Bowel and Bladder
Function
Elimination, Impairments, and Interventions
The management of elimination problems is an area of
ongoing concern for rehabilitation nurses and therapists.
For clients in the rehab setting, alteration in elimination
patterns can create feeling of powerlessness,
dependency, and loss of control. This self-directed
learning module contains information rehab
professionals need to understand relative to the causes
and manifestations of different types of neurogenic
bladder and bowel conditions in order to provide quality
care to the rehab client.
Target Audience: SCI Program Team Members
including RN, LPN, PT, PTA, OT, COTA, SLP, TR,
SW, MS
Recommended: Ancillary Team Members including
RN, LPN all teams
Contents
Instructions ........................................................2
Learning Objectives...........................................2
Module Content .................................................3
Job Aid ..............................................................17
Posttest .............................................................18-19
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Bowel and Bladder
The material in this module is an introduction to important general information. After
completing this module, contact your manager to obtain additional information
specific to your unit.
•
Read this module.
•
If you have any questions about the material, ask your manager.
•
Complete the online post test for this module.
•
The Job Aid on page 17 may be used as a quick reference guide.
•
Completion of this module will be recorded under My Learning in
PeopleLink.
Learning Objectives:
When you finish this module, you will be able to:
•
Identify the types of neurogenic bowel and bladder dysfunctions found in
the rehabilitation setting
•
Understand normal defecation and micturation
•
Understand and differentiate between injuries of upper motor neurons
and lower motor neurons and how they affect bowel and bladder function
•
Recognize and identify the causes of elimination dysfunctions commonly
found in the rehab patient
•
Identify appropriate interventions for the different types of bowel and
bladder conditions
•
Identify methods for establishing bowel and bladder programs for
patients with varying dysfunctions
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Bowel and Bladder
I. Introduction to Elimination Patterns
The management of elimination problems is an area of ongoing concern for
rehabilitation nurses and therapists. For clients in the rehab setting, alteration in
elimination patterns can create feeling of powerlessness, dependency, and
loss of control. Loss of control of bowel and urinary elimination can lead to
embarrassment, shame and isolation and in turn, can limit the client’s involvement in
vocational, social, and other aspects of daily living. Incontinence is the most
common reason for a client to limit activity or to leave a social situation and has
been noted to be a restrictive factor in sexual satisfaction for both the individual and
his or her partner. The ability for a patient to maintain continence may make the
difference between discharge to a long-term care facility and returning home,
and is the number one predictor of discharge disposition from the rehab
setting.
It is estimated that urinary incontinence affects 10 million people in the United States
annually. At least half of the 1.5 million residents of nursing homes in the U.S. (50%
both men and women) are incontinent of urine at least once a day. A conservative
estimate of the direct cost of this problem is $16 billion per year. The indirect
costs incurred by individuals and their families can be immeasurable.
In rehabilitation, we most commonly see patients with bladder or bowel
dysfunction caused by neurological damage. The etiology of the elimination
problem in the rehab patient is significant, as rehab professionals we need to
understand the causes and manifestations of different types of neurogenic bladder
and bowel conditions.
II. Nursing Assessment of Bowel and Bladder
It is vital that the rehabilitation nurse obtain an accurate and complete
assessment of the patient in order to determine the best intervention for a
patient’s bowel or bladder condition.
