Beverley-Travis Natural Laxative Mixture Ingredients

Continence Care

Episode 1 Liquid

1. Beverley-Travis Natural Laxative Mixture Ingredients

1 cup raisins 1 cup pitted prunes 1 cup figs 1 cup dates 1 cup currants 1 cup prune concentrate Directions

Combine contents together in grinder or blender to a thick- ened consistency. Store in refrigerator between uses.

Dosage

Administer 2 tablespoons (tbs) twice a day (once in the morning and once in the evening). May increase or de- crease according to the frequency of bowel movements.

Nutritional Composition

Each 2-tbs dose contains the following:

61 calories 137 mg potassium 8 mg sodium 11.9 g sugar 0.5 g protein 1.4 g fiber 2. Power Pudding Ingredients

1 cup wheat bran 1 cup applesauce 1 cup prune juice Directions

Mix and store in refrigerator. Start with administration of 1 tbs/day. Increase slowly until desired effect is achieved and no disagreeable symptoms occur.

BOX

10-7

Natural Laxative Recipes

From Hale E, Smith E, St. James J, et al: Pilot study of the feasibility and effectiveness of a natural laxative mixture, Geriatr Nurs 28(2):104-111, 2007.

SAFETY ALERT

Sodium phosphate enemas (Fleets) should not be used because they may lead to severe metabolic disorders associated with high mortality and morbidity (Ori et al., 2012). Oil retention enemas are used for refractory consti- pation and in the treatment of fecal impaction.

A program to prevent as well as treat constipation that incorporates a high-fiber diet, liberal fluid intake, daily exercise, and environmental modifications that promote a regular pattern of bowel elimination must be developed for each client. Interventions in any setting are based on a thorough assessment. Assessment and management of bowel function are an important nursing responsibility.

Fecal Incontinence

Fecal incontinence (FI) is defined as “continuous or recur- rent uncontrolled passage of fecal material for at least one month in a mature person” (Stevens & Palmer, 2007).

Estimates are that more than 6.5 million Americans have fecal incontinence. Accurate estimates are difficult to obtain because many people are reluctant to discuss this disorder and many primary care providers do not ask about it. Prevalence varies with the study population: 2% to 17%

in community-dwelling older people, 50% to 65% in older adults in nursing homes, and 33% in hospitalized older adults. Fecal incontinence is a significant risk factor for nursing home placement. Higher prevalence rates are found among patients with diabetes, irritable bowel syn- drome, stroke (new onset, 30%; 15% at three years post- stroke), multiple sclerosis, and spinal cord injury (Roach &

Christie, 2008; Grover et al., 2010).

Often FI is associated with urinary incontinence and as many as 50% to 70% of patients with UI also carry the diagnosis of FI. FI can be transient (episodes of diarrhea, acute illness, fecal impaction) or persistent. Fecal inconti- nence, like urinary incontinence, has devastating social ramifications for the individuals and families who experi- ence it. UI and FI share similar contributing factors, in- cluding damage to the pelvic floor as a result of surgery or trauma, neurological disorders, functional impairment, im- mobility, and dementia.

Implications for Gerontological Nursing and Healhty Aging

Assessment

Assessment should include a complete client history as in urinary incontinence (described earlier in this chapter) and investigation into stool consistency and frequency, use of laxatives or enemas, surgical and obstetrical history, medi- cations, effect of FI on quality of life, focused physical ex- amination with attention to the gastrointestinal system, and a bowel record. A digital rectal examination should be performed to identify any presence of a mass, impaction, or occult blood.

Interventions

Nursing interventions are aimed at managing and/or re- storing bowel continence. Therapies similar to those used to treat urinary incontinence such as environmental ma- nipulation (access to toilet), diet alterations, habit-training schedules, improving transfer and ambulation ability,

sphincter-training exercises, biofeedback, medications, and/or surgery to correct underlying defects are effective.

