When encouraging hospitalized clients to void the most basic method for the nurse to employ is

Preventing re-hospitalization is a huge responsibility, especially in consideration of costly penalties that are levied for early readmissions. To accomplish this, nurses need to constantly improve patient teaching and education prior to discharge. Some of the things nurses can do to advance patient education include:

• Delegate more responsibilities to support staff and be more focused on patient education.
• Begin educating patients with every encounter from admission.
• Find out what the patient already knows. Correct any misinformation.
• Feed patients information in layman’s terms. Utilize visual aids as often as possible.
• Question their understanding of the care, and plan for the next lesson.
• Use return demonstration when administering care. Involve the patient from the very first treatment.
• Ask the patient to tell you how they would explain (step-by-step) their disease or treatment to their loved one.
• Make sure the patient understands the medications as you administer them. Make sure they understand how and when to refill medications.
• Provide patients with information about signs and symptoms of their condition that will require immediate attention.

Five strategies for patient education success

Teaching patients is an important aspect of nursing care. Whether teaching a new mom how to bathe a newborn baby or instructing an adult who is living with a chronic heart disease, a successful outcome depends on the quality of the nurse’s instruction and support. Consider these five strategies.

1. Take advantage of educational technology

Technology has made patient education materials more accessible. Educational resources can be customized and printed out for patients with the touch of a button. Make sure the patient’s individualized needs are addressed. Don't simply hand the patient a stack of papers to read, review them with patients to ensure they understand the instructions and answer questions that arise. Some resources are available in several languages.

2. Determine the patient’s learning style

Similar information may be provided by a range of techniques. In fact, providing education using different modalities reinforces teaching. Patients have different learning styles so ask if your patient learns best by watching a DVD or by reading. A hands on approach where the patient gets to perform a procedure with your guidance is often the best method.

3. Stimulate the patient’s interest

It's essential that patients understand why this is important. Establish rapport, ask and answer questions, and consider specific patient concerns. Some patients may want detailed information about every aspect of their health condition while others may want just the facts, and do better with a simple checklist.

4. Consider the patient’s limitations and strengths

Does the patient have physical, mental, or emotional impairments that impact the ability to learn? Some patients may need large print materials and if the patient is hearing impaired, use visual materials and hands on methods instead of simply providing verbal instruction. Always have patients explain what you taught them. Often people will nod “yes” or say that they comprehend what is taught even if they have not really heard or understood. Consider factors such as fatigue and the shock of learning a critical diagnosis when educating patients.

5. Include family members in health care management

Involving family members in patient teaching improves the chances that your instructions will be followed. In many cases, you will be providing most of the instruction to family members. Families play a critical role in health care management.

Teaching patients and their families can be one of the most challenging, yet also rewarding elements of providing nursing care. First-rate instruction improves patient outcomes dramatically.

The value of patient education resources

For further resources that will strength your organization’s patient-teaching, let Lippincott Advisor help. Our best-in-class, evidence-based decision support software for institutions includes over 16,000 customizable patient teaching handouts and content entries.

Bladder training is an important form of behavior therapy that can be effective in treating urinary incontinence. The goals are to increase the amount of time between emptying your bladder and the amount of fluids your bladder can hold. It also can diminish leakage and the sense of urgency associated with the problem.

Bladder training requires following a fixed voiding schedule, whether or not you feel the urge to urinate. If you feel an urge to urinate before the assigned interval, you should use urge suppression techniques — such as relaxation and Kegel exercises.

As success is achieved, the interval is lengthened in 15- to 30-minute increments until it is possible to remain comfortable for three or four hours. This goal can be individualized to suit each woman's needs and desires.

Keeping a diary of your bladder activity is very important. This helps your health care provider determine the correct place to start the training and to monitor your progress throughout your program.

Bladder Retraining Instructions

• Empty your bladder as soon as you get up in the morning. This act starts your retraining schedule.
• Go to the bathroom at the specific times you and your health care provider have discussed. Wait until your next scheduled time before you urinate again. Be sure to empty your bladder even if you feel no urge to urinate. Follow the schedule during waking hours only. At night, go to the bathroom only if you awaken and find it necessary.
• When you feel the urge to urinate before the next designated time, use "urge suppression" techniques or try relaxation techniques like deep breathing. Focus on relaxing all other muscles. If possible, sit down until the sensation passes.

  If the urge is suppressed, adhere to the schedule. If you cannot suppress the urge, wait five minutes then slowly make your way to the bathroom. After urinating, re-establish the schedule. Repeat this process every time an urge is felt.

