Continence - adults with urinary dysfunction · 2019. 4. 11. · Continence assessment is clearly...

Best Practice Statement ~ November 2005

Continence - adults with urinarydysfunction

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Contents

Introduction i

Key stages in the development of best practice statements ii

Best Practice Statement on Continence – adults with urinary iiidysfunction

Section 1: Promoting continence awareness 1

Section 2: Access to toileting facilities 2

Section 3: Assessment of urinary dysfunction 3

Table 1: Initial assessment of urinary dysfunction 4

Section 4: Continence care planning 6

Table 2: Basic guidance for continence care planning 7

2a. Functional incontinence 7

2b. Stress incontinence 9

2c. Urge incontinence 10

2d. Mixed urge and stress incontinence 11

2e. Overflow incontinence/incomplete 12bladder emptying

2f. Reflex incontinence 13

2g. Nocturnal enuresis 14

Glossary 15

References 17

Appendix 1: Best practice statement audit tool 19

Appendix 2: Who was involved in developing and reviewing 21the statement?

Continence - adults with urinary dysfunction

Introduction

NHS Quality Improvement Scotland (NHS QIS) was set up by the ScottishParliament in 2003 to take the lead in improving the quality of care andtreatment delivered by NHSScotland.

The purpose of NHS QIS is to improve the quality of healthcare inScotland by setting standards and monitoring performance, and byproviding NHS Scotland with advice, guidance and support on effectiveclinical practice and service improvements.

A series of best practice statements has been produced within thePractice Development Unit of NHS QIS, designed to offer guidance onbest and achievable practice in a specific area of care. These statementsreflect the current emphasis on delivering care that is patient-centred,cost-effective and fair. They reflect the commitment of NHS QIS tosharing local excellence at a national level.

Best practice statements are produced by a systematic process, outlinedoverleaf, and underpinned by a number of key principles:

• They are intended to guide practice and promote a consistent,cohesive and achievable approach to care. Their aims are realistic butchallenging.

• They are primarily intended for use by registered nurses, midwives,allied health professionals, and the staff who support them.

• They are developed where variation in practice exists and seek toestablish an agreed approach for practitioners.

• Responsibility for implementation of these statements rests at locallevel.

Best Practice Statements are reviewed, and, if necessary, updated after 3years in order to ensure the statements continue to reflect currentthinking with regard to best practice.

i

ii

Key Stages in the development of best practice statements

Topic selection and Scoping Process

Establish working group.Review literature on topic.

Source grey literature.

Ascertain current policy and legislation.

Seek information from manufacturers,

voluntary groups and other relevant

sources.

Establish reference group to

advise on consultation drafts.

Determine focus and content

of statement.

Review evidence for

relevance to practice.

Determine process for

incorporating patients’ views.

Draft document sent to

reference group.

Wide consultation process.

Review and update process. Identify

new research/ findings affecting topic.

Consider challenges of using

statement in practice.

Review and revise statement

in light of consultation

comments.

Publish and disseminate

statement.

Feedback on impact

of statement is

sought/impact

evaluation.

▲

▲

▲

▲

▲

▲

▲

▲

▲

▲

▲


Best Practice Statement on Continence - adults withurinary dysfunction

This best practice statement was originally produced by the Nursing andMidwifery Practice Development Unit to offer guidance to nurses,midwives and health visitors on best practice relating to the assessmentof urinary dysfunction in the care of adults in primary and secondarycare settings. A multidisciplinary working group was set up withprofessional representation from across Scotland. (Appendix 2 ). Thestatement was reviewed and updated in 2005. In addition to the reviewprocess, an audit tool has been developed to supportpractitioners/organisations wishing to audit their continence care.

Continence issues can affect people of all ages who come into contactwith health services in both primary and secondary care settings. It isestimated that between 5 and 9% of the adult population in Scotlandhave significant problems with urinary continence (SIGN guideline 79).The Continence Foundation estimates that incontinence costs the NHSacross the UK £423 million. Causes and contributing factors are many andvaried. Incontinence can have a profound effect on an individual’s qualityof life. There may also be an impact on wider health issues, eg urgeincontinence in older women has been associated with an increased riskof falls and fractures (Brown JS et al 2000). This best practice statementaims to provide practitioners with a framework which can be used whenmaking decisions about the management of continence. A thorough andaccurate assessment of individual continence status is essential in order todetermine appropriate treatment.

The statement covers all care settings. It is recognised that where apatient does not have a holistic assessment undertaken (eg minor injuriesunit) then