Urinary incontinence and Nursing Care Strategies
UI In Old Age as Health Care Issue
Despite evidence supporting urinary incontinence (UI) management strategies ( DuBeau et al., 2010, Fantl et al., 1996), nursing staff and laypersons often use containment strategies, such as adult briefs or other absorbent products, to manage UI.
In addition, individuals with Ul erroneously believe that containing UI is a normal consequence of aging (Bush, Castelluci , & Phillips, 2001; Dowd, 1991; Kinchen et al., 2003; Milne, 2000; Mitteness , 1987a, 1987b), feel that UI is a difficult-to-discuss personal problem (Bush et al., 2001), and prefer self-help strategies rather than seeking professional advice (Milne, 2000).
Personal care strategies are often the result of information gained through lay media and personal contacts, not necessarily from health care professionals (Cochran, 2000; Jeter & Wagner, 1990; Miller, Brown, Smith, & Chiarelli, 2003; Milne, 2000).
In comparison to nurses in other health care settings, nurses in hospitals view incontinent patients more negatively ( Vinsnes , Harkless, Haltbakk , Bohm, &Hunskaar , 2001).
Therefore, attitudes and beliefs regarding Ul are important for the nurse
to consider in an effort to best assess and manage UI.
Background and Statement of Problem
Ul affects more than 17 million adults in the United States and is most often defined as the involuntary loss of urine sufficient to be a problem ( Fantl et al., 1996; National Association for Continence, 1998; Resnick &Ouslander , 1990).
Prevalence and incidence rates of UI are viewed cautiously due to inconsistencies with definitions and measurements of both these epidemiological statistics.
In addition, variable or poorly articulated UI definitions (Abrams et al., 2003; Palmer, 1988) as well as underreporting and underassessment of UI (Schultz, Dickey, &Skoner , 1997) in the hospital setting can render data of questionable reliability.
Prevalence of Ul in community-dwelling adult populations ranges from 8% to 46% (Anger, Saigal, & Litwin, 2006; Diokno, Brock, Brown, & Herzog, 1986; Du Moulin, Hamers , Ambergen , Janssen , &Halfens , 2008 ; Herzog & Fultz, 1990; TM Johnson et al., 1998; Lee, Cigolle , &Blaum , 2009).
For individuals with dementia, UI prevalence rates range from 11% to 90%; higher prevalence rates reflect institutionalized cognitively impaired older adults (Brandeis, Baumann, Hossain, Morris, & Resnick, 1997; Skelly & Flint, 1995).
Although the highest prevalence rate occurs in institutionalized older adults, 15%-53% of home bound older adults and 10%-42% of older adults admitted to acute care also suffer from UI (Dowd & Campbell, 1995; Fantl et al. , 1996 ; McDowell et al., 1999; Palmer, Bone, Fahey, Mamon , &Steinwachs , 1992; Schultz et al., 1997).
Twelve percent to 36% of older hospitalized adults develop acute UI (eg,
new-onset UI, meaning that these individuals were continent on hospital
admission; Kresevic, 1997; Sier , Ouslander , &Orzeck , 1987); for patients
undergoing hip surgery, the incidence of acute Ul ranges from 19% to 32%
(Palmer, Baumgarten, Langenberg , & Carson, 2002; Palmer, Myers,
&Fedenko , 1997).
In addition to being a common geriatric syndrome, UI significantly affects health-related quality of life (HRQOL; DuBeau , Simon, & Morris, 2006; Shumaker, Wyman, Uebersax , McClish , &Fantl , 1994). The consequences of UI may be characterized physically, psychosocially, and economically.
For example, an episode of urge UI occurring once a week, or more frequently, has been associated with falls or fracture (Brown, Sawaya , Thom, & Grady, 2000; Chiarelli, Mackenzie, &Osmotherly , 2009; Hasegawa. Kuzuya , & Iguchi, 2010).
Other physical consequences associated with UI include skin irritations or infections, urinary tract infections (UTIs), pressure ulcers, and limitation of functional status ( Fantl et al., 1996; TM Johnson et al., 1998).
UI is associated with psychological distress (Bogner et al., 2002) including depression, poor self-rated health, and social isolation or condition-specific functional loss (Bogner et al., 2002; Fantl et al., 1996: TM Johnson et al., 1998), and poststroke UI is risk factor for poor outcomes (Pettersen, Saxby, &Wyller , 2007).
