Chapter 18: Elimination

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Welcome back to The Deep Dive.

We are jumping straight into some really essential geriatric care today.

We are.

We're looking at Chapter 18 from Basic Geriatric Nursing.

Right.

And it covers a topic that, well, can feel a bit delicate, but it's absolutely fundamental.

We're talking about elimination.

It's a core chapter, definitely.

And our goal today is really to give you a clear kind of conversational path through the main ideas.

Yeah, like the key concepts, the age -related risks, which are pretty significant, and probably most importantly, the nursing interventions you need to know.

Exactly.

We want to make it feel less like reading a textbook and more like, you know, understanding the flow.

And the central theme that really jumps out from the chapter, the thing we need to focus on, isn't just like the mechanics of getting rid of waste.

No, it's deeper than that.

It's the huge impact that losing control over these processes has on an older person's life.

We're talking bowel and bladder incontinence here.

Which is just devastating for many.

It leads to isolation,

psychological distress, all sorts of physical problems.

And tragically, the chapter points out, it's one of the most common reasons older adults end up needing institutional care.

Yeah.

And when you frame it like that as an issue of sort of autonomy and dignity and control,

it really highlights why getting the nursing assessment and the interventions right is just non -negotiable.

It's critical.

Okay, so let's unpack this.

Let's start with the basics, the digestive tract.

Bowel elimination.

Before we get into the problems, what does normal even look like here?

Well, normal is less about a strict rule and more about what's usual for that specific person, their lifelong pattern, you know.

Right.

The range can be anything from, say, several times a day to maybe just two or three times a week.

Most adults probably fall in the every one to two -day range.

The process itself is called defecation.

And there's a timing element too, isn't there, with reflexes?

Yes, absolutely.

The key physiological triggers, the gastrocolic reflex and the defecation reflex, they tend to be strongest about 30 to 45 minutes after eating a meal.

Okay.

Or often first thing in the morning, maybe helped along by a warm drink.

And it's those routines, those lifelong habits that get so easily disrupted as people age, right?

Which probably contributes to why elimination problems are so common.

Exactly.

Those established rituals are fragile later in life.

So let's talk about constipation.

What are the main age -related changes physiologically that increase the risk for older adults?

You're looking at kind of a perfect storm of things slowing down.

Naturally, peristalsis, that gut movement, it gets slower.

Abdominal muscle tone often decreases, making it harder to push effectively.

And then there's often increase in activity or immobility.

And lifestyle factors.

Oh, huge ones.

The two biggest culprits and often the most fixable are not getting enough dietary fiber and crucially not taking in enough fluids.

Okay.

The fluid part is really interesting because the chapter points out something almost counterintuitive about how dehydration affects the bowels.

It does.

It's like the body turns its own coping mechanism against the bowel.

How so?

Well, if the body senses its low on fluids, its priority is survival, right?

Right.

So it tries to conserve water wherever it can.

That means it pulls back as much fluid as possible from the waste moving through the intestine.

Combine that fluid reabsorption with the already slower transit time.

And you get hard, dry stools.

Exactly.

Hard, dry, difficult to pass.

Requires a lot more effort.

So we've got the body slowing down, dehydration working against us.

What about medications?

The chapter mentions these as like silent saboteurs.

Yeah.

Medications are a huge factor.

We really need to watch out for narcotic painkillers, especially things with codeine.

They slow everything down.

Right.

Then you have anticholinergics, and these are common, found in many allergy meds.

Some antidepressants, they basically inhibit the signals for gut motility.

Any others?

Definitely.

Diuretics, obviously, because they increase fluid loss.

Iron supplements are notorious.

Calcium channel blockers, used for blood pressure.

And certain other antihypertensives or antidepressants can contribute, too.

So you really need to look at the whole medication list.

Absolutely.

It's often a combination.

Given that normal varies so much, how do nurses actually define constipation objectively?

It can't just be asking, how often do you go?

No, exactly.

We need something more concrete.

We use tools like the Rome Fee Criteria.

Okay, what does that involve?

It defines constipation not just by how often someone goes, but by the difficulty and the stool characteristics.

To meet the criteria, a patient needs to have at least two specific symptoms.

Things like excessive straining during defecation, having hard or lumpy stools most of the time, feeling like they haven't completely emptied, or even needing to use fingers to help pass the stool.

