May 2, 2012 | by I Advance Senior Care

Practical tips to promote continence

“I gotta go! Oops, too late.” This may be a common phrase heard by staff in long-term care (LTC) settings or the staff may find that the patient is incontinent of urine without requesting to toilet. More than 50 percent of residents in LTC facilities have urinary incontinence (UI).

Incontinence is associated with falls, skin breakdown and social isolation. An incontinence assessment is important for new residents and any resident who has had a change in their continence status. The assessment provides a review of potential reversible causes, identification of the resident’s symptoms and the foundation for the treatment plan.1-3 However, there are basic strategies such as hydration and toileting that need to be integrated with the treatment plan. The following are practical tips to promote continence in your facility.

USEFUL STRATEGIES

Hydration is often a challenge, and is important in the treatment of urinary incontinence and constipation. Concentrated urine from poor fluid intake may act as an irritant to the bladder and make urge incontinence worse. Constipation and fecal impaction may impair bladder emptying and lead to urinary retention and overflow incontinencesince the bladder is limited in the space to expand.4,5 It is often a battle to get older residents to consume a large glass of fluid. Offer residents small amounts of liquids frequently. Look for ways to integrate fluids into their diet with lunch and snacks such as broths, gelatins, puddings, ice cream and popsicles. Meanwhile, avoid offering fluids that act as a bladder irritant such as caffeine—not just coffee and tea, but chocolates as well. Be creative and avoid the battle.

Promote toileting in the resident’s routine. It is a great way to have ambulatory residents exercise by walking to the bathroom, especially if you have a restorative program. Walking also helps with constipation. If the resident is independent, make sure the bathroom is clearly marked with signage. Often a picture of a toilet on the door will help. At night, make sure the bathroom is easy to access. Ensure that the path is clear and a night light is on.

Toilets should be easy to use. Assess height and side rails. If the toilet is too low, a bedside commode placed over the toilet can be adjusted for appropriate height and side rails for support. Assess how well the resident is able to manipulate his or her clothing to use the toilet. Elastic waist pants are usually easier than buttons and zippers.

At times, a resident may need to use a toilet substitute such as a bedpan or urinal. For women, offer a fracture bedpan. It requires less hip flexion and is more comfortable to sit on. Make sure the head of the bed is elevated to allow gravity to facilitate bladder emptying. Male residents might need to use a urinal while in bed. Again, elevate the head of the bed to facilitate emptying.

Residents with functional impairments, stress and/or urge incontinence may benefit from a toileting schedule such as every two to four hours while awake. This prevents the bladder from distending and will decrease the amount of leakage with stress and decrease or eliminate the episodes of urgency to get to the bathroom. The schedule can be adjusted depending on the resident’s response.5

Prompted voiding combines scheduled toileting with cueing the patient to void every two to four hours while awake and praising the patient for toileting and if they remain dry in between. This requires staff participation and monitoring of bladder records. The goal is to increase patient’s self-initiation to request toileting. A three-day trial of prompted voiding to identify residents who will respond is suggested.6

TRAINING TECHNIQUES

Residents identified with elevated post-void residual may benefit from integrating some strategies to help facilitate emptying. While voiding, have the resident bend forward. Some residents, such as women with mild pelvic prolapse, may benefit from double voiding. After urination, instruct them to stand and then sit back down and try to void again. If constipation is present, initiate a treatment plan to evaluate the impact on bladder emptying.

If a resident has issues with nocturia, try limiting fluids in the evening to evaluate the impact. Avoid caffeinated products late in the afternoon and evening that stimulate urination. Check the resident’s lower extremities for edema. If present the fluid may mobilize at night when he or she lies down, contributing to his or her nighttime voiding or incontinence. Support stockings are often not tolerated, so try having the patient elevate his or her legs in the afternoon for at least an hour to see if the fluid will mobilize and decrease nocturia.

EDUCATION

Teaching staff, residents (if appropriate) and families about incontinence and the practical tips described is an important component of promoting continence. The interdisciplinary team approach enhances the continence evaluation and the development and implementation of the plan of care.5 The resident (when appropriate) and family’s understanding and involvement are vital to the success.

CHARTING PATTERNS

Bladder records are important in establishing baseline incontinent patterns, evaluating the intervention, and providing feedback to staff and resident. Bladder records capture the times the resident voids in the toilet, incontinent episodes, and activities associated with leakage. Encourage your staff to create a bladder record that they feel will provide the information and is easy to complete. Having staff involved promotes ownership of the program.7

MANAGING WITH MEDICATION

Managing incontinence can be a challenge. Other treatment options, such as medications, may be considered especially if the above strategies do not show benefit. Most commonly, medication is prescribed for urge incontinence or overactive bladder; however, residents often do not tolerate these medications because of side effects such as dry mouth, confusion or constipation. These medications can also contribute to urinary retention. Therefore, it is best to start with strategies that have no potential adverse effects and evaluate their impact on incontinence.2 Try some of these practical tips to make a difference in the lives of your residents.

Jane Marks, MS, RN, FNGNA is Associate Director, Johns Hopkins Geriatric Education Center, Johns Hopkins University, Division of Geriatric Medicine & Gerontology. V. Inez Wendel, MS, CRNP, is a nurse practitioner at Johns Hopkins University, Division of Geriatric Medicine & Gerontology, Baltimore, Md. Contact Ms. Marks at jmarks@jhmi.edu.

REFERENCES

  1. AMDA Clinical Practice Guidelines: Urinary Incontinence. Columbia, Maryland, 2012
  2. Fantl A, Newman DK, Colling J, et al. (1996). Urinary Incontinence in Adults: Acute and Chronic Management. Agency for Health Care Policy and Research, Publication No. 92-0047: Rockville, MD.
  3. Johnson TM, Ouslander JG. The Newly Revised F-Tag 315 and surveyor Guidance for Urinary Incontinence in Long Term Care. Journal of American Medical Director Association 2006; Nov, 7(9):594-600.
  4. Resnick NM, Yalla SV. Management of Urinary Incontinence in the Elderly. New England Journal of Medicine 1985;313:800-4.
  5. Schnelle JF, Cadogan MP, Grbic D, et al. A Standardized Quality Assessment System to Evaluate Incontinence Care in the Nursing Home. JAGS 2003; Dec. 51 (12):1754-6.
  6. Ouslander JG, Schnelle J, Uman G, et al. Predictors of Successful Prompted Voiding Among Incontinent Nursing Home Residents. Journal of the American Medical Association 1995; May 3, 273(17):1366-70.

Ouslander JG, Urman H, Uman G. Development and T

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