Therefore, it is essential that nurses
assess and treat UI when addressing other health problems such as depression or
falls.
Although there is conflicting evidence regarding the role of UI as a predictor for nursing home placement.
Ul has been identified as a marker of frailty in community dwelling older adults (Holroyd-Leduc, Mehta, &Covinsky , 2004) and a predictor of 1-year mortality among older adults hospitalized for an acute myocardial infarction ( Krumholz , Chen, Chen, Wang, & Radford, 2001).
The negative psychosocial impact of Ul affects not only the individual but also family caregivers (CGs; Brittain & Shaw, 2007; Cassells & Watt, 2003; Gotoh et al., 2009). Economically, the total direct cost for all incontinent individuals is estimated to be more than $16 billion annually in the United States (Landefeld et al., 2008; Wilson, Brown, Shin, Luc, &Subak , 2001: Wyman, 1997).
Nurses are in a key position to identify and treat UI, a quality indicator ("Assessing Care," 2007), in hospitalized older adults. This chapter reviews the etiologies and consequences of UI, with emphasis on the most common types of Ul encountered in the acute care setting.
Assessment parameters and care strategies for UI are highlighted and a nursing standard of practice protocol focused on comprehensive assessment and management of UI for hospitalized older adults is included.
Assessment
Adverse physiological consequences of UI commonly encountered in acute care settings include an increased potential for UTIs and indwelling urinary catheter use, dermatitis, skin infections, and pressure ulcers ( Sier et al., 1987). Moreover, UI that results in functional decline predisposes older individuals to complications associated with bed rest and immobility (Harper & Lyles, 1988).
Etiologies of Urinary Incontinence
Continence is a complex, multidimensional phenomenon influenced by anatomical, physiological, psychological, and cultural factors (Gray, 2000).
Thus, continence requires intact lower urinary tract function, as well as cognitive and functional ability to recognize voiding signals and use a toilet or commode, the motivation to maintain continence, and an environment that facilitates the process ( Jirovec , Brink, & Wells , 1988 ).
Physiologically. continence is a result of urethral pressure being equal to or greater than bladder pressure (CP Hodgkinson, 1965), of which angulation of the urethra, supported by pelvic muscles, plays a role (Delancey, 1994, 2010).
Continence also requires the ability to suppress auto-contractility of the detrusor (CP Hodgkinson, 1965). Micturition (urination) involves voluntary as well as reflexive control of the bladder, urethra, detrusor muscle, and urethral sphincter.
When the bladder volume reaches approximately 400 ml, stretch receptors in the bladder wall send a message to the brain and an impulse for voiding is sent back to the bladder. The detrusor muscle then contracts and the urethral sphincter relaxes to allow urination (Gray, Rayome , & Moore, 1995).
Normally, the micturition reflex can be voluntarily inhibited (at least for a time) until an individual desires to void or finds an appropriate place for voiding. Ul occurs as the result of a disruption at any point during this process. For a comprehensive review, Gray (2000) provided a detailed analysis of voiding physiology.
Common age-associated changes,
including a decrease in bladder capacity, benign prostatic hyperplasia (BPH) in
men, and menopausal loss of estrogen in women, can affect lower urinary tract
function and predispose older individuals to UI (Bradway & Yetman , 2002 )
. Despite these aging changes, UI is not considered a normal consequence of
aging.
The two major types of UI are transient (or acute/reversible) and established (or chronic/persistent; Newman & Wein, 2009). Transient UI is characterized by the sudden onset of potentially reversible symptoms.
Causes of transient Ul include delirium, infections (eg untreated UTI), atrophic vaginitis, urethritis, pharmaceuticals, depression or other psychological disorders that affect motivation or function, excessive urine production, restricted mobility, and stool impaction or constipation (eg, that creates additional pressure on the bladder and can cause urinary urgency and frequency).
Hospitalized older adults are at risk of developing transient Ul . Complicated by shorter hospital stays, these individuals may also be at risk of being discharged without resolution of transient UI and, thus, urine leakage persists and may become established Ul .