1. Take a detailed history including:
a. Traumatic injuries
b. Preexisting conditions
c. Sexually transmitted diseases
d. Diabetes
e. Past surgeries
f. Number of pregnancies and type of delivery
g. Mental status
2. Review medications with special attention to:
a. Diuretics
b. Sedatives
c. Hypnotics
d. Anticholinergics
e. Beta-blockers
f. Antidepressants
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Bowel and Bladder
3. Assess continence history for:
a. Premorbid status
b. Symptoms
c. Level of awareness of need to void
d. Frequency, quantity and color of urine
e. Dribbling
f. Fluid intake and type of fluid
g. Time of incontinent episodes
h. Exact methods the client uses to control or manage incontinence
4. Physical examination:
a. Bowel sounds, palpate abdomen
b. Genital abnormalities
c. Rectal exam (fecal impaction)
d. Neurological exam:
Test for saddle sensation: critical determinant of neurological
integrity of sacral nerves (S2, S3, S4); these sacral nerve roots
determine sensation and sphincter function; test by pinprick or
light touch
Test for bulbocavernosus (BC) reflex: indicates an intact reflex
of sensory and motor components of S2, S3, S4; squeezing of
the glans penis or clitoris (sensory input) should elicit tightening
of the external anal sphincter (motor response)
Anal reflex, or anal wink: another indication of intact sacral
nerve roots wherein a pinprick to one or both sides of external
anal sphincter results in tightening of the sphincter.
5. Consider patient’s functional ability to use a commode, remove
clothing and perform hygiene
6. Determine home bathroom’s accessibility and the patient’s anticipated
toileting needs for discharge.
III. Upper and Lower Motor Neurons
Upper and lower motor neuron involvement is an important concept in rehabilitation
nursing. Differentiating between upper and lower motor neuron involvement is
essential to determine the nature and extent of bladder and bowel dysfunction.
The central nervous system (CNS) has upper motor neurons (UMN) and lower motor
neurons (LMN). Upper motor neurons originate in the brain - are attached to the
motor strip in the cerebral cortex - and run up and down the CNS (from the brain to
the spinal cord and back to the brain). There is an UMN connection to every level of
the spinal cord where it can connect and interact with the lower motor neurons
(LMN).
Lower motor neurons originate in the spinal cord and respond by neuro
pathways to the muscles and the organs. Actually, where these responses run in
and out of the spinal cord is referred to as the 'reflex arc.' There is a LMN
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Bowel and Bladder
connection to every level of the spinal cord where it can connect and interact with
the UMN. Although lower motor neuron damage can occur at any segment of the
cord, significant manifestations typically result when there is injury to the
sacral portion of the cord. The sacral portion is considered at the level T-12 and
below.
The distinction between UMN (above T-12) and LMN (T-12 and below) is
important to know.
The purpose of the UMN is to allow the brain to control any reflexes caused by
the LMN that it (the brain) considers inappropriate. The brain sends the
message via the spinal cord path to the LMN and relays the message to stop the
reflex. So the brain inhibits or suppresses lower motor neurons so that they do not
become hyperactive to local stimuli. This keeps the body in homeostasis.
When there is a disruption of communication from the brain (UMN) to control
reflexes, this is called an upper motor neuron lesion (or injury). When there is
injury to the UMN, the patient still has reflexes; this also means they have a bowel
and bladder that act by reflex.
Some characteristics of patients with UMN injury:
Reflex bladder (increased muscle tone)
Reflex bowel (increased muscle tone)
Reflex erections
Bowel/bladder programs more easily regulated with consistent good results
When there is injury to the LMN, the reflex arc is no longer intact; therefore the
patient can no longer initiate an involuntary action (spasm, reflex). This type of injury
is referred to as lower motor neuron lesion.
Some characteristics of patients with LMN injury:
Areflexic bladder / flaccid (loss of muscle tone)
Areflexic bowel / flaccid (loss of muscle tone)
No reflex erections possible
Retention of stool tends to be more of a problem; bowel programs more difficult
to regulate
IV. Bowel Elimination
Bowel incontinence is typically less of a daily problem and can usually be managed
with effective bowel programs and medications. Constipation and regularity are
often the major focus due to the patient’s immobility, hydration and diet concerns. A
thorough assessment, both premorbid and current, is important to establish routines
and formulate a plan for bowel management. Typically, it is up to the rehab nurse
to assess and manage the bowel programs of the patient in the inpatient
setting.
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Bowel and Bladder
A. Normal mechanisms promoting fecal continence
1. The colon performs secretory and absorptive functions and is responsible
for moving stool toward the rectum.