And these symptoms need to have been happening pretty consistently, present for at least 25 % of bowel movements over the last three months.

That gives a much clearer picture.

Now, if constipation isn't managed, it can lead to something much more serious.

Fecal impaction.

What exactly is that?

Fecal impaction is basically unreleaved constipation that results in a large, hardened, massive stool getting stuck, usually low down in the rectum or sigmoid colon.

It physically cannot be passed.

And there's a really tricky warning sign, isn't there?

Something paradoxical.

Yes, this is critical to recognize.

The key sign is often the passage of small amounts of liquid stool, but with no formed feces.

So it looks like diarrhea.

Exactly.

People, even health care staff sometimes mistakenly think the patient has diarrhea.

But what's happening is liquid waste from higher up is managing to seep around the solid blockage.

That distinction is crucial.

And speaking of crucial, the book has a major safety alert about actually removing an impaction manually with a digital exam.

What's the risk, especially for cardiac patients?

Oh, this needs flashing red lights around it.

First, the procedure itself can be traumatic to the rectal tissues.

But the big immediate danger is stimulating the vagus nerve during the digital exam or removal.

What does that do?

That stimulation can cause a sudden, profound drop in heart rate bradycardia.

In some cases, it can lead to fainting, syncope, or worse, especially in someone with an existing heart condition.

So it's not something to be done lightly.

Absolutely not.

It needs extreme caution, usually a specific doctor's order, because of that vagal risk.

Let's shift gears slightly to talk about something related.

The habit of chronic laxative, or enema use.

The chapter says this is pretty common in older adults.

It is, often stemming from a lifelong belief that you must have a bowel movement every single day.

What's the clinical downside to relying on these all the time?

The biggest issue is dependency.

The bowel essentially becomes lazy.

It forgets how to initiate elimination on its own because it's always being artificially stimulated.

So it makes the underlying problem worse long term.

Exactly.

Re -establishing normal function after chronic use is incredibly difficult.

Plus, there's another safety alert connecting chronic laxative use, particularly stimulants, to a higher risk of falls.

Falls?

How?

Possibly due to sudden, uncontrollable urgency or maybe electrolyte imbalances caused by the laxatives.

It just throws the whole system off balance.

Okay, moving to the other end of the spectrum

If an older adult develops frequent liquid stools, what's the number one immediate concern for nurses?

Fluid loss.

Period.

That's the major, potentially life -threatening risk.

Why is it so dangerous in this population?

Because older adults often have less fluid reserve to begin with.

Diarrhea means stool is moving too quickly through the intestine for adequate water absorption.

So they lose a lot of fluid very fast.

Waiting too.

Severe dehydration, often very quickly.

You'll see signs like poor skin turgor, dizziness when standing up, which is orthostatic hypotension, and a rapid heart rate, tachycardia.

So what's the nursing action?

Prompt reporting to the primary care provider is essential.

You have to find the cause.

Is it a malabsorption issue?

An infection like C.

diff, maybe related to tube feedings being too concentrated.

You need to know why it's happening to treat it.

Okay, let's pivot now to the urinary system, another major area where control can be lost.

Let's start with urinary retention.

What's the clinical definition here?

Urinary retention basically means the bladder isn't emptying completely.

Clinically, we often define it as leaving more than, say, 50 millimiles of urine in the bladder after voiding that's post -void residual.

What causes it?

It can be a few things.

Maybe decreased muscle tone in the bladder itself.

Prostate enlargement in men is a very common cause.

Nerve damage from conditions like stroke or diabetes, even sometimes anxiety or certain medications.

And what's the key symptom to watch for?

It can be misleading, right?

Very misleading.

The classic sign is actually frequent urination, but only passing small amounts each time, maybe 25 to 50 millirels.

This is called retention with overflow.

The bladder is full, but only a little bit can leak out.

Got it.

Now onto the really big one, urinary incontinence, UI.

The chapter stresses this point heavily, and I think we need to repeat it.

Yes, please.

Despite being incredibly common, the stats are staggering.

Up to 46 % in the community, maybe 90 % in dementia patients.

UI is not a normal part of aging.

Cannot say that enough.

It's a treatable or at least manageable medical condition.

Assuming it's normal does a huge disservice to patients.

And the consequences go way beyond just inconvenience, don't they?