Keeping accurate bowel records and identifying trig- gers that influence incontinence are important. For exam- ple, eating a meal stimulates defecation 30 minutes after completion of the meal, or defecation occurs after the morning cup of coffee. If the fecal incontinence occurs only once or twice each day, it can be controlled by being prepared. Placing the individual on the toilet, com- mode, or bedpan at a given time after the trigger event facilitates defecation in the appropriate place at the appropriate time (see Box 10-6). The judicious use of non- irritant laxatives can help to maintain bowel function and prevent constipation.

The effectiveness of interventions in fecal incontinence will be self-evident but will take time. As in the treatment of urinary incontinence, goals must be realistic. It cannot be stated too often or too strongly that the nurse must always provide immaculate skin care to persons with incontinence, because self-esteem and skin integrity depend on it.

Application of Maslow’s Hierarchy

Meeting elimination needs is basic to the maintenance of biological and physiological integrity, but its importance reaches far higher on the hierarchy. Often nurses are key to ensuring that these basic needs are met. Inadequate atten- tion to this basic need can cause excess disability and inse- curity, affect safety, cause social isolation and curtailment of meaningful activities and relationships, and interfere with the ability of the older person to achieve a meaningful and fulfilling life.

KEY CONCEPTS

• Urinary incontinence is not a part of normal aging. UI is a symptom of an underlying problem and calls for thorough assessment.

• Urinary incontinence can be minimized or cured, and there are many therapeutic modalities available for treatment of UI that nurses can implement.

• Health promotion teaching, identification of risk factors, comprehensive assessments of UI, education of informal and formal caregivers, and use of evidence-based inter- ventions are basic continence competencies for nurses.

• A number of interventions for urinary incontinence are applicable to the management of bowel incontinence.

ACTIVITIES AND DISCUSSION QUESTIONS

 1. Discuss risk factors for UI in older adults.

 2. Conduct a UI history with a partner or with an older adult.

Juthani-Mehta M, Quagliarello V, Perrelli E, et al: Clinical features to identify urinary tract infection in nursing home residents: a cohort study, J Am Geriatr Soc 57: 963, 2009.

Lawhorne L, Ouslander J, Parmelee P, et al: Urinary incontinence:

a neglected geriatric syndrome in nursing facilities, J Am Med Dir Assoc 9(1):9–35, 2008.

Lewis SJ, Heaton KW: Stool Form Scale as a useful guide to in- testinal transit time, Scand J Gastroenterol 32:920, 1997.

MacDonald C, Butler L: Silent no more: elderly women’s stories of living with urinary incontinence in long-term care, J Gerontol Nurs 33(1):14–20, 2007.

Mason DJ, Newman DK, Palmer MH: Changing UI practice, Am J Nurs 3(Suppl):2–3, 2003.

Mouton C, Adenuga B, Vijayan J: Urinary tract infections in long-term care, Ann Longterm Care 18:35, 2010.

Muller N: What Americans understand and how they are affected by bladder control problems: highlights of recent nationwide consumer research, Urol Nurs 25(2):109–115, 2005.

Newman DK, Palmer MH, editors: The state of the science on urinary incontinence, Am J Nurs 3(Suppl):1–58, 2003.

Ori Y, Rozen-Zvi B, Chagnac A, et al: Fatalities and severe meta- bolic disorders associated with use of sodium phosphate enemas, Arch Intern Med 172(3):263–265, 2012.

Osei-Boamah E, Chui J, Diaz C, et al: Constipation in the hospi- talized older patient. Clinical Geriatrics 20(10):20–26, 2012.

Palmer MH, Newman D: Bladder control educational needs of older adults, J Gerontol Nurs 32(10):28–32, 2006.

Roach M, Christie J: Fecal incontinence in the elderly, Geriatrics 63(2):13–22, 2008.

Robinson JP, Shea JA: Development and testing of a measure of health-related quality of life for men with urinary inconti- nence, J Am Geriatr Soc 50(5):935–945, 2002.

Shamliyan T, Wyman J, Bliss DZ, et al: Prevention of fecal and urinary incontinence in adults, Rockville, MD, 2007, Agency for Healthcare Research and Quality.