2. Rectal compliance and capacity are critical factors in maintaining bowel
continence; in turn, there are several important factors related to these:
a. Reverse colon gradient activity that occurs from distal to
proximal: inhibits progression of feces-that is, there is a
mechanism in the colon to retain stool until voluntary defecation is
initiated
b. Anal canal and rectal pressures: responsible for maintaining
continence; however, internal sphincter is major controller of
continence
c. Abdominal musculature strength
d. Weight and volume of stool
e. Internal and external anal sphincter (Innervated by sacral roots
2, 3, and 4 (S2, S3, S4)
3. Influence of autonomic and somatic nervous systems on normal fecal
continence
a. In the intact system, cortical recognition of stimuli will initiate or
inhibit defecation mechanisms
b. With distention of colon, rectal stretch receptors are stimulated,
impulses enter spinal cord, ascend to cortex, and initiate
awareness of colonic and rectal distention
c. Peristalsis of colon propels feces to rectum, which initiates a reflex
rectal contraction mediated by pelvic splanchnic nerves originating
from S2, S3, and S4
d. Rectal reflexes relax internal sphincter and contract external
sphincter so that stool can be expelled.
e. Voluntary defecation begins with closure of the glottis, followed by
descent of diaphragm and contraction of abdominal muscles; this
provides increased intra-abdominal pressure, which provides
movement of stool
f. Pelvic musculature relaxes simultaneously with internal and
external anal sphincters until complete emptying occurs
B.
Neurogenic Bowel Conditions
1. Occur most commonly as a result of one of three types of conditions
a. Central nervous system vascular disorders (e.g., stroke)
b. Traumatic injury (e.g., intracranial bleeding, traumatic brain injury,
or spinal cord injury)
c. Neurological diseases (e.g., multiple sclerosis, Parkinson’s
disease)
2. Such conditions can cause partial or complete loss of innervation of
gastrointestinal tract, resulting in incontinence and/or constipation
3. Neurogenic bowel is influenced by alterations in mobility, activity,
cognition, diet, and medications
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Bowel and Bladder
Neurogenic bowel alterations typically are categorized into three
classifications: uninhibited, reflex, and areflexic:
Uninhibited Neurogenic Bowel
Definition: Impaired cortical awareness of urge to defecate, characterized by urgency and
involuntary stools
Causes
Characteristics
Interventions
Damage to upper
motor neurons
(typically after CVA,
TBI, MS, trauma)
Internal and external sphincters
intact or hypertonic
Saddle sensation preserved
Bulbocavernosus (BC) reflex
varied or increased
Sacral reflex intact
Defecation is involuntary and
sudden
Hard stool with smearing
Adequate fiber and bulk in diet
Establish bowel routine with
consistency of diet and timing
Bisacodyl enema or suppository to
stimulate rectal emptying-apply
directly along rectal mucosa
Adequate hydration and exercise
Watch for constipation
Reflex Neurogenic Bowel
Also called: UMN paralysis or spastic bowel paralysis
Definition: Partial or complete loss of cortical control of defecation process with partial or
complete loss of voluntary sphincter activity resulting in reflex bowel emptying
Causes
Characteristics
Interventions
Complete or
incomplete spinal
cord trauma or any
CNS pathology
above T12 or L1
Defecation is involuntary; there
is sudden, mass emptying
when rectal vault becomes full
(due to sacral reflex)
Partial or total sensory loss in
perineum and/or rectum
Partial or total loss of external
sphincter control
Diminished or absent saddle
sensation
Increased BC reflex and anal
reflexes
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Irritant cathartics, bulk formers and
stool softeners
Regularly timed bowel programs
Insert suppository while patient
lying on side, transfer to toilet 1520 minutes after insertion to
complete emptying
Circular digital stimulation to
facilitate reflex contraction of colon
and rectum
Use adequate lubricant to
decrease trauma and risk of
dysreflexia
Ensure adequate, consistent
amounts of fluids and fiber in diet
Bowel and Bladder
Areflexic Neurogenic Bowel
Also called: Autonomous neurogenic bowel, LMN paralysis, or flaccid bowel paralysis