• When you have accomplished your initial goal, gradually increase the time between emptying your bladder by 15-minute intervals. Try to increase your interval each week. However, you will be the best judge of how quickly you can advance to the next step. Increase the time between each urination until you reach a three- to four-hour voiding interval.
• It should take between six to 12 weeks to accomplish your ultimate goal. Don't be discouraged by setbacks. You may find you have good days and bad days. As you continue bladder retraining, you will start to notice more and more good days, so keep practicing.
• You will hasten your success by doing your pelvic muscles exercises faithfully every day. Your diaries will help you see your progress and identify your problem times.

The Center for Urogynecology and Women's Pelvic Health is here to help and support you. Be sure to keep your regularly scheduled visits. If you need more help, medication and other treatments are available and may be useful.

Assisting patients with elimination is an essential aspect of the nurse's role and has important medical significance as well as psychosocial effects on the client's quality of life.[1]  As the pattern of healthy bowel movements and urination vary in different patient groups, the management for each patient population may differ. Nurses need to assist with healthy elimination patterns to ensure patients are having regular soft bowel movements and adequate urination and to identify abnormal patterns such as flatulence, constipation, diarrhea, incontinence, fecal impaction, hemorrhoids as well as polyuria, anuria, and other abnormalities which can be signs of underlying medical conditions. 

While there are pharmacologic alternatives to assist with elimination issues, assistance by nurses is often required. For instance, in abdominal pain syndrome and constipation, studies show that abdominal massage appears to increase bowel function, but without the negative effects of laxatives.[2] 

Conversely, certain medications can cause constipation, diarrhea, and hinder or exacerbate elimination. Opioids, NSAIDs, antibiotics, anticoagulants, can all induce constipation.[3] It is vital nurses know which patients are at risk for bowel and bladder disruption and monitor them for these issues. 

The nursing team must provide strong supportive communication when assisting clients with elimination. A study found that the nurse's attitudes toward excretion-related nursing care strongly influenced the use of a toilet and physical functions of the elderly.[4] Patients may be reluctant to discuss their bowel and bladder problems due to embarrassment. It is vital that nurses maintain open communication and empathy with their clients and ask questions as well as physically assess patients for signs of bladder and bowel irregularities.[5][6]

Elimination issues may occur due to a variety of different medical conditions; for instance, post-surgical patients are at risk for ileus, congenital malformations in infants can cause bowel and bladder disruption, and cancer patients and the elderly can have altered elimination secondary to drugs and therapy.[7][8]

The inability to effectively eliminate waste products from the bowel and bladder may lead to serious medical conditions and can be a psychosocial factor contributing to decreased quality of living.[5] Special consideration is necessary for patients at risk for bowel and bladder dysfunction such as patients with decreased fiber or fluid intake, or those with decreased bulk in their diet, patients on bed rest, those with kidney, CNS, or heart disease, the elderly, infants and cancer patients.[6]

Management may differ based on the diagnosis of the patient. For instance, a study found that enterally fed preterm infants would benefit from abdominal massage twice a day, whereas cancer patients with elimination issues may benefit from Sitz baths.[9][7][10]

Non-invasive interventions such as repositioning the patient, providing counseling in regards to a high fiber diet rich in prunes, stool softeners, removing drugs that may be causing gastrointestinal or genitourinary side effects, and abdominal massage can aid the patient in elimination. Additionally, more invasive interventions such as the use of suppositories, urinary catheters, enemas, bowel and bladder training, and management can also help clients who have failed initial interventions.[6]

Urinary catheterization for retention is possible with the use of ointments such as zinc oxide and topical agents to keep the skin protected. A recent meta-analysis found that periurethral cleaning with water before urinary catheterization is as effective as using anti-septic agents and does not increase the risk of UTI's.[11] Bladder, colostomy, and urinary catheter irrigations can also be performed to assist with elimination.[11] 

Various enemas can also be used depending on the issue; cleansing enemas are used before procedures like colonoscopies to clean the colon of fecal material for optimal visualization, retention enemas may help lubricate the rectum and deliver medication, and lastly, return-flow enemas are often used after anesthesia to stimulate peristalsis.[12]

If less invasive techniques are unsuccessful, colostomies, or urostomies are options. However, given that these are invasive procedures, there is an increased risk of complications such as infections, B12 deficiency, dehiscence, and necrosis, and these patients require thorough monitoring.[13]

Invasive methods may lead to long term adverse outcomes. A study found that decreasing the use of the invasive practices routinely adopted in nursing homes (laxatives, enemas, rectal exploration) improved constipation in nursing home residents.[14] Thus, empathetic nursing care, counseling, and non-invasive methods are ideal for improving excretion issues.