However, transient Ul is often preventable, or at least reversible (eg, transient Ul precipitated by a UTI that resolves with successful treatment, or acute Ul related to diuretic therapy for heart failure exacerbation), if the underlying cause for the UI is identified and treated (Ding &Jayaratnam , 1994; Fantl et al., 1996; Palmer, 1996).
Kresevic (1997) reported that hospitalized older adults with new-onset Ul were more likely to be on bed rest, restrained, depressed, dehydrated, malnourished , and dependent in ambulation when compared with their continent counterparts.
Furthermore, the relative risk of developing new-onset Ul was twofold for older adults with depression (OR = 2.28), malnutrition (OR = 2.29), and dependent ambulation (OR 2.55). Study participants identified that being able to walk, having use of a bedpan or commode, and nursing assistance fostered continence (Kresevic, 1997).
Likewise, Palmer et al. (2002) determined
that in addition to mobility dependency, other risk factors for new-onset Ul .
specific to a hip fracture population included: institutionalization prior to
hospital, the presence of confusion (identified by a retrospective chart
review) preceding hip fracture, and being an African American woman.
Established UI has either a sudden or gradual onset and is often present prior to hospital admission; however, health care providers or family CGs may first identify UI during the course of an acute illness, hospitalization, or abrupt change in environment or daily routine (Palmer, 1996).
Types of established UI include stress, urge, mixed, overflow, and functional UI.Stress UI is defined as an involuntary loss of urine associated with activities that increase intra-abdominal pressure.
Symptomatically, individuals with stress Ul usually present with complaints of small amounts of daytime urine loss that occurs during physical effort or exertion (eg, position change, coughing, sneezing) that result in increased intra-abdominal pressure.
Stress UI is more common in women; however, stress Ul may also occur in men postprostatectomy (Abrams et al., 2003; Fantl et al., 1996; Hunter, Moore, Cody, &Glazener , 2004; Jayasekara, 2009).
Urge UI is characterized by an involuntary urine loss associated with a strong desire to void (urgency). Individuals with urge Ul often complain of being unable to hold the urge to urinate and leak on the way to the bathroom. This history is most helpful to the identification of urge UI (Holroyd-Leduc, Tannenbaum. Thorpe, & Straus, 2008).
In addition to urinary urgency, signs and symptoms of urge UI most often include urinary frequency, nocturia and enuresis, and UI of moderate to large amounts. Bladder changes common in aging make older adults particularly prone to this type of UI (Abrams et al., 2003; Fanti et al., 1996; Jayasekara, 2009).
Individuals with overactive bladder (OAB) may complain of urgency, with or without UI, as well as urinary frequency and nocturia. Assessment should focus on pathological or metabolic conditions that may explain these symptoms (Abrams et al., 2003).
Mixed UI is defined as involuntary urine loss as a result of both increased
intra-abdominal pressure and detrusor instability ( Fantl et al., 1996;
Jayasekara, 2009). On history, individuals describe symptoms of stress Ul in
combination with symptoms of urge Ul and OAB.
Overflow UI is an involuntary loss of urine associated with overdistention of the bladder - der, and may be caused by an underactive detrusor muscle or outlet obstruction leading to overdistention of the bladder and leakage of urine.
Individuals with overflow UI often describe dribbling, urinary retention or hesitancy, urine loss without a recognizable urge, an uncomfortable sensation of fullness or pressure in the lower abdomen, and incomplete bladder emptying Clinically, suprapubic palpation may reveal a distended or painful bladder as a result of urine retention, which may be acute or chronic.
A common condition associated with this type of UI is BPH. Neurological conditions such as multiple sclerosis and spinal cord injuries or diabetes mellitus, which result in bladder muscle denervation, may also cause overflow UI (Abrams et al., 2003; Doughty, 2000; Fantl et al., 1996; Jayasekara, 2009 ) , Functional UI is caused by non-genitourinary factors such as cognitive or physical impairments that result in an inability for the individual to be independent in voiding.
For example, acutely ill hospitalized
individuals may be challenged by a combination of an acute illness and
environmental changes. This, in turn, makes the voiding process even more
complex, resulting in a functional type of UI ( Fantl et al., 1996; B.
HodgKinson , Synnott , Josephs, Leira , &Hegney , 2008).
Assessment Parameters
Nurse continence experts suggest that entry-level nurses demonstrate the ability to collect and organize data surrounding urine control, and implement nursing interventions that promote continence ( Jirovec , Wyman, & Wells, 1998).
