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The Memorial Sloan Kettering Cancer Center GERIATRIC PLAN©: Toileting

An Ambulatory Nurses' Guide to Assist Older Adults Through Cancer Treatment

T=Toileting

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

T=Toileting

Nursing Intervention:

Urinary Dysfunction

  • Determine underlying etiology of altered renal status and correct if possible
  • Review laboratory results: urinalysis, cultures, electrolytes. Identify whether a urinary tract infection is present
  • Monitor I&O and voiding diary
  • Identify/determine patterns and timing of voiding with intake and suggest changes to improve symptoms (i.e. nocturia: limiting fluid amount consumed late in evening)
  • Instruct patient on scheduled toileting: plan on increasing intervals as continence improves
  • Medication review and assess impact on bowel, bladder, and renal function; discuss changing diuretic administration to morning if previously taken at night if nocturia is problematic
  • Monitor IPSS score and discuss changes with LIP
  • Patient education: Kegel’s exercises, use of products such as incontinence barriers, diapers, condom catheters, self-catheterization techniques as necessary; circumvent environmental barriers to incontinence (easy-open Velcro waistband closures, nearby bedside commode/urinal at night)
  • Preservation of skin integrity by providing immediate cleansing following each episode with use of barrier ointments and protective absorbent products
  • Collaboration with other healthcare providers
  • Evaluate effectiveness of interventions and modify as needed

Interventions:

Urinary Dysfunction

  • Identify whether a urinary tract infection is present
  • Scheduled toileting with increasingly longer intervals as continent control improves
  • Patient education: Kegel’s exercises, bladder training for cognitively intact patients, self-catheterization if ordered
  • Fluid and electrolyte balance
  • External catheters
  • Circumvent environmental barriers to incontinence (easy-open Velcro closures, elastic waistbands, nearby bedside commode/urinal at night)
  • Preservation of skin integrity by providing immediate cleansing following incontinent episode with use of barrier ointments and protective absorbent products
  • Limiting fluid amount consumed in the late evening
  • Changing diuretic administration to morning if previously taken at night
  • Teach self-catheterization techniques if ordered
  • Medication review as above

Bowel Dysfunction: Diarrhea and Constipation

  • Determine underlying etiology of bowel dysfunction and correct if possible
  • Review laboratory results: CBC, chemistries, stool specimen results (Ova and parasites, Clostridium difficile, Giardia cultures)
  • Review stool diary for patterns of elimination and any dietary or medication-related triggers
  • Prevent constipation: If no contraindications, fluid intake of 2-3 liters per day, increase fiber intake, and increase physical activity
  • Protect skin integrity with prompt cleaning, barrier creams, and use of absorbent products
  • Monitor for impaction and/or seepage pattern (constipation or watery stool, nausea, abdominal pain, leakage of stool following a normal bowel movement)
  • Dietary interventions (based on current assessment): BRAT diet for diarrhea (Bananas, rice,applesauce, toast), fluid/fiber for constipation as appropriate, referral to registered dietician may be helpful in making food choices
  • Patient education: medication teaching about antidiarrheals, stool softeners, and laxatives as indicated
  • Discuss toileting patterns: suggest toileting when patient awakens in the morning, 30 minutes after meals, or when urge is strongest rather than suppressing urge
  • Collaborate with other healthcare providers
  • Evaluate effectiveness of interventions and modify as needed

References

Dowling-Castronovo, A., & Bradway, C. (2012). Urinary Incontinence. Nursing Standard of Practice Protocol:Urinary Incontinence (UI) in Older Adults Admitted to Acute Care. In M. Boltz, E. Capezuti, T. Fulmer, D. Zwicker, & A. O'Meara (Eds.), Evidence-based geriatric nursing protocols for best practice (4th ed.). New York: Springer Pub.
Rao, S.S. & Go, J.T. (2010). Update on the Management of Constipation in the Elderly: New Treatment Options. Clinical Interventions in Aging, 5, 163-171.
Resnick, N.M. & Yalla, S.V. (1985). Management of urinary incontinence in the elderly. New England Journal of Medicine, 313(13), 800-805.