Any patient without a bowel movement for several days requires assessment for constipation or small bowel obstruction. Nurses may assess bladder function by measuring the amount of residual urine. On average, adults urinate 30 mL each hour.[4]

Secondary complications of disrupted elimination such as delirium secondary to UTI’s, or a positive FOBT secondary to ulcers or hemorrhoids also need monitoring.[15]

It is also essential to monitor elimination to prevent the spread of hospital-acquired infections such as Clostridium difficile and to isolate the client and use hand hygiene and gown and glove precautions when assisting the patient.[16]

Thus, by following these methods and being knowledgeable about elimination and the complications associated with patient elimination, nurses can adequately assist with this fundamental aspect of patient care. 

Review Questions

1.

Coggrave M. Neurogenic continence. Part 3: Bowel management strategies. 2008 Aug 14-Sep 10Br J Nurs. 17(15):962-8. [PubMed: 18983017]

Lämås K, Lindholm L, Stenlund H, Engström B, Jacobsson C. Effects of abdominal massage in management of constipation--a randomized controlled trial. Int J Nurs Stud. 2009 Jun;46(6):759-67. [PubMed: 19217105]

Sharma A, Rao S. Constipation: Pathophysiology and Current Therapeutic Approaches. Handb Exp Pharmacol. 2017;239:59-74. [PubMed: 28185025]

Tanaka K, Takeda K, Suyama K, Kooka A, Nakamura S. Factors related to the urination methods of elderly people with incontinence who require at-home nursing care. Nihon Ronen Igakkai Zasshi. 2016;53(2):133-42. [PubMed: 27250220]

Cauley CE, Savitt LR, Weinstein M, Wakamatsu MM, Kunitake H, Ricciardi R, Staller K, Bordeianou L. A Quality-of-Life Comparison of Two Fecal Incontinence Phenotypes: Isolated Fecal Incontinence Versus Concurrent Fecal Incontinence With Constipation. Dis Colon Rectum. 2019 Jan;62(1):63-70. [PubMed: 30451749]

Pellatt GC. Clinical skills: bowel elimination and management of complications. 2007 Mar 22-Apr 11Br J Nurs. 16(6):351-5. [PubMed: 17505389]

Wickham RJ. Managing Constipation in Adults With Cancer. J Adv Pract Oncol. 2017 Mar;8(2):149-161. [PMC free article: PMC5995490] [PubMed: 29900023]

Powell M, Rigby D. Management of bowel dysfunction: evacuation difficulties. Nurs Stand. 2000 Aug 9-15;14(47):47-51; quiz 53-4. [PubMed: 11974378]

Tekgündüz KŞ, Gürol A, Apay SE, Caner I. Effect of abdomen massage for prevention of feeding intolerance in preterm infants. Ital J Pediatr. 2014 Nov 14;40:89. [PMC free article: PMC4236471] [PubMed: 25394549]

Tseng YL, Lin SY, Tseng HC, Wang JY, Chiu JL, Weng KT. Stress and other factors associated with colorectal cancer outpatients with temporary colostomies. Eur J Cancer Care (Engl). 2019 Jul;28(4):e13054. [PubMed: 30993754]

Huang K, Liang J, Mo T, Zhou Y, Ying Y. Does periurethral cleaning with water prior to indwelling urinary catheterization increase the risk of urinary tract infections? A systematic review and meta-analysis. Am J Infect Control. 2018 Dec;46(12):1400-1405. [PubMed: 29778430]

Peate I. How to administer an enema. Nurs Stand. 2015 Dec 02;30(14):34-6. [PubMed: 26639291]

de Oliveira AL, Boroni Moreira AP, Pereira Netto M, Gonçalves Leite IC. A Cross-sectional Study of Nutritional Status, Diet, and Dietary Restrictions Among Persons With an Ileostomy or Colostomy. Ostomy Wound Manage. 2018 May;64(5):18-29. [PubMed: 29847308]

Palese A, Granzotto D, Broll MG, Carlesso N. From health organization-centred standardization work process to a personhood-centred care process in an Italian nursing home: effectiveness on bowel elimination model. Int J Older People Nurs. 2010 Jun;5(2):179-87. [PubMed: 20925719]

Kobayashi Y, Watabe H, Yamada A, Suzuki H, Hirata Y, Yamaji Y, Yoshida H, Koike K. Impact of fecal occult blood on obscure gastrointestinal bleeding: observational study. World J Gastroenterol. 2015 Jan 07;21(1):326-32. [PMC free article: PMC4284352] [PubMed: 25574108]

Read ME, Olson AJ, Calderwood MS. Front-line education by infection preventionists helps reduce Clostridioides difficile infections. Am J Infect Control. 2020 Feb;48(2):227-229. [PubMed: 31515098]