Nurses play a critical role in the basic assessment and management of UI in hospitalized older adults. Because Ul is an interdisciplinary issue, collaboration with other members of the health care team is essential. It is not sufficient for nurses to only identify and document the presence of UI.
Instead, the type of UI should be determined and documented based on a careful history and focused assessment; urodynamic tests are not required as part of the initial assessment of UI ( DuBeau et al., 2010).
Basic history and examination techniques are presented here to assist the nurse
in identifying the type of Ul along with a nursing standard of practice
protocol (see Protocol 18.1) to guide Ul assessment and management.
UI and Patient History
When a patient is admitted to the hospital, nursing history should include questions to determine if the individual has preexisting UI or risk factors for Ul .
The nurse should be alert for the following Ul -associated risk factors specific to the hospital setting: depression, malnourishment, dependent ambulation, being a resident of a long-term care institution, confusion, and being an African American woman (Kresevic, 1997; Palmer et al., 2002).
Therefore, the nurse should screen for depression,
determine body mass index (BMI), monitor albumin and total protein levels if
available, consult with a dietitian, and perform a validated assessment of both
cognitive and functional status.
The nurse should include screening questions such as “Have you ever leaked urine? If yes, how much does it bother you?” for all older adult patients.
Although not validated in the hospital setting, examples of screening instruments used in other settings include the Urinary Distress Inventory-6 (UDI-6) and the Male Urinary Distress Inventory (MUDI).
The UDI-6 is a self-report symptom inventory for UI that is reliable and valid for identifying the type of established UI in community-dwelling females ( Lemack & Zimmer, 1999; Uebersax , Wyman, Shumaker, McClish , &Fantl , 1995) .
The MUDI is a valid and reliable measure of urinary symptoms in the male population (Robinson & Shea, 2002). Determining the degree of “both” and the effect on HRQOL is important and should include the perspective of both the patient and CG or significant other.
Various instruments for quantifying bother and HRQOL exist
(Abrams et al., 2003; Bradway , 2003; Robinson & Shea, 2002; Shumaker et
al., 1994).
Historical questions should focus on the characteristics of Ul : time of onset, frequency, and severity of the problem. Questions also should review past health history and address possible precipitants of Ul such as coughing, uncontrollable urinary urgency, functional decline, and acute illness (eg, UTI, hip fracture).
Nurses should inquire about lower urinary tract symptoms such as nocturia, hematuria, and urinary been recommended as more feasible in outpatient and long-term care settings ( DuBeau et al., 2010; Fant et al., 1996).
A voiding record completed for even 1 day may help identify patients with bladder dysfunction or those requiring further referral.
Advanced
practice nurses or urologic/continence specialists can assist nursing staff
with interpretation and offer suggestions regarding nursing interventions based
on information from the voiding record.
C omprehensive Assessment
A wide variety of medications can adversely affect continence. Diuretics are the most commonly known class of medications that contribute to Ul due to polyuria, frequency, and urgency.
Medications with anticholinergic and antispasmodic properties may cause mental status changes, urinary retention with or without overflow incontinence, and stool impaction.
Various psychotropic medications (eg, tricyclic antidepressants, antipsychotics, sedative-hypnotics) have anticholinergic effects, contribute to immobility, and cause sedation and possibly delirium-each of which negatively affects bladder control.
Alpha-adrenergic blockers may cause urethral relaxation, whereas
alpha-adrenergic agonists may cause urinary retention. Calcium channel blockers
also may cause urinary retention (Newman & Wein, 2009).
Nurses should document all over-the-counter, herbal, and prescription medications on admission. Additionally, nurses must closely scrutinize new medications as possible causes if UI suddenly develops during the patient's hospital stay.
Medications that may contribute to iatrogenic ( ic , hospital-caused) UI include diuretics and sedative-hypnotics. Essentially, when a hospitalized patient develops transient Ul , the nurse must ask the question: Could a new medication be affecting this patient's bladder control?
If the answer is yes, then the nurse reviews this finding with the prescribing
practitioner to learn if the contributing medication may be discontinued or
modified.
Important components of a comprehensive examination include abdominal, genital, rectal, and skin examinations. In particular, the abdominal examination should assess for suprapubic distention indicative of urinary retention.