Definition: Involuntary defecation due to partial or total absence of rectal compliance and/or
sphincter control
Causes
Characteristics
Interventions
Complete or
incomplete LMN
trauma or any
CNS pathology
at or below T12
Partial or
complete
destruction of
reflex arc of S2,
S3, and S4
Injury to the
lumbosacral
core and spinal
roots (LMN),
trauma, or
postoperative
complications
Hard, formed stool requiring
disimpaction
Stool leakage with activity or
stress
Decreased or absent sensory
awareness or urge to defecate
Partial or total sensory loss in
perineum and rectum
Partial or total loss of external
sphincter control
Diminished or absent saddle
sensation
Diminished or absent BC and
anal reflexes
Maintain adequate nutrition and
hydration
Maintain consistent routine
Add bulk formers
Evacuate stool from distal colon
and rectum with suppository
Establish routine based on
premorbid bowel habits
Abdominal binder or abdominal
massage (right to left, up, around,
and down to facilitate emptying
Ostomy as a last resort
Some final notes about bowel programs:
When initiating a bowel program, it is very important to begin with a clean
bowel. The lower colon must be free from impacted feces.
A bowel movement every 1-3 days is considered normal and regular. The
rehab nurse and therapist must teach the patient and family to reassess the
bowel program as changes in health, activity, nutritional level or lifestyle
necessitate. However, the bowel program should not be changed more
frequently than every 3-5 days in order to allow stool softeners or bulk-forming
agents time to work. It may take up to 3 days for these agents to have their
effect. When making adjustments to the bowel program, only change one
intervention at a time so that the effectiveness can be assessed more
accurately.
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Bowel and Bladder
V. Bladder Elimination
Urinary incontinence is defined as the involuntary loss of urine in sufficient
amounts to be a problem for the patient. Causes of urinary incontinence include
immobility, diminished cognitive status, medications, smoking, low fluid
intake, constipation, weakness of bladder and support muscles, urethra
obstruction, hormonal imbalances, neurological disorders and overactive
bladder muscles.
Although many patients have a combination of symptoms and factors that
complicate treatment of urinary incontinence, there are three broad types of
incontinence: urge, stress, and overflow.
Urge incontinence is the involuntary loss of urine associated with a strong
sensation to empty the bladder.
Stress incontinence is losing urine with activity such as bending or laughing.
Overflow incontinence occurs when the bladder does not empty completely, thus
the bladder overflows.
A. Normal mechanisms promoting urinary continence
1. Normal anatomy/physiology of lower urinary tract
a. Bladder
Functions as a reservoir
Main body comprised of smooth muscle called Detrusor-allows
for expansion and maintains fairly constant low pressure
Trigone muscle is interlacing network of smooth muscle
forming base of bladder and proximal urethral
b. Urethra
Passageway for urine
Internal sphincter (bladder neck) remains compressed in
resting state to prevent leakage
c. External sphincter:
Striated skeletal muscle surrounds distal portion of urethra
Last line of defense for maintaining continence
2. Neurological control of lower urinary tract
a. Central Nervous System
Frontal cerebral cortex facilitates or inhibits pontine micturation
center
Pontine micturation center (in the brainstem) facilitates
impulses to the bladder
Spinal cord tracts
o Spinothalamic tracts (sensory, ascending): carry pain and
temperature messages from lower urinary tract to brain
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Bowel and Bladder
o Posterior columns (sensory, ascending): carry sensations
of fullness and desire to void to brain
o Reticulospinal tract (motor, descending): transmits inhibitory
messages from the pons (brain) to the detrusor (bladder)
o Corticospinal tract (motor, descending): carries messages
from brain to bladder to provide voluntary control over
external sphincter
b. Peripheral nervous system
Parasympathetic, sympathetic and somatic innervations provide
stimulation as needed to certain functions of the lower urinary
tract (i.e. voluntary control of external sphincter)
B. Normal Micturation (voiding)
1. Filling phase:
