Related Issues:
Incontinence, frequency, urgency, obstructive voiding issues, nocturia, hematuria, dysuria, renal function, fecal incontinence, hemorrhoids, melena, constipation, diarrhea
- Urinary: incontinence, frequency, urgency, and obstructive voiding issues
- Bowel: constipation and diarrhea
Why Toileting Issues are Important:
Urinary Dysfunction
- Increased incidence of urinary tract infections and obstructive voiding patterns can cause local skin irritation, rashes, pressure sores, and predispose to systemic infection and sepsis
- Decreased quality of life (discomfort, restlessness, depression, anxiety, loss of sleep, social isolation), can contribute to increased incidence of falls and resultant injuries
Diarrhea and Constipation
- Diarrhea – Can lead to electrolyte imbalances, dehydration, and skin breakdown; can be indicative of an underlying infection which can predispose to sepsis
- Constipation – Can cause pain, discomfort, bloating, nausea and vomiting; can lead to fecal impaction, obstipation, ulcerative bleeding, may contribute to pelvic floor laxity and rectal prolapse, urinary/sexual dysfunction
Normal Age-Related Changes:
- Decreased GFR, renal mass, and blood flow
- Decreased ability to recognize thirst which can lead to a hypovolemic state
- Decreased water and solute reabsorption and decreased ability to concentrate urine leading to electrolyte abnormalities
- Bladder muscle tone decreases which can impact the ability to hold urine and to completely empty bladder during urination
- Decreased bladder tone and capacity
- Weakening of pelvic muscles and slower peristaltic movement in bowels leads to constipation
Older adults are at increased risk if they have any of the following:
Conditions
- Decreased mobility/arthritis/motor impairment
- Altered cognition/dementia
- Preexisting ostomies, catheters, and drains
- Prostatic hypertrophy
- Renal insufficiency
- Decreased or absent bowel sphincter control
- Poor nutritional intake (constipation)
- Amyloidosis
- Diabetes
- Sexually transmitted diseases
- Urinary tract infections
- Gastrointestinal conditions (Diverticulosis, Crohn’s, ulcerative colitis, chronic constipation)
- Renal insufficiency
- Neurological impairment
- Previous abdominal surgeries causing adhesion formation
- Cardiovascular disease with poor exercise tolerance
- Respiratory disease with poor mobility, presence of acute or chronic cough, or dyspnea
Behavioral Risk Factors
- Diet: decreased fiber, decreased fluid intake
- Laxative use
- Immobility
- Nonadherence/noncompliance to medication regime (holding diuretics because of travel or limiting oral fluid intake due to fears of excessive urination)
Medication-Related Risk Factors
- Bladder sensation changes or incontinence: sedatives, opioids, diuretics
- Constipation: calcium, opiods, antidepressants, anticonvulsants, iron supplements, calcium channel blockers, antacids containing aluminum
- Diarrhea: acid-reducing agents such as proton pump inhibitors, magnesium-containing antacids, quinidine, antibiotics, NSAIDS, antineoplastics, colchicine, antiretrovirals, beta blockers
- Polyuria: diuretics
- Renal insufficiency: NSAIDS, diuretics, contrast dye
- Urinary retention: sedatives, anticholinergics, tricyclic antidepressants, opioids
Chemotherapy-Related Risk Factors
- Diarrhea: irinotecan (CPT-11) 5-fluorouracil (5FU),capecitabine (Xeloda), levamisole, interleukin 2, lapatinib (Tykerb)
- Nephrotoxicity: cisplatin, carboplatin, bisphosphonates, carmustine, mitomycin, interkeukin 2, alpha interferon, bevacizumab
- Bladder irritation: ifosfamide, cyclophosphamide, intravesicular chemotherapy (BCG, thiotepa, mitomycin)
- Constipation: vincristine, thalidomide, lenolidamide, temozolomide, 5HT3 antiemetic therapy (Zofran, Kytril)
Surgery-Related Risk Factors
- Development of adhesions leading to possibility of small bowel obstruction
- Decreased activity
- Possible post-op urinary retention
- Possible urinary tract infections from prolonged usage of indwelling catheters
- Possible post or intraoperative hypoperfusion causing renal dysfunction
- Surgical alteration of normal anatomy (Neobladder creation, ostomies, stomas)
Radiation Risk Factors
- Abdominal/pelvic radiation
- Urgency
- Frequency
- Incontinence
- Cystitis
- Strictures
- Diarrhea
- Colitis
- Adhesions
Cancer Diagnoses
- Colorectal
- Bladder
- Prostate
- Gynecological
- Multiple myeloma
- Large tumor burden in abdomen/pelvis
- Spinal cord involvement
Assessment:
1. Screening Questions
- Do you ever feel you have to urinate or that your bladder doesn’t completely empty after urination?
- Do you ever have problems getting to the bathroom in time or get up many times at night to urinate?
- Do you sometimes leak urine? If you do leak urine, is it accompanied by a feeling of urgency or is there any relationship to physical activity, coughing, or sneezing when leakage occurs?
- Have you identified any triggers? How do you currently manage episodes?
- Do you have any chronic diarrhea, constipation, or recent change in bowel habits?
2. Observations
- Any frequent or prolonged bathroom visits?
- Any excrement staining clothing or odor?
3. Screening Tests and Measurements
- Voiding diary: have patient record fluid intake and document times of urination (may also collect data on urine volumes, color, and any associated symptoms).
- American Urological Scale (IPSS score)
- Presence of blood in stool/hemeoccult
- UA, C&S
- DIAPPERS: a mnemonic acronym for treatable causes of fecal and urinary incontinence (Resnick & Yalla, 1985)
D elerium
I nfection--urinary (symptomatic)
A trophic urethritis and vaginitis
P harmaceuticals
P sychologic disorders, especially depression
E xcessive urine output (e.g. from heart failure or hyperglycemia)
R estricted mobility
S tool impaction
4. Physical Assessment and Observations
- Standard observation with a special focus on abdominal/pelvic/rectal and for symptoms of pain, discomfort, fullness, nausea, vomiting, bloating, cramps, and any skin or perineal excoriation