Inspection of male and female genitalia can be completed during bathing or as part of the skin assessment. The nurse should observe the patient for signs of perineal irritation, lesions, or discharge.
In women, a Valsalva maneuver (if not medically contraindicated) or voluntary cough may identify pelvic prolapse (e.g. cystocele, rectocele, uterine prolapse) or stress UI as a result of increased intra-abdominal pressure with bearing down (Burns, 2000). Postmenopausal women are especially prone to atrophic vaginitis.
Significant findings for atrophic vaginitis include perineal inflammation, tenderness (and, on occasion, trauma as a result of touch), and thin, pale genital tissues.
During the genital examination, patients should be instructed to cough or
perform the Valsalva maneuver (sometimes referred to as a bladder stress test)
to determine if there is urine leakage, again caused by increased
intra-abdominal pressure, which may be attributed to stress UI (Holroyd-Leduc
et al., 2008).
Digital rectal and skin examinations are essential in identifying transient causes of Ul such as constipation, fecal impaction, and the presence of fungal rashes. The “anal wink” (contraction of the external anal sphincter) indicates intact sacral nerve innervation and is assessed by lightly stroking the circumoral skin.
Absence of the anal wink may suggest sphincter denervation (Burns, 2000) and risk of stress UI. In men, the prostate gland should be palpated during the rectal examination because BPH may contribute to urge or overflow Ul .
A normal prostate gland is symmetrically heart-shaped, about the size of a large chestnut, and often described as "rubbery" or similar to the tip of the nose. When enlarged, as with BPH, the examiner may palpate symmetrical enlargement.
Pain on palpation or asymmetrical borders may be indicative of prostatitis or prostate cancer, respectively (Gray & Haas, 2000).
In some cases, diagnostic testing may provide additional information. The most common diagnostic tests include urinalysis, urine culture and sensitivity, and postvoid residual (PVR) urine ( Dubeau et al., 2010).
Urinalysis and urine cultures are used to identify the presence of a UTI and bacterial agent responsible, which may contribute to acute UI. A measurement of PVR may reveal incomplete bladder emptying.
Two methods for accurately
evaluating PVR are bladder sonography and sterile catheter insertion after the
patient has voided (see Table 18.2).
An additional diagnostic test such as a simple bedside urodynamic test, which provides information regarding detrusor activity, may be warranted in some cases (Burns, 2000; Newman & Wein, 2009).
A simple bedside urodynamic test is most likely to be performed by an advanced practice nurse or physician. It is done after a PVR has been performed and measured via the sterile catheterization method.
After the bladder is emptied, the catheter is maintained in the bladder, and a 50-ml syringe (without plunger) is connected to the catheter, with the center of the syringe in alignment with the symphysis pubis. Sterile water is then instilled to fill the bladder.
The fluid level is
monitored for evidence of bladder contractions, which are reflected in the
movement of the fluid level.
Functional, environmental, and mental status assessments are essential components of the UI evaluation in older adults.
The nurse should
observe the patient voiding, assess mobility, note any use of assistive
devices, and identify any obstacles that interfere with appropriate use of
toilets or toilet substitutes such as bedside commode.
Interventions and Care Strategies
Evidence demonstrates hospital nurses lack the knowledge necessary for evidence-based incontinence care (Coffey, McCarthy, McCormack, Wright, & Slater, 2007; Connor &Kooker , 1996; Cooper & Watt, 2003); therefore, adapting this for the acute care environment includes staff education.
A brief, unit-based in-service followed by patient rounds may be instrumental in identifying patients at risk for UI and those actually experiencing UI.
The North American Nursing Diagnosis Association (NANDA). Nursing Interventions Classification (NIC), and Nursing Outcomes Classification (NOC) provide structure for planning and evaluating UI assessment and management (M. Johnson, Bulechek , McCloskey- Dochterman , Maas, & Moorhead, 2001).
However, there is no structured guidance for the assessment and management of trans - sient UI.
Nurses are likely to be the first to
identify, and perhaps prevent, transient UI. Research is needed to understand
the role nurses play in preventing UI ( Sampleselle , Palmer, Boyington ,
O'Dell, & Wooldridge, 2004).