Shamliyan T, Wyman J, Kane RL: Nonsurgical treatments for urinary incontinence in adult women: diagnosis and comparative effective- ness (2012). Available at www.effectivehealthcare.ahrq.gov/

reports/final.cfm.

Stevens T, Palmer R: Fecal incontinence in LTC patients, LTC Clin Interface 8(4):35–39, 2007.

Tettamanti G, Altman D, Pedersen NL, et al: Effects of coffee and tea consumption on urinary incontinence in female twins, BJOG An International Journal of Obstetrics and Gynaecology 2011.

Townsend M, Curhan G, Resnik N, et al: Rates of remission im- provement, and progression of urinary incontinence in Asian Black, and white women, Am J Nurs 111(4):26–33, 2011.

Zarowitz B, Ouslander J: The applications of evidence-based principles of care in older persons (issue 6): urinary inconti- nence, J Am Med Dir Assoc 8:35, 2007.

REFERENCES

Agency for Healthcare Research and Quality: Experts seek better diagnosis and treatment for women’s urinary incontinence and chronic pelvic pain, AHRQ Research Activities 383, 2012.

Barry MJ, Meleth S, Lee JY, et al: Effect of increasing doses of saw palmetto extract on lower urinary tract symptoms: a random- ized trial, JAMA 28 (305):1344–1351, 2011.

Barton C, Sklenicka J, Sayegh P, et al: Contraindicated medica- tion use among patients in a memory disorders clinic, Am J Geriatr Pharmacother 6(3):147–152, 2008.

Bucci A: Be a continence champion: use the CHAMMP tool to individualize the plan of care, Geriatr Nurs 28(2):120–124, 2007.

DeMaagd G: Urinary incontinence: treatment update with a focus on pharmacological management (2007). Available at http://www.

uspharmacist.com/content/d/feature/c/10310/.

Dowling-Castronovo A, Bradway C: Urinary incontinence. In Boltz M, Capezuti E, Fulmer T, et al, editors: Evidence-based geriatric nurs- ing protocols for best practice, New York, 2012, Springer.

Dowling-Castronovo A, Spiro E: Urinary incontinence assessment in older adults: Part I—Transient urinary incontinence (2013).

Available at http://consultgerirn.org/uploads/File/trythis/

issue11-1.pdf.

Dowling-Castronovo A, Spiro E: Urinary incontinence assessment in older adults: Part II—Established urinary incontinence (2008). Available at http://consultgerirn.org/uploads/File/

trythis/issue11-2.pdf.

DuBeau CE: Therapeutic/pharmacologic approaches to urinary incontinence in older adults, Clinical Pharmacology 85:98, 2009.

Fink HA, Taylor BC, Tacklind JW, et al: Treatment interventions in nursing home residents with urinary incontinence: a systematic review of randomized trials, Mayo Clin Proc 83(12):

1332–1343, 2008.

Genato L, Buhr W: Urinary tract infections in older adult residing in long-term care facilities, Ann Longterm Care 20(4):33–38, 2012.

Grover M, Busby-Whitehead J, Palmer MH, et al: Survey of geriatricians on the effect of fecal incontinence on nursing home referral, J Am Geriatr Soc 58:1058, 2010.

Ham R, Sloane P, Warshaw G, et al: Primary care geriatrics: a case- based approach, ed 4, St. Louis, 2007, Mosby.

Inelmen E, Giuseppe S, Giuliano E: When are indwelling catheters appropriate in elderly patients? Geriatrics 62(10):18–22, 2007.

Johnson T, Ouslander J: The newly revised F-Tag 315 and sur- veyor guidance for urinary incontinence in long-term care, J Am Med Dir Assoc 7(9):594–600, 2006.

 3. What measures can be taken to cure or decrease urinary incontinence in the community and long-term care settings?

 4. Devise a nursing care plan for an older adult with urinary incontinence or fecal incontinence.

T H E L I V E D E X P E R I E N C E

You know, I never get a decent night’s sleep. I wake up at least 4 times every night, and I just know I won’t get back to sleep. I really don’t want to keep taking pills for sleep, but when I lie there awake, I just think of all the difficult times and situations I can’t manage. After a while, I’m really in a stew about everything.

