

An​ 80-year-old male client reporting frequent urination at night The client who is 80 years old with frequent urination at night may be having problems with his prostate. Older male adults experience urinary retention due to prostate​ enlargement, causing an alteration in urinary elimination. The​ 25-year-old experiencing low​ self-esteem has a psychological problem and will need therapy to find the root of the problem. The client who had bladder cancer and now has an ileal conduit​ doesn't have kidney​ damage, only the bladder removed. Continued urine production through the ileal conduit will need to be observed and assessed frequently by the staff. The client with high blood pressure takes medication to remove excess fluid from the​ body, and as long as urine elimination​ increases, there should be no problems.

The nurse is caring for an older adult client on a​ medical-surgical unit. The client tells the​ nurse, "I​ don't get any sleep at night because I have to get up and use the bathroom every couple of​ hours!" When providing an explanation for the​ nocturia, which statement by the nurse is the most​ appropriate?

As you get​ older, you may have a decreased bladder​ capacity." Approximately​ 70% of older women and​ 50% of older men have to get up two or more times during the night to empty their bladders due to decreased bladder capacity. A decrease in blood supply causes an increase in urine concentration. A decrease in the number of nephrons decreases the filtration rate. A decrease in cardiac output decreases peripheral​ circulation, which would decrease urinary output day or night.

The home health nurse is conducting an assessment of an older woman. Which observation should a nurse include to help determine the presence of urinary incontinence?

Assessing for the odor of urine The process of observation uses all of the nurse's senses. Noting the odor of urine is an important assessment and can help bridge the conversation with the patient. Checking the patient's underwear is rather invasive and not appropriate for the nurse to do. Asking the patient about incontinence is not an observation technique. Palpating the bladder to look for leakage is not a valid observation mechanism by the nurse.

The nurse is preparing to administer an antidiarrheal agent to a patient with severe diarrhea lasting several days. Before administering the medication, what lab result(s) should the nurse check?

Blood urea nitrogen (BUN) and creatinine Antidiarrheal agents are contraindicated in patients with severe dehydration, electrolyte imbalance, liver and renal disorders, and glaucoma. The nurse should check the most recent BUN and creatinine levels and withhold the medication if they are elevated. TSH level evaluates the thyroid gland; abnormal levels are not contraindicated in the administration of an antidiarrheal agent. An abnormal hemoglobin level can indicate anemia; it is not contraindicated for the administration of an antidiarrheal. Antidiarrheals are not contraindicated in patients with abnormal blood clotting factors.

The nurse is evaluating a patient with new onset of fecal incontinence. Which collaborative activity should the nurse anticipate to evaluate the patient's sphincter tone?

Digital rectal exam. A digital rectal exam provides information about anorectal sphincter tone. A colonoscopy evaluates the intestines for growths, masses, polyps, lesions, bleeding, or diverticula. Retrograde pyelography and cystoscopy are diagnostic procedures to evaluate urinary system disorders, not bowel incontinence.

The nurse is caring for a 60-year-old patient being treated for constipation. Which procedure should the nurse teach the patient to help establish regular bowel movements?

Digital stimulation Bowel training/digital stimulation can be used or taught to the patient to establish regular defecation. Kegel exercises are useful in the treatment of urinary incontinence. Anal hygiene will not help to establish regular defecation. Self-catheterization is appropriate for a patient with urinary retention.

The nurse is caring for a client with a history of urinary tract infections​ (UTIs). Which action by the nurse would decrease the risk of the client experiencing future​ UTIs?

Instruct the client to avoid delaying urination. Suppressing urination increases the risk of urinary tract infections. The pelvic floor muscles should not be used to force urine​ flow, and doing so is considered a poor toileting habit. The client should wipe from front to back because wiping from back to front would contaminate the urinary meatus. The client should decrease the use of caffeine in the diet because caffeine is a bladder irritant.

Which specific instruction should the nurse provide to a patient experiencing an alteration in bowel function?

Instruction on increased fluid and fiber intake The nurse should educate the patient on increased fluid and fiber intake. Instructions on self-catheterization, assessment of the fecal matter, and the prevalence of bowel problems are not specific subjects taught to patients experiencing an alteration in bowel function.

The nurse is preparing to administer an anticholinergic agent to a patient with urinary urgency. For which medical condition should the nurse assess before administering the drug?

Narrow-angle glaucoma Anticholinergics are contraindicated in patients with uncontrolled narrow-angle glaucoma, urinary retention, or gastrointestinal motility problems. Asthma, bradycardia, and Parkinson disease are contraindications for cholinergic agents.

The nurse is teaching the parents of a new baby about bowel elimination. Which instruction should the nurse include?

Newborns pass meconium within the first 48 hours. Most newborns will pass meconium, a black and tar-like stool, within the first 6-24 hours of life, up to 48 hours. Meconium will begin to transition to fecal material within the first few days. Infants (not newborns) will pass stool up to 10 times per day. Formula-fed infants are more likely to become constipated and tend to pass stool less frequently than do breastfed infants. The image below represents newborn stool samples: A: meconium—thick, tarry black. B: breastfed newborn stool—soft, liquid, mustard yellow. C: formula-fed newborn stool—slightly firmer than breastfed infant stool.

The nurse is performing an abdominal assessment on an older adult patient. Which information should the nurse consider while performing the assessment?

Older adult patients can sometimes have shortness of breath while in the supine position for an extended period of time. When performing an abdominal assessment, the patient should lie supine while the nurse percusses, auscultates, and palpates the abdomen. In some older adult patients, this can lead to shortness of breath or difficulty breathing. The nurse should avoid having the patient in that position for an extended period of time. It is not appropriate to place a patient in the prone, lithotomy, or side-lying position for an abdominal assessment.