Treating Transient and Functional Causes of Urinary Incontinence
First, transient causes of UI should be investigated, identified, and treated. Individuals with a history of established UI should have usual voiding routines and continence strategies immediately incorporated into the acute care plan, whenever possible.
Nurses play an essential role in the
initiation of discharge planning and patient or CG teaching regarding all
aspects of Ul . Teaching and discharge planning should begin at admission as
appropriate, reviewed continually, and revised as necessary.
The environment is vital in managing UI, particularly functional Ul . Incontinent older adults are often dependent on an adaptive device (eg, walker) or CGs for assistance with voiding, making them “dependently continent.”
Call bells should be identified and within easy reach. If limited mobility is anticipated, nursing staff should consider using an elevated toilet or commode seat, male or female urinal, or bedpan.
Nurses should obtain referrals to physical and occupational therapy for ambulance aids, gait training, further assessment of activities of daily living associated with continence, and improved muscle strength.
Physical and chemical restraints
should be avoided including side rails (see Case Study). Patients should be
encouraged and assisted to void before leaving the unit for tests ( Fantl et
al., 1996; Jirovec , 2000; Jirovec et al., 1988; Palmer, 1996).
Toileting programs (eg, individualized, scheduled toileting programs including timed voiding: prompted voiding) have varied success rates (Colling. Ouslander , Hadley, Eisch , & Campbell, 1992; Eustice, Roe, & Paterson, 2000; Ostaszkiewicz , Johnston. & Roc, 2004; Rathnayake , 2009c).
Timed voiding has been promoted as a strategy for managing Ul in individuals who are not cognitively or physically able to participate in independent toileting ( Rathnayake , 2009c).
A voiding record is essential for developing an individualized scheduled toileting or timed voiding program, which mimics the patient's normal voiding patterns and requires continual assessment and reevaluation for successful outcomes.
For example, if the initial scheduled toileting time is set for 8:00 a.m., yet at 6:30 am, the patient consistently attempts to independently void or is noted to be incontinent, then the toileting time should be adjusted to 6: 00 am.
Evidence is lacking regarding
the effectiveness of timed voiding as a primary management strategy for Ul ;
however, it may be used based on the nurse's judgment of the clinical situation
( Rathnayake , 2009c).
The CG to ask if the patient needs to void, offer assistance , and then offer praise for successful voiding (Eustice et al., 2000; Jirovec , 2000; Ostaszkiewicz et al., 2004).
In nursing home residents with UI, prompt voiding
may achieve short-term improvement in daytime UI and may be effective in
reducing UI in cognitively intact older adults (B. Hodgkinson et al., 2008;
Rathnayake , 2009b). Prompt voiding has not been studied in hospitalized
patients.
Healthy Bladder Behavior Skills
Traditionally, nursing interventions for UI focus on containment strategies by means of receptacles (eg, bedpan, urinal, commode, urinary catheters) or by various absorbent products (eg, sanitary napkin, adult brief, incontinent pad: Harmer & Henderson, 1955: Henderson & Nite, 1978; Palese et al., 2007).
Various treatments beyond containment strategies include dietary management, pelvic floor muscle exercises (PFMES; Kegel, 1956). urge inhibition and bladder training (retraining) strategies, toileting programs (eg, individualized, scheduled toileting programs/timed voiding: prompted voiding), pharmacological therapy, and surgical options ( Fantl et al., 1996; B. HodgKinson et al., 2008).
These treatments (excluding pharmacological and surgical options) are viewed as healthy bladder behavior skills (HBBS).
Although the recommendation is to offer HBBS to all older adults with Ul ( Fantl et al., 1996; Teunissen , de Jonge , van Weel , &Lagro-Janseen , 2004), it is unclear how to best incorporate HBBS in the care of hospitalized older adults.
Despite the fact that contemporary nursing practice textbooks list and describe HBBS as nursing interventions (Kozier, Erb , Berman, & Snyder, 2004; Newman & Wein, 2009; Taylor, Lillis, &LeMone , 2005), many of these interventions have not been adequately examined in the acute care setting, and nurses do not routinely implement these interventions in the acute care setting (Bayliss, Salter, & Locke, 2003; Schnell et al., 2003; Watson , Brink, Zimmer, & Mayer, 2003).