Richard, a 67-year-old recent retiree This is really beginning to tire me out. Richard keeps waking me at night because he can’t sleep. I try to tell him to get up and read or something. I really need my sleep if I’m going to get to work on time. I wonder if Richard needs to see a doctor. Maybe he is depressed about being retired and alone while I’m at work. I’ll talk to him about it.

Clara, Richard’s wife

G L O S S A R Y

Circadian rhythm ​Regular​recurrence​of​certain​phenomena​in​cycles​of​approximately​24​hours.

Insomnia ​Disturbed​sleep​pattern​in​presence​of​adequate​opportunity​and​circumstances​for​sleep.

Non–rapid eye movement (NREM) sleep ​First​four​stages​of​sleep.

Obstructive sleep apnea ​Repetitive​cessation​(.10​seconds)​of​respiration​during​sleep.

Rapid eye movement (REM) sleep ​Wakeful​and​active​form​of​sleep​during​which​dreaming​occurs​or​

tension​is​discharged.

L E A R N I N G O B J E C T I V E S

Upon completion of this chapter, the reader will be able to:

• Identify​age-related​changes​that​affect​rest,​sleep,​and​activity.

• Discuss​the​importance​of​sleep​and​activity​to​the​health​and​well-being​of​older​adults.

• Describe​the​beneficial​effects​of​exercise​and​appropriate​exercise​regimens​for​older​adults.

• ​Use​evidence-based​protocols​in​assessment​and​development​of​interventions​for​rest,​sleep,​and​

promotion​of​activity.

R

est,​sleep,​and​activity​depend​on​one​another.​Inad- equacy​of​rest​and​sleep​affects​any​activity,​whether​​

​it​is​considered​strenuous​exertion​or​falls​under​the​

heading​of​the​activities​of​daily​living.​Activity,​in​turn,​is​

necessary​ to​ maintain​ physical​ and​ physiological​ integrity​

(e.g.,​ cardiopulmonary​ endurance​ and​ function;​ musculo-​

skeletal​strength,​agility,​and​structure)​and​it​helps​a​person​

obtain​ adequate​ sleep.​ Rest,​ sleep,​ and​ activity​ contribute​

greatly​to​overall​physical​and​mental​well-being.

Rest and Sleep

The​human​organism​needs​rest​and​sleep​to​conserve​en- ergy,​ prevent​ fatigue,​ provide​ organ​ respite,​ and​ relieve​

evolve.elsevier.com/Ebersole/gerontological

Rest, Sleep, and Activity

Theris A. Touhy

11

CHAPTER

169

tension.​Sleep​is​an​extension​of​rest,​and​both​are​physio- logical​and​mental​necessities​for​survival.​Sleep​is​a​basic​

need.​Rest​occurs​with​sleep​in​sustained​unbroken​periods.​

Sleep​occupies​a​third​of​our​lives​and​is​a​vital​function​and​

basic​need.​Sleep​deprivation​and​fragmentation​of​sleep​in​

older​adults​may​adversely​affect​cognitive,​emotional,​and​

physical​functioning​as​well​as​quality​of​life​(Martin​et​al.,​

2010;​Teodorescu​&​Husain,​2010).​Because​of​the​public​

health​burden​of​chronic​sleep​loss​and​sleep​disorders,​and​

the​low​awareness​of​poor​sleep​health,​Healthy People 2020 includes​sleep​health​as​a​special​topic​area.​Goals​for​adults​

are​presented​in​the​Healthy​People​box.

movement​ (REM)​ sleep​ and​ non–rapid​ eye​ movement​

(NREM)​ sleep.​ Sleep​ structure​ is​ shown​ in​Box​ 11-1.​

Most​ of​ the​ changes​ in​ sleep​ architecture​ in​ healthy​

adults​begin​between​the​ages​of​40​and​60​years.​The​

age-related​ changes​ include​ less​ time​ spent​ in​ stages​​

3​ and​ 4​ sleep​ and​ more​ time​ spent​ awake​ or​ in​ stage​​

1​sleep.​Declines​in​stage​3​and​4​sleep​begin​between​​

20​and​30​years​of​age​and​are​nearly​complete​by​the​age​

of​ 50​ to​ 60​ years.​The​ amount​ of​ deep​ sleep​ in​ stages​​

3​and​4​contributes​to​how​rested​and​refreshed​a​person​

feels​ the​ next​ day.​ Time​ spent​ in​ REM​ sleep​ also​​

declines​with​age,​and​transitions​between​stages​1​and​

2​ are​ more​ common.​ The​ changes​ that​ occur​ in​ sleep​

with​aging​are​summarized​in​Box​11-2.