Immense consequences.

Huge economic costs, obviously.

But also social isolation, embarrassment,

psychological distress, and very real physical risks.

Skin breakdown,

pressure injuries from wetness, and a significant risk of falls.

Falls from rushing to the toilet.

Yes, rushing, slipping on urine, getting up at night when it's dark.

It's a major safety issue.

The chapter does a great job breaking down UI into five distinct types.

Could you walk us through those?

Understanding the type is key to management.

Absolutely.

Knowing the why directs the what to do.

First is stress UI.

This is probably the most commonly known type.

Leakage with coughing, sneezing.

Exactly.

Any increase in pressure inside the abdomen.

Coughing, sneezing, laughing, lifting forces a small amount of urine out because the pelvic floor muscles or the urethral sphincter are weak.

Okay, number two.

Urge UI.

This is about that sudden, intense, got to go now feeling.

It's caused by involuntary contractions of the bladder muscle, the detrusor muscle.

What causes those contractions?

Often age -related changes like the bladder holding less volume or those detrusor spasms just happening out of the blue.

Certain diseases like Parkinson's or stroke can also trigger it.

The person often doesn't have time to make it to the toilet.

Got it.

Third type.

Reflex UI.

This is an involuntary loss of urine that happens at predictable intervals, usually when the bladder reaches a specific volume.

You see this often with spinal cord injuries above a certain level.

The person might not feel the urge.

Okay, fourth.

Overflow UI.

This is leakage of small amounts dribbling from a bladder that's already too full and just can't empty properly.

Kind of like the retention with overflow we discussed.

Very similar mechanism, yes.

It's common in men with BPH,

benign prostatic hyperplasia, or in anyone with nerve damage affecting the bladder like from diabetes.

And the last one, functional UI sounds a bit different.

It is fundamentally different.

With functional UI, the bladder and the urethra are actually working perfectly fine physiologically.

So what's the problem?

The problem is, the person can't get to the toilet or manage their clothing in time.

It could be due to mobility issues like severe arthritis, problems with dexterity, cognitive impairment like dementia, or even environmental barriers like the bathroom being too far, or call lights not being answered quickly enough.

Ah, so the urinary system is okay, but the person or the environment prevents continence.

Precisely.

It's a crucial distinction.

And just like with constipation, medications pop up again as potential culprits for UI, according to table 18 .2 in the text.

They do.

Different drugs interfere in different ways.

Diuretics, for example, just make the bladder fill up really fast, creating urgency that can overwhelm someone.

Makes sense.

Anticholinergics can actually hinder the bladder muscle's ability to contract and empty, leading to retention and overflow.

They can also sometimes reduce the sensation or awareness of needing to void.

And sedatives?

Sedatives, narcotics.

They can dull a person's awareness or alertness, so they simply don't recognize the signals from their bladder until it's too late.

So again, you have to review those meds.

Okay, so that covers the problems.

Let's shift to solutions.

What does all this mean for nursing care?

Starting back with the bowels, how do we intervene non -pharmacologically?

The foundation is really lifestyle and habit training.

First,

increase activity.

Even small movements like twisting in a chair or a simple range of motion exercises can help stimulate peristalsis.

Fluids and fiber.

Absolutely crucial.

Aim for about two liters of fluid a day, assuming there are no restrictions, and boost that dietary fiber, aiming for maybe 21 to 30 grams per day through foods like fruits, vegetables, whole grains.

And we need to work with the body's natural timing, right?

Yes.

Capitalize on those reflexes.

Encourage toileting right after meals or first thing in the morning when the urge is likely strongest.

Critically, teach patients not to suppress the urge when they feel it, as that damages the reflex over time.

Positioning matters too, doesn't it?

Huge difference.

Sitting upright, ideally squatting slightly.

Maybe using a small footstool is the best position.

It helps align the anatomy for easier passage.

Using a bedpan is really the least effective position and should be avoided if possible.

And privacy.

Essential.

Provide stripped privacy and approach the whole topic with tact and sensitivity.

Embarrassment can absolutely cause someone to hold back.

Making constipation worse.

If these lifestyle changes aren't enough, then we look at medications for constipation.

What's the typical approach?

You generally start with the gentlest options.

Skull softeners, like docu -sate sodium, don't actually stimulate the bowel.