Under- reporting and underassessment are barriers to optimally addressing UI in the hospital setting as reflected in the study by Schultz et al. (1997), which reported that only 0.1% of medical records captured the problem of Ul present at the time of hospital admission.
Accurate assessment and identification of type of UI is needed before care
strategies are initiated.
Prior to instituting HBBS, the nurse needs to assess the motivation of the patient, informal CG, and nursing staff because behavior modification is a premise of HBBS (Palmer, 2004).
Examples of dietary management strategies include avoiding certain foods and beverages known to be bladder irritants such as caffeine, acidic foods or fluids, and NutraSweet (Gray & Haas, 2000).
Some individuals with a BMI greater than 27 may benefit from a weight-loss
program. For example, in one study, a weight loss of 5%-10% significantly
decreased UI episodes for some obese women ( Subak et al., 2005).
If not contraindicated, the nurse recommends adequate fluid intake, specifically water, and an increased intake of dietary fiber to maintain bowel regularity. It is important to work closely with older adults who fear that unwanted urine loss is a result of increased fluid intake.
Education should focus on the adverse consequence of inadequate fluid intake such as volume depletion or potential for dehydration, and that too little fluid intake may result in concentrated urine, which, in turn, may cause increased bladder contractions and increased feelings of urinary urgency.
Lastly, to manage and limit nocturia, patients may be advised to limit fluid intake a few hours before bedtime (Doughty, 2000; Fantl et al., 1996); however, this is questionable for older adults who do not have easy access to fluids or have diminished third sensation ( DuBeau et al., 2010).
In the hospital setting, the nurse must note the schedule of diuretics. For example, many institutions schedule every 12-hour diuretic dose times at 10 am and 10 pm For some patients, it will be extremely important that nurses navigate organizational processes to reschedule diuretic doses to an alternate time such as 6 am and 4 pm or 6 pm.
This simple strategy may decrease nocturia, which, in turn, will likely decrease the risk of falls. Research that examines which UI interventions best modify fall risk is needed (Wolf, Riolo , &Ouslander , 2000).
For community-dwelling, cognitively intact older adults, PFME is at least as effective as pharmacological therapies in treating stress and urge UI (B. Hodgkinson et al., 2008). PFME holds promise for the primary prevention of Ul but requires additional research (Hay-Smith, Herbison , &Morkved , 2002), particularly in the acute care setting.
PFMEs were developed to augment the
strength, endurance, and coordination of the pelvic muscles, which play a role
in maintaining continence.
Integrating PFMEs into the plan of care requires an assessment of the patient's baseline understanding of PFMEs to identify knowledge deficits. Ideally, PFMEs are taught during a vaginal or rectal examination when the clinician manually assists the patient to identify the pelvic muscles by instructing the patient to squeeze around the gloved examination finger.
This method allows for performance appraisal (Hay-Smith et al., 2002); and together with weekly phone consults and monthly performance appraisal, this method is known to improve Ul outcomes for community-dwelling individuals (Tsai & Liu, 2009). Alternately, PEMEs may be verbally taught by instructing the patient to gently squeeze or contract the rectal or vaginal muscles.
Either
teaching method includes instructions to not squeeze the stomach, buttocks, or
thigh muscles (because this only increases intra-abdominal pressure) but to
isolate the contraction of the pelvic muscles.
Preferably, each exercise should consist of contracting for 10 seconds and relaxing for 10 seconds. Some patients may need to start with 3 or 5 seconds, and then increase as their muscle becomes stronger.
There is no set “exercise dose” (Du Moulin. Hamers , Paulus, Berendsen, &Halfens , 2005); however, it is usual practice to recommend 15 PFMEs three times per day. For community-dwelling women with stress, urge, or mixed UI, PFMEs (at least 24 per day for at least 6 weeks) should be included in first line conservative management programs (Choi, Palmer, & Park, 2007: Syah , 2010 ) .
Patients may notice improvement in 2-4 weeks but not immediately. Nurses should reinforce compliance and other HBBS and initiate a referral for discharge follow-up with a continence specialist for PFME reinforcement via biofeedback, if available ( Bradway &Hernly , 1998).
In a study of community-dwelling
adults, PFME instruction and reinforcement using biofeedback improved both UI
outcomes and concurrent depressive symptoms (Tadic et al., 2007); Therefore,
hospitalized patients may benefit from a referral to a continence nurse or
other provider specializing in care of individuals with UI (eg. urologist,
gynecologist, urogynecologist) for follow-up after discharge.