Biorhythm and Sleep

Our​lives​proceed​in​a​series​of​rhythms​that​influence​and​

regulate​ physiological​ function,​ chemical​ concentrations,​

performance,​behavioral​responses,​moods,​and​the​ability​to​

adapt.​Biorhythms​vary​between​individuals​and​age-related​

changes​in​biorhythms​(circadian​rhythms)​are​relevant​to​

health​and​the​process​of​aging.​With​aging,​there​is​a​reduc- tion​in​the​amplitude​of​all​circadian​endogenous​responses​

(e.g.,​ body​ temperature,​ pulse,​ blood​ pressure,​ hormonal​

levels).​ The​ most​ important​ biorhythm​ is​ the​ circadian​

sleep-wake​ rhythm.​ As​ people​ age,​ the​ natural​ circadian​

rhythm​may​become​less​responsive​to​external​stimuli,​such​

as​changes​in​light​during​the​course​of​the​day.

Sleep and Aging

The​ predictable​ pattern​ of​ normal​ sleep​ is​ called​ sleep​​

architecture.​The​body​progresses​through​the​five​stages​

of​ the​ normal​ sleep​ pattern​ consisting​ of​ rapid​ eye​​ Adapted from Beers MH, Berkow R: The Merck manual of geriatrics, ed 3, Whitehouse Station, NJ, 2000, Merck Research Laboratories.

Four Stages of Non–Rapid Eye Movement (NREM) Sleep

Stage 1 Lightest level Easy to awaken

Comprises 5% of sleep in young Stage 2

Decreases with age

Low-voltage activity on electroencephalogram (EEG) May cease in old age

Stage 3

Decreases with age High-voltage activity on EEG May cease in old age Stage 4

Decreases with age High-voltage activity on EEG Comprises 15% of sleep in elders Rapid Eye Movement (REM) Sleep

Alternates with NREM sleep throughout the night Rapid eye movements are the key feature Breathing increases in rate and depth Muscle tone relaxed

85% of dreaming occurs in REM sleep BOX

11-1

Sleep Structure

HEALTHY PEOPLE 2020

Sleep Health Goals:

• Increase public knowledge of how adequate sleep and treatment of sleep disorders improve health, productivity, wellness, quality of life, and safety on roads and in the workplace.

• Increase the proportion of persons with symptoms of obstructive sleep apnea who seek medical evaluation.

• Increase the proportion of adults who get sufficient sleep.

From U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion: Healthy people 2020 (2012). Available at http://www.healthypeople.gov/2020.

Older​adults​with​good​general​health,​positive​moods,​

and​engagement​in​more​active​lifestyles​and​meaningful​

activities​ report​ better​ sleep​ and​ fewer​ sleep​ complaints.​

Results​of​a​recent​large​study​of​155,877​participants​ex- ploring​the​prevalence​of​sleep-related​complaints​across​

age​ groups​ found​ that​ on​ average,​ older​ adults​ reported​

sleeping​better​than​younger​adults.​Sleep​complaints​are​

usually​linked​to​other​health​problems​and​sleep​disor- ders.​Poor​sleep​is​not​an​inevitable​consequence​of​aging​

but​rather​an​indicator​of​health​status​and​calls​for​inves- tigation​(Grandner​et​al.,​2012).

