SHRTN Continence Co P Long Term Care HomesIC

SHRTN Continence Co. P Long Term Care Homes-IC 3 Project Appendix G: Continence Promotion and Management June 16, 2010 Barbara Cowie (Cassel), RN, BSc. N, MN, GNC(C) Advanced Practice Nurse Amputee Rehabilitation and Complex Continuing Care Nurse Continence Advisor West Park Healthcare Centre 416 -243 -3600 (4532) Barbara. Cowie@westpark. org West Park Healthcare Centre

Presentation Overview n Prevalence n Resources n Impact n Barriers n Assessment n n Treatment Continence care work at West Park

What is incontinence? n It has been defined by the International Continence Society as: a condition where involuntary loss of urine is a social or hygienic problem (ICS, 1987)

Prevalence n 5 to 10 % in the Community n 10 to 20 % in Acute Care n 50 to 70 % of Complex Continuing Care w 1 in 4 women w 1 in 10 men

An Important Problem n UI is a strong predictor of functional recovery (Brittain 2001) n Discharge destination - institution vs. community/home (Brittain 2001; Patel et al. , 2001) n Impact on quality of life for the individual and family n Resumption of social participation (Gallagher 1998) w Low self-esteem w Social isolation w Depression

Requirements of Continence n Aware of urge to void n Able to get to the bathroom n Able to suppress the urge until you reach the bathroom n Able to void when you get there

Bladder pressure Normal Micturition Cycle Bladder filling Detrusor muscle relaxes + Urethral sphincter tone + Pelvic floor tone Storage phase First sensation to void Detrusor muscle relaxed + Urethral sphincter contracts + Pelvic floor contracts Emptying phase Normal desire to void Bladder filling Detrusor muscle contracts + Urethral sphincter relaxes (voluntary control) + Pelvic floor relaxes Detrusor muscle relaxes + Urethral sphincter tone + Pelvic floor tone MICTURITION 6 West Park Healthcare Centre

Types of UI Stress Urge (OAB) Functional Overflow 7 West Park Healthcare Centre

Stress Incontinence 8 q loss of urine with a sudden increase in intraabdominal pressure (e. g. coughing, sneezing, exercise) q most common in women q sometimes occurs in men following prostate surgery West Park Healthcare Centre

Structure of the Female Lower Urinary Tract Ureter Outer peritoneal coat Detrusor smooth muscle Mucosa Trigone Proximal smooth muscle sphincteric mechanism External urethral sphincter urethra 9 Pelvic floor (striated muscle) West Park Healthcare Centre

Urogenital Changes Vagina Bladder Dryness Urgency Painful intercourse Frequency Recurrent UTI 10 Recurrent infection West Park Healthcare Centre

Pelvic Floor 11 West Park Healthcare Centre

Pelvic Floor Decent 12 West Park Healthcare Centre

Structure of the Male Lower Urinary Tract Ureter Outer peritoneal coat Detrusor smooth muscle Mucosa Trigone Proximal smooth muscle sphincteric mechanism Prostate gland External urethral sphincter urethra 13 Pelvic floor (striated muscle) West Park Healthcare Centre

Urge Incontinence (overactive bladder) 14 q loss of urine with a strong unstoppable urge to urinate q usually associated with frequent urination during the day and night q common in women and men q sometimes referred to as an overactive bladder West Park Healthcare Centre

Overflow Incontinence 15 q bladder is full at all times and leaks at any time, day or night q usually associated with symptoms of slow stream and difficulty urinating q more common in men as a result of the enlargement of the prostate gland West Park Healthcare Centre

Functional Incontinence 16 q patient either has decreased mental ability (e. g. Alzheimer’s disease) q or decreased physical ability (e. g. arthritis) and is unable to make it to the bathroom in time West Park Healthcare Centre

DISAPPEAR – Transient Causes of UI n D Delirium n I Intake of fluid n S Stool impaction n A Atrophic changes/urethritis n P Psychological problems n P Pharmaceuticals that can contribute to incontinence n E Excess urine output n A Abnormal lab values n R Restricted mobility Whytock, S (Chapter 3) Promoting Continence Care, A Bladder and Bowel Handbook for Care Providers. Skelly J, Carr M, Cassel B, Robbs L, Whytock S, Edited by Paula Eyles 2006 17 West Park Healthcare Centre

Age Related Factors n Increased w Detrusor Overactivity w Nocturnal urine output w BPH w PVR (<100 ml) w Bacteruria (20%) n Decreased w Bladder Contractility w Bladder Sensation w Sphincter Strength (F) n Unchanged w Bladder Capacity w Bladder Compliance

Structured Assessment 19 n Specialist professional structured assessment: w Incontinence history (premorbid urinary incontinence) w Fluid Intake w Bowel elimination history w Medical History w Medications w Functional Ability n A bladder diary is helpful with identifying voiding frequency, voided volumes and frequency of incontinence n Focused physical evaluation (pelvic exam for women / PVR bladder scan / Urine dipstick) n Simple tests n The assessment may take 2 to 3 sessions West Park Healthcare Centre

Incontinence History Assessment resources: n Link to Urinary Continence Assessment Tool http: //www. rnao. org/Storage/24/1905_ FINAL_continence_chart. pdf n 20 Promoting Continence Care, A Bladder and Bowel Handbook for Care Providers. Skelly J, Carr M, Cassel B, Robbs L, Whytock S, Edited by Paula Eyles 2006 n Onset n Duration n Daytime / Nighttime n Accidents n Stress loss n Urge loss n Aware of loss West Park Healthcare Centre