Bladder slowly fills with urine and maintains low bladder pressure
with increasing volume; continence is maintained as long as
pressure within the bladder is lower than urethral pressure
As volume of urine increases, sensory receptors in bladder wall are
stimulated and transmit message to sacral cord reflex center (S2,
S3, S4); first urge to void occurs when the urine level is around
150-200cc…a marked sensation of fullness occurs at 300-400cc
Sensory messages are sent from the spinal cord to brain through
the spinothalamic tract and posterior columns
2. Postponement phase:
Inhibitory centers in brain (frontal lobe) can override the voiding
reflex (micturation reflex) by voluntarily contracting the external
sphincter via the pudendal nerve
Postponement becomes more difficult as volume increases, which
causes sensory receptors to bombard the sacral reflex center, and
as bladder pressure increases and approaches the level of urethral
pressure, detrusor muscle begins rhythmic contractions, causing
notable discomfort.
3. Emptying phase:
1. Messages of fullness and urge to void are processed in the brain
(frontal lobe) and motor messages are sent through the
corticospinal tract to the sacral reflex center (S2, S3, S4)
2. Peripheral nervous system relays the message to the bladder to
stimulate the detrusor muscle to contract and the external sphincter
to relax simultaneously.
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Bowel and Bladder
C.
Neurogenic Bladder Conditions
Any disruption of sensory or motor pathways in the central or peripheral
nervous systems that have input to the bladder will cause a disruption
in micturation cycle.
Disruption in CNS above sacral reflex center generally causes a
hyperreflexic bladder and is considered an upper motor neuron injury.
Disruption at sacral reflex center or in peripheral nervous system causes
an areflexic bladder and is considered a lower motor neuron injury.
Neurogenic bladder alterations typically are categorized into five
classifications: uninhibited, reflex, and autonomous (areflexic), motor
paralytic, and sensory paralytic:
Uninhibited Neurogenic Bladder
Causes
Characteristics
Lesions in the cerebral cortex
and pontine center (from CVA,
TBI, MS, and brain tumor)
Strong uncontrolled voiding contractions of the bladder muscle
Urgency, frequency, nocturia resulting in urge incontinence
Reduced bladder capacity with little or no residual urine
Intact saddle sensation and BC reflex
Reflex Neurogenic Bladder
Causes
Characteristics
Spinal cord lesions above T12L1 secondary to trauma,
tumors, infection, vascular
infarction, or MS
Disruption of both sensory and motor nerve tracts above S2,
S3, S4
Loss of control from higher brain centers results in uninhibited,
involuntary detrusor contractions and uncontrolled voiding;
spinal reflex arc takes over control of micturation
Decreased bladder capacity with high urine residuals
Inability of external sphincter to relax in coordination with
detrusor contractions (called detrusor external sphincter
dyssynergia); this results in increased bladder pressure with
emptying and large residuals
Impaired or absent saddle sensation and hyperactive BC reflex
Areflexic (Autonomous) Neurogenic Bladder
Causes
Spinal cord lesions at or below
T12-L1 or other conditions that
damage the LMN (spina bifida,
meningocele, and herniated
intervertebral disc)
Characteristics
Disruption of the sensory and motor branches of the sacral
spinal reflex arc S2, S3, S4 (LMN damage)
Decreased sensation of fullness, weak or absent detrusor
contractions, increased bladder capacity with high residual
urine
Loss of voluntary voiding except with straining; overflow
incontinence is common
Impaired or absent saddle sensation and absent BC reflex
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Bowel and Bladder
Motor Paralytic Neurogenic Bladder
Causes
Characteristics
Poliomyelitis, herniated disc,
trauma, or tumors
Disruption of motor branches of S2, S3, S4 or damage to
anterior portion of spinal cord
Partial or complete motor loss of bladder function; intact
sensory nerves
Difficulty with starting a stream, decreased force of urinary
stream, or a need to strain to void
Increased bladder capacity with high residual urine; overflow
incontinence is common
Intact saddle sensation; absent BC reflex
Sensory Paralytic Neurogenic Bladder
Causes
Characteristics