Urge inhibition is based on behavioral theory and is another recommended HBBS for treatment of urge UI ( Teunissen et al., 2004), although the mechanism of how urge inhibition works is not well understood (Gray, 2005; Smith, 2000).
Urge inhibition includes distraction techniques (eg, reciting a
favorite poem or song), relaxation techniques, and rapid pelvic floor muscle
contractions with the goal being to suppress the urge to void until desirable
(Smith, 2000).
Bladder training (retraining) is another behavioral technique used to treat urge Ul ( DuBeau et al., 2010; Teunissen et al., 2004) and OAB, is often used in conjunction with urge-inhibition techniques and Functional Incontinence Training (FIT; DuBeau et al., 2010; Schnelle et al., 2003), and may be more effective if used in combination with PFMES or anticholinergic drugs ( Rathnayake , 2009a).
Bladder training requires a baseline voiding record to determine the timing of voids and Ul episodes. If urinary frequency is present, the patient is instructed to lengthen the time between voids in an effort to retrain the bladder.
When a strong urge to void occurs, the patient is instructed to use urge-inhibition techniques to suppress urinary urgency. For example. if the patient is not in a position to empty the bladder in a socially appropriate manner, the nurse instructs the patient to quickly squeeze and relax pelvic floor muscles several times to suppress the urge to void.
This
technique is sometimes referred to as “quick flicks” (Gray, 2005). Relaxation
and distraction and urge inhibition techniques are also beneficial during
bladder training.
In some instances (eg. for patients experiencing incomplete bladder emptying or overflow UI), patients and staff can use Crede's maneuvers (ie, deep suprapubic palpation) to facilitate bladder emptying.
The Crede's maneuver is used with caution and requires manual compression over the suprapubic area during bladder emptying.
The Crede's maneuver should be avoided if vesicoureteral reflux ( ie , abnormal flow of urine from the bladder back up the ureters) or overactive sphincter mechanisms are suspected because it may dangerously elevate pressure within the bladder (Doughty, 2000).
In some cases,
instructing patients to double void ( ie ., after an initial void, instructing
patients to stand or reposition for a second void) also facilitates bladder
emptying.
Additional Nursing Interventions
A causal link between Ul and skin breakdown has not been adequately supported; however, maintaining skin integrity is a goal of nursing care.
Decomposition of urinary urea by microorganisms' releases ammonia and forms ammonium hydroxide, an alkali. This alkali makes the protective “acid mantle” of the skin vulnerable and jeopardizes skin integrity.
If Ul episodes persist
despite management strategies, perineal skin care interventions should focus on
maintaining the integrity of the protective acid mantle of the skin .
Although absorbent products are commonly used for Ul containment, there is little evidence available to guide product selection and no evidence of how absorbent products may interact with the acid mantle (Fader, Cottenden , &Getliffe , 2008).
Community-dwelling women with light UI reported important characteristics of absorbent pads including the ability to hold and hide UI and ease of use ( Getliffe , Fader. Cottenden , Jamieson, & Green, 2007).
In hospitals, nursing staff reported problems with quality and availability of absorbent products ( Clayman , Thompson, & Forth, 2005).
Pertaining to reusable versus disposable absorbent products, there is no demonstrable risk of cross-infection with reusable absorbent products when appropriate laundering protocols are followed, and there are no clear cost savings with using one over the other.
Reusable products have limited acceptability among users (Fader et al., 2008), and use of adult briefs is significantly associated with an increased risk of infection ( Zimakoff , Stickler, Pontoppidan, & Larsen, 1996).
Although bed pads contain urine, consumer satisfaction is questionable, and there are no studies on the use of chair pads.
Although limited evidence exists, suggesting that disposable insert pads may be more effective for women with Ul than other absorbent products ( Rathnayake , 2009d), there is no clear evidence to suggest one absorbent product being superior to another, particularly in the acute care setting.
Evidence
does support pilot testing of absorbent products according to individual
circumstances, including patient, family, and institutional preferences, and
offering a choice of products to women with UI (Dunn, Kowanko, Paterson,
&Pretty , 2002: Fader et al., 2008 ; Rathnayake , 2009).
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