Sleep Disorders Insomnia

Insomnia​is​defined​as​“a​complaint​of​disturbed​sleep​in​

the​presence​of​an​adequate​opportunity​and​circumstance​

for​ sleep”​ (Bloom​ et​ al.,​ 2009,​ p.​ 6).​ The​ diagnosis​ of​

insomnia​ requires​ that​ the​ person​ has​ difficulty​ falling​

asleep​for​at​least​1​month​and​that​impairment​in​daytime​

functioning​ results​ from​ difficulty​ sleeping.​ Insomnia​ is​

classified​as​either​primary​or​comorbid.​Primary​insomnia​

implies​that​no​other​cause​of​sleep​disturbance​has​been​

identified.​ Comorbid​ insomnia​ is​ more​ common​ and​ is​

associated​with​psychiatric​and​medical​disorders,​medica- tions,​and​primary​sleep​disorders,​such​as​obstructive​sleep​

apnea​or​restless​legs​syndrome.​Comorbid​insomnia​does​

not​suggest​that​these​conditions​cause​insomnia​but​that​

insomnia​and​the​other​conditions​co-occur​and​each​may​

require​attention​and​treatment​(Bloom​et​al.,​2009).​In- somnia​ has​ a​ higher​ prevalence​ in​ older​ adults​ and​​

there​are​many​influencing​factors,​both​physiological​and​

behavioral​(Box​11-3).

Prescription​and​nonprescription​medications​also​cre- ate​sleep​disturbances.​Drugs​and​alcohol​use​are​thought​

to​ account​ for​ 10%​ to​ 15%​ of​ cases​ of​ insomnia​ (Ham​

et​ al.,​ 2007).​ Problematic​ drugs​ include​ serotonin​ reup- take​inhibitors​(SSRIs),​antihypertensives​(clonidine,​beta​

blockers,​reserpine,​methyldopa),​anticholinergics,​sympa- thomimetic​ amines,​ diuretics,​ opiates,​ cough​ and​ cold​

medications,​ thyroid​ preparations,​ phenytoin,​ cortisone,​

and​levodopa.​The​times​of​day​that​medications​are​given​

can​ also​ contribute​ to​ sleep​ problems—for​ example,​ a​​

diuretic​given​before​bedtime​or​sedating​medication​given​

in​the​morning​(Rose​&​Lorenz,​2010).

Sleep Apnea

Sleep​apnea​is​a​condition​in​which​people​stop​breathing​

while​ asleep.​ Apneas​ (complete​ cessation​ of​ respiration)​

Adapted from Subramanian S, Surani S: Sleep disorders in the elderly, Geriatrics 62(12):10-32, 2007.

• More time spent in bed awake before falling asleep

• Total sleep time and sleep efficiency are reduced

• Awakenings are frequent, increasing after age 50 (.30 minutes of wakefulness after sleep onset in .50% of older subjects)

• Daytime napping

• Changes in circadian rhythm (early to bed, early to rise)

• Sleep is subjectively and objectively lighter (more stage 1, little stage 4, more disruptions)

• Rapid eye movement (REM) sleep is short, less intense, and more evenly distributed.

BOX

11-2

Age-Related Sleep Changes

BOX

11-3

Factors Contributing to Sleep Problems in Older Adults

BPH, Benign prostatic hyperplasia; CNS, central nervous system; GI, gastro- intestinal; GERD, gastroesophageal reflux disease; PUD, peptic ulcer disease.

Adapted from Subramanian S, Surani S: Sleep disorders in the elderly, Geriatrics 62(12):10-32, 2007.

• Age-related changes in sleep architecture

• Comorbidities (cardiovascular disease, diabetes, pulmonary disease, musculoskeletal disorders), CNS disorders (Parkinson’s disease, seizure disorder, dementia), GI disorders (hiatal hernia, GERD, PUD), urinary disorders (incontinence, BPH)

• Depression, anxiety, delirium, psychosis

• Pain

• Polypharmacy

• Life stressors

• Limited exposure to sunlight

• Environmental noises, institutional routines

• Poor sleep hygiene

• Lack of exercise

• Excessive napping

• Caregiving for a dependent elder

• Sleep apnea

• Restless legs syndrome

• Periodic leg movement

• Rapid eye movement behavior disorder

• Alcohol

• Smoking