Disruption of sensory segment
of reflex arc secondary to
diabetic neuropathy, tabes
dorsalis, syringomyelia, and
MS
Disruption of sensory branches of S2, S3, S4 or in pathways
that carry sensory messages to brain
Decreased or absent sensations of pain, temperature, and/or
fullness in bladder
Infrequent voiding with large output; increased bladder capacity
with overflow incontinence is also common
Variable saddle sensation and BC reflex according to
progression of underlying disease
Overflow incontinence is more common in men than in women. The most
common non-neurogenic cause of overflow incontinence in men is prostatic
hypertrophy, because it causes an outlet obstruction. Outlet obstruction is rare in
women, though it can occur in the event of severe pelvic organ prolapse or as a
complication of an anti-incontinence surgical procedure.
The typical types of neurogenic bladder dysfunctions seen in rehab
patients can result in one or more functional problems: incontinence,
retention, and high risk for urinary tract infections. Listed below are
interventions and expected outcomes for these nursing diagnoses.
Urinary Incontinence
Interventions:
1. Reduce or eliminate factors contributing to incontinence, if possible
a. UTI
b. Medications that can exacerbate incontinence
Diuretics
Sedatives, hypnotics, tranquilizers
Anticholinergics
Antihypertensives
Antiarrhythmics
Over-the-counter cold medications
c. Environmental barriers
Remove obstacles in path to bathroom, ensure adequate
lighting
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Bowel and Bladder
2.
3.
4.
5.
6.
Assess bathroom size, height of toilet, grab bars, and other adaptive
equipment
Consider use of bedside commode for nighttime use
Ensure that there is an adequate signal system for requesting
assistance
Maintain adequate hydration
a. Increase fluid intake to approximately 2,000-3,000 cc/day unless
contraindicated
b. Ensure that consistent amounts of fluids are given throughout the day and
consider need to decrease fluids in the early evening
c. Decrease and/or eliminate intake of fluids with diuretic, dehydrating, or
irritating effects on bladder
Caffeinated drinks (coffee, tea, colas)
Grapefruit juice
Drinks containing aspartame
d. If patient is on a bladder management program, document fluid intake and
involve the patient in keeping his own record, if possible
Ensure adequate bowel elimination
Promote individual’s personal integrity, self-esteem and privacy
Maintain skin integrity
Establish a bladder program: Incorporate management strategies appropriate for
the specific type of neurogenic bladder
a. Teach about and administer medications as ordered; monitor response
Bladder Medications
Type
Example
Cholinergic
Urecholine
Bethanechol
Anticholinergic
1.Detrol
2.Detrol LA
3.Ditropan IR
4.Ditropan XL
5.Enabelex
6.Gelnique
7. Levsin
8.Sanctura
9.Toviaz
10. Vesicare
1 Pyridium
2. Urispas
3.Urogesic
blue
Antispasmotic
Alphaadrenergic
blockers
1.Flomax
2. Rapaflo
Action
Side Effects
Relieves retention by
causing detrusor
contraction and bladder
emptying
Also increases tone and
peristalsis in the GI tract
Inhibits bladder contraction
Increases bladder capacity
Also decreases GI mobility
and inhibit gastric acid
secretion
Headache
Bradycardia
Hypotension
Abdominal cramps
Diarrhea
Urgency
Confusion
Palpitations
Dry mouth
Hypotension
Constipation
Depresses smooth muscle
Produces local anesthesia
Increases bladder capacity
Palpitations
Tachycardia
Urine retention
Dry mouth
Constipation
Confusion
Dizziness
Headache
Hypotension
Reduces urethral
resistance
Used mostly for benign
prostatic hyperplasia
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Contraindication
Urinary
Obstruction
Glaucoma
Glaucoma
Bowel and Bladder
b. Implement bladder management techniques:
Intermittent Catherizations
1. Empty bladder at regular intervals
2. Monitor fluid intake relative to cathed amounts and adjust
accordingly
3. Incorporate bladder-triggering techniques to facilitate
bladder emptying before catheterizations
a. Suprapubic stimulation for patients with UMN
lesions (tapping suprapubic area, pulling pubic
hairs, stroking medial thighs)
b. Valsalva maneuver for patients with LMN lesions
(lean forward, strain or bear down, hold one’s
breath)
c. Crede maneuver for LMN lesions only (manual
expression of bladder by pressing firmly just below
the umbilical area)