Impact of cognitive impairment on ability to be continent n ability to follow and understand prompts or cues n ability to interact with others n ability to complete self care tasks n social awareness

Interpretation n recognition n recall Impact on continence n identifying the urge to void n remembering how to respond n locating the toilet

Interaction n comprehension n expression Impact on Continence n understanding reminders n asking for assistance

Self Care n voluntary and purposeful movement n spatial orientation Impact on Continence n removing clothing n sitting on the toilet

Social n attention deficits n conversation Impact on continence n remembering how to respond n motivation to be continent

Voiding Record Time and amount of: – fluid intake – urine voided – incontinence – For 4 or 5 days

Urology Consult Cystoscopy n performed by a physician when the condition cannot be completely diagnosed by simpler, less invasive tests Urodynamics n used to assess the function of the bladder and urethra n used to determine the problem in more complicated situations n often done in conjunction with a cystoscopy

Contributing Factors n Urinary Tract Infections n Mobility n Fluid Intake n Environmental Factors n Caffeine / Alcohol Intake n Cognitive Impairment n Constipation n Childbirth n Medications n Pelvic muscle tone n Weight n Atrophic Changes It is important to determine the contributing factors, this will lead logically to intervention planning.

Making the “leap” from assessment to treatment q. So what do you do with all this information you have gathered? q. The assessment follows a logical path to help you to think about the patient’s problem of UI 29 West Park Healthcare Centre

Conservative Management qclient focused qusing education qbehavior modification qproblem solving strategies 30 West Park Healthcare Centre

Treatment Options Surgery Medication Behavioural Most cases of UI can be effectively managed with conservative approaches. 31 West Park Healthcare Centre

Conservative Treatment Options Functional Toileting ISC Stress Overflow Urge Pessaries Kegal Exercises 32 Behavior modification Urge Suppression West Park Healthcare Centre

Preventing Urinary Tract Infections n drink extra fluids like water n There is some evidence to show that use of cranberry juice or capsules can prevent UTI’s in women w Cochrane Reviews 33 West Park Healthcare Centre

Personal Care 34 n Wash and wipe from the front to the back n Wash with warm water and pat or blow dry n No soap n Use a product that dosen’t affect vaginal p. H West Park Healthcare Centre

Contributing Factor - Loss of Estrogen 35 § tablet, patch, ring or cream § works by improving the tissues of the vagina and urethra in post-menopausal women § risks concerns w breast cancer w uterine cancer West Park Healthcare Centre

Increase Water Intake 36 n Increase intake of healthy fluids, especially water n Try adding a slice of lemon or a sprig of mint to the water n Offering fluid frequently or readily accessible West Park Healthcare Centre

Reduce - Caffeine 37 • slowly cut down on the amount of caffeine to 1 -2 cups a day (1 cup=250 ml) • slowly switch to decaffeinated beverages (eg. decaffeinated tea, decaffeinated coffee, caffeine-free beverages) • read labels closely (eg. green tea is caffeinated) West Park Healthcare Centre

Managing Constipation 38 n Provide opportunities for exercise everyday n Offer plenty of “healthy” fluid (warm water may stimulate the bowel) n Introduce gradually, foods high in fibre such as bran, oatmeal, whole wheat, green leafy vegetables n Avoid using laxatives on a regular basis West Park Healthcare Centre

Limited Mobility 39 • Ensure a toilet is close by (a bedside commode or bedpan) • Offer regular timed trips to the washroom • Keep walking aide near (cane, crutches, or walker) • Provide clothing that can be easily removed West Park Healthcare Centre

Developing Best Practice Guidelines 40 West Park Healthcare Centre

Prompted Voiding 41 n It has been shown to decrease the number of incontinent episodes per day and increase the number of continent voids (A level evidence) n It can be used with persons who have physical or mental impairments or little ability to determine how best to meet their needs n The identification of individual voiding patterns (individualized toileting) rather than routine toileting (e. g. q 2 h) can promote the highest level of success with toileting West Park Healthcare Centre

3 -Day Voiding Record q q 42 3 -day voiding record recommended Identify patterns of voiding Use to monitor interventions Motivates staff & residents West Park Healthcare Centre

Prompted Voiding It aims to improve bladder control for people with or without dementia using verbal prompts and positive reinforcement. 43 West Park Healthcare Centre

Prompted Voiding Intervention There are three primary behaviours that the caregiver uses each time PV is initiated – Monitoring – Prompting – Praising 44 West Park Healthcare Centre

Environment Provide visual cues in the environment to promote desired toileting behaviour 45 West Park Healthcare Centre

Using the right product 46 West Park Healthcare Centre

Resources n Clinical Practice Guidelines for Urinary Continence Management of Stroke Survivors in Acute and Rehabilitation Settings, The Ottawa Hospital, 2008 n Registered Nurses’ Association of Ontario (2006). Self-Learning Package: Continence Care Education. Toronto, Canada: Registered Nurses’ Association of Ontario. http: //www. rnao. org/Page. asp? Page. ID=924&Content. ID=1274 n Hospital Report Research Collaborative, IC 5 Improving Continence Care in Complex Continuing Care w Facilitation using Quality Improvement Methodology http: //www. hospitalreport. ca/projects/QI_projects/IC 5. html n Incontinence: A Canadian Perspective A comprehensive look at incontinence in Canada A 37 page burden of illness paper commissioned by TCCF in 2007 http: //www. canadiancontinence. ca/health-profs. html 47 West Park Healthcare Centre

Comments? Feedback? 48 West Park Healthcare Centre