A patient reports intense thirst, weight loss, and a large volume of urine when voiding. Which condition should the nurse suspect the patient is experiencing?

Polyuria Polyuria can cause excessive fluid loss, leading to intense thirst, dehydration, and weight loss. The assessment findings do not describe enuresis, urgency, or dysuria. Enuresis is the involuntary passage of urine after toilet training has been well established at around 5 years of age. Urgency is a sudden strong desire to urinate. Dysuria refers to painful or difficult urination.

The nurse is caring for a 23-year-old female patient who is complaining of urinary frequency, and voiding a lot more than usual. How should the nurse document the patient's complaint?

Polyuria The nurse would document the patient's complaint as polyuria, which is the passage of large amounts of urine. Complete lack of voiding, incomplete bladder emptying, overflow incontinence, pain, constant urge to urinate, and weak urinary flow are signs of urinary retention. Dysuria is painful or difficult urination. Urgency is a sudden strong urge to urinate, regardless of the amount of urine in the bladder.

A patient diagnosed with bowel obstruction is scheduled for surgical resection of the bowel. Which nursing action is most appropriate for this patient?

Preparing needed preoperative instructions The patient who needs surgical resection of the bowel will need preoperative instructions, and it is the nurse's role to provide them. Enemas are used for impactions, not obstructions. Chemotherapy and radiation therapy are used for bowel cancer. Instruction on care and cleaning of the ostomy pouch will depend on whether the resection requires one.

An older male patient is experiencing dysuria and urinary retention. The nurse should suspect which condition first as the most likely cause of these clinical manifestations?

Prostatic hyperplasia Prostatic hyperplasia (BPH), which is enlargement of the prostate, can cause urinary retention, dribbling at the end of urination, incontinence, and nocturnal enuresis. Renal failure does not cause dysuria or retention. Polyuria is a term that describes an increase in urination. Anuria is the absence of urination.

A nurse is caring for an 83-year-old patient with a history of urinary incontinence. What is the priority nursing diagnosis for this patient?

Skin Integrity, Risk for Impaired A patient with urinary incontinence is at risk for impaired skin integrity due to the excess moisture and friction to which the skin is subjected. There is no evidence that the patient has impaired perfusion or a self-care deficit. While the patient may have difficulty coping with urinary incontinence, it is not the priority in this situation. (NANDA-I © 2014)

A female patient is experiencing problems with urinary elimination. After an initial assessment interview, the nurse performs a physical examination. Which specific assessment should the nurse include?

Skin assessment A focused nursing assessment of the urinary system includes a skin assessment, an abdominal assessment, a urinary meatus assessment, a kidney assessment, and a bladder assessment. Dietary, perianal, and inguinal area assessments would be appropriate for a patient experiencing an alteration in bowel function.

The nurse is providing dietary teaching to a patient with chronic constipation. Which food selection by the patient indicates that the instructions were understood?

Split pea soup A patient with chronic constipation should be encouraged to increase their fiber and fluid intake. Split pea soup is high in fiber. White bread, creamed wheat cereal, and chocolate pudding are all low-fiber foods and indicate that the patient did not understand the instructions.

A older male patient is experiencing urinary retention. Which collaborative activity should the nurse anticipate for this patient?

Ultrasonic bladder scans Ultrasonic bladder scans are used to evaluate bladder emptying and to examine for residual urine. While a urinalysis, cystoscopy, and renal ultrasound are often prescribed for patients with alterations in urinary function, these tests will not diagnose the cause of the urinary retention the patient is experiencing.

The nurse is preparing a presentation on urinary elimination problems for a group of older adults. Which important fact should the nurse include?

Urinary retention is uncommon in women. Urinary retention is quite uncommon among women unless there is a physiological basis, such as a neurogenic bladder. Up to 60% of men over the age of 60 report having issues with urinary incontinence, usually associated with treatment for an enlarged prostate. Only about 7% of young, healthy men without a history of prostate problems report lower urinary tract symptoms. Around 94.3% of women reported incontinence or lower urinary tract symptoms.

The nurse is reviewing the urinalysis test results conducted on a patient. The report states that the patient's urine appears cloudy. Which diagnosis should the nurse anticipate based on the urinalysis?

Urinary tract infection Hazy or cloudy urine indicates the presence of bacteria, pus, RBCs, WBCs, phosphates, prostatic fluid, spermatozoa, or urates, which can indicate a urinary tract infection. Concentrated or dark urine is found with dehydration and fever. Cirrhosis of the liver and hyperglycemia do not cause the urine to appear cloudy or hazy.

The nurse is observing a new graduate nurse provide care for a patient with Clostridium difficile (C. diff) infection. Which action by the new graduate nurse requires immediate intervention?

Washing hands with a hand sanitizer C. diff is a serious infection that causes frequent diarrhea. Nurses caring for a patient with a C. diff infection should wash their hands frequently using soap and water, not hand sanitizer. It's important to implement strict isolation precautions and provide perineal care as necessary.

The nurse is caring for a patient who presents with severe diarrhea. The healthcare provider has ordered an antidiarrheal agent. Before administering the medication, the nurse reviews the most recent lab orders and notes that the patient is severely dehydrated and has an elevated blood urea nitrogen (BUN) and creatinine. Which is the priority action by the nurse?

Withholding the antidiarrheal agent and notifying the provider Antidiarrheal agents are contraindicated in patients with severe dehydration, electrolyte imbalance, liver and renal disorders, and glaucoma. The nurse should withhold the medication and notify the provider. Administering the medication is not appropriate in light of these contraindications and the latest lab results. Rerunning the blood tests is a collaborative intervention and requires a physician order.