They just help draw water into the stool to keep it soft.

Okay, what's next?

Bulk -forming laxatives, like psyllium.

These add mass to the stool and absorb water.

But there's a really important safety point here.

Which is?

They must be taken with plenty of fluid.

If not, they can actually swell up too early, like in the esophagus or intestine, and cause a blockage or impaction.

Good warning.

And if those don't work?

Then you might move to osmotic agents, which draw water into the colon, or stimulant laxatives, which directly trigger bowel contractions.

But these are usually for shorter -term use or when other methods fail, due to the dependency risk we talked about.

Okay, let's switch to urinary incontinence management.

It seems like a really multi -pronged approach is needed.

It absolutely is.

You need behavioral strategies, environmental changes, maybe medication adjustments.

What are the key behavioral things nurses can teach or implement?

Well, for stress UI especially, the gold standard is Kegel exercises.

But they need to be taught correctly.

How does the chapter describe teaching them?

It suggests a modified approach.

First, help the person identify the right muscles, usually by trying to stop the flow of urine midstream.

Once they know the feeling, teach them to contract those muscles, hold for a count of four, and relax.

How often?

The recommendation is often around 100 repetitions total, maybe spread over three sessions a day.

And importantly, they need to stick with it.

It can take three or four months to see significant improvement.

Patience is key.

What about fluid management for UI?

Modifying when and what they drink can help.

Encourage most fluid intake earlier in the day.

Maybe restrict fluids after 7 p .m.

to reduce nighttime voiding.

And identify and avoid bladder irritants.

Caffeine and alcohol are common ones.

And tackling that functional UI,

the environmental and access issues.

This is where nursing and the healthcare system can make a huge difference.

Look at clothing.

Can we switch to Velcro closures or elastic waistbands?

Make the environment safer and easier?

Install grab bars?

Use raised toilet seats?

And staff responsiveness?

Absolutely critical, especially in institutional settings.

Answering call lights promptly isn't just about convenience.

It's a primary intervention to prevent functional incontinence episodes.

Delaying help can directly cause incontinence.

So a delay makes it a system failure, not just a patient problem.

Precisely.

It shifts the responsibility.

What about scheduled toileting?

Very effective, especially for urge or functional incontinence.

You start by taking the person to the toilet on a regular schedule, maybe every two hours, whether they feel the urge or not.

Then you gradually try to increase the time between voids to help retrain the bladder and increase its capacity.

One last very important point from the chapter.

Using indwelling catheters for incontinence.

The message is clear.

It's highly discouraged just for managing UI.

The risk of catheter -associated urinary tract infections, UTIs, is just too high.

UTIs can be serious, even life -threatening in older adults.

Catheters should really be a last resort for specific medical reasons, not just for convenience.

And if a catheter has been in place and needs to come out?

If it's been in for a while, the bladder might have lost tone and capacity.

Sometimes a protocol of intermittent clamping before removal is used to help the bladder gradually stretch and regain its ability to hold urine.

That's a really thorough journey through the chapter's key points on elimination.

We've covered normal function, the major risks like constipation, impaction, dehydration from diarrhea,

retention, the different types of incontinence.

And crucially, the nursing interventions focusing on lifestyle, behavior, environment, and cautious medication use.

So the big takeaway seems to be that these elimination problems are serious geriatric issues, far more than just inconveniences.

Absolutely.

And the nursing focus really needs to be proactive early assessment, digging into the underlying causes like diet, meds, mobility, and then implementing these patient -centered strategies, especially the behavioral and environmental ones.

So as you listening integrate this, maybe we can leave you with a final thought, a challenge from the chapter's concepts.

Okay.

Thinking about functional incontinence defined as that inability to reach the toilet due to physical, cognitive, or environmental barriers,

how much of what we label as incontinence in our patients is truly an unavoidable physiological issue.

Versus?

Versus how much might actually be an avoidable failure, a failure of the environment we provide, the clothing choices we facilitate, or even the speed with which we respond to their needs.

That really forces you to look critically at the care system itself, doesn't it?

From the patient's viewpoint, it ties right into teamwork and ensuring the environment supports continence rather than hinders it.

A powerful thought to consider in practice.

Indeed.

Well, thank you for diving deep into this vital chapter with us today.

My pleasure.

That's important stuff.

We'll see you next time on The Deep Dive.