4. Teach patient/family clean technique for home and longterm use.
Reflex Voiding
This is when the bladder empties due to reflex
contraction that is not controlled by the patient. This
involves a condom catheter placed over the penis to collect
urine into a drainage bag for males. Females would reflex
into a diaper.
Residual urine should be monitored by BVI (Bladder
scanning) or post void catheterization.
Indwelling Catheter or Suprapubic tube
1. Only as last resort
2. Use aseptic technique and proper perineal hygiene
Behavioral strategies
For patients with uninhibited or sensory paralytic bladders:
1. Timed voiding (toileting patient at regular 2- to 3-hour
intervals)
2. Prompted voiding (reminders to void on a regular
schedule) -teaches the patient to take responsibility for
toileting
3. Habit training (individualizing a toileting schedule to
patient’s voiding pattern)
4. Pelvic muscle (Kegel) exercises (strengthens
pubococcygeal muscle)-helps with stress and urge
incontinence
c. Expected outcomes:
Client achieves an acceptable level of continence
Client and family follows a bladder management program
consistent with lifestyle
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Client verbalizes knowledge of medications related to bladder
management program
Client demonstrates, as applicable, the ability to care for
indwelling or intermittent catheterization or external urinary
collection devices and perineal/periurethral skin
Urinary Retention
Interventions:
1. Initiate a bladder management program with a combination of the following
techniques depending on cause of retention (see previous descriptions)
a. Timed voiding schedule with intermittent catheterizations for post void
residual (for mild-to-moderate outlet obstruction)
b. Double voiding: patient is taught to void, wait a few minutes, and then
void again (for mild-to-moderate outlet obstruction)
c. Distribute fluids during waking hours
d. Intermittent catheterization program
e. Triggering techniques
f. Teach and administer medications as ordered, monitor response
g. Indwelling catheter as a last resort
h. Teach patient/family symptoms and treatment of acute urinary
retention
Relax by sitting in warm tub of water or standing in warm
shower
Drink warm liquids
Seek emergency care if necessary
Teach patient with prostatic outlet obstruction to avoid factors
that can precipitate an episode of acute urinary retention
o Alcohol consumption
o Cold medicines
o Antidepressant or anticholinergic medications
2. Expected outcomes:
a. Client achieves complete bladder emptying by using appropriate
bladder management techniques
b. Client verbalizes signs and symptoms of urinary retention and actions
to take when it occurs
c. Client verbalizes signs and symptoms of urinary tract infection and the
actions to take when these occur
d. Client verbalizes knowledge of prescribed medications and their side
effects
e. Client demonstrates correct bladder management techniques, as
appropriate (intermittent caths, triggering, etc.)
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Bowel and Bladder
High Risk of Urinary Tract Infection
Risk Factors:
1. Urinary retention
2. Indwelling catheter
3. Urinary calculi
4. Neurogenic bladder
5. Poor personal hygiene
6. Any surgery or trauma to the GU tract
Interventions:
1. Ensure adequate fluid intake (at least 2,500-3,500 cc/day) unless
contraindicated
2. Encourage acidic fluids (cranberry juice, apple juice, grape juice)
3. Eliminate residual urine by facilitating urine outflow through various
techniques (see previous descriptions)
Double voiding
Valsalva maneuver
Suprapubic tapping
Crede maneuver (use only if there is LMN damage and there
is no evidence or history of reflux)
Intermittent caths
4. Monitor residual urine
5. Maintain sterile technique when catheterizing
6. Implement measures to prevent or reduce exposure to infectious
agents
Good hand hygiene
Using aseptic technique
Avoiding use of indwelling catheters
Maintaining closed drainage systems when indwelling
catheters are necessary
Administering anti-infective medications
7. Instruct patient on signs and symptoms of urinary tract infection
Expected outcomes:
Client is free of symptoms of UTI
Client verbalizes signs and symptoms of UTI and follows measures to
prevent and/or reduce infection.
References:
Jacelon,Cynthia. (Ed.). (2011). The Specialty Practice of Rehabilitation Nursing: A
Core Curriculum (6th ed.). Glenview, IL: Association of Rehabilitation Nurses.
Smith. Sandra.F, 2008. Clinical Nursing Skills 7th edition Upper Saddle River, N.J.
Pearson Prentice Hall.
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Bowel and Bladder
JOB AID
• Continence is the #1 predictor of discharge disposition in rehab patients
• Exercises that strengthen pubococcygeal muscles are found to be
helpful with urinary incontinence, particularly for women who have had
multiple childbirths.
• Loss of control of bowel and urinary elimination can lead to
embarrassment, shame and isolation
• In rehabilitation, we most commonly see patients with bladder or bowel
dysfunction related to neurological damage
• Differentiating between upper and lower motor neuron involvement is
essential to determine the nature and extent of bladder and bowel
dysfunction
• When initiating a bowel program, it is very important to begin with a
clean bowel. The lower colon must be free from impacted feces
• Although many patients have a combination of symptoms and factors
that complicate treatment of urinary incontinence, there are three broad
types of incontinence: urge, stress, and overflow
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Bowel and Bladder
Posttest
Name: _____________________________________________
Date: ______________________________________________
1. With uninhibited neurogenic bladder, the neurologic disruption is present at the
level of
a.
b.
c.
d.
The ascending sensory tracts
Sensory and motor branches of S2, S3, and S4
The cerebral cortex
The posterior columns
2. Which of the following type of urinary incontinence is more common in men than
in women?
a.
b.
c.
d.
Stress incontinence
Overflow incontinence
Urge incontinence
Neurologic incontinence
3. Which of the following medications may be useful to increase contractility of the
detrusor muscle?
a.
b.
c.
d.
Dibenzyline
Bethanechol
Imipramine
Mandelamine
4. Kegel exercises are thought to be helpful for which of the following types of
incontinence?
a.
b.
c.
d.
Stress
Urge
Functional
Stress and Urge
5. What percentage of men and women living in nursing homes are incontinent of
urine at least once daily?
a.
b.
c.
d.
30% of women and 15% of men
25% of women and 10% of men
50% of both women and men
80% of both women and men
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Bowel and Bladder
6. A bowel program should not be changed more often than
a.
b.
c.
d.
every day
every 3-5 days
every 8 days
every 10 days
7. Digital stimulation would most likely be used as a component of a bowel routine
for a client with a
a.
b.
c.
d.
spinal cord injury at S2
traumatic brain injury
spinal cord injury at C3
stroke
8. Poor abdominal muscle tone can contribute to
a.
b.
c.
d.
fecal incontinence
loose stools
constipation
Both a and c
9. When initiating a bowel program, it is important to begin with
a.
b.
c.
d.
a clean bowel
a period of constipation
the client’s awareness of the urge to defecate
an empty bladder
10. Continence is the number one predictor of discharge disposition in the
rehabilitation setting.
a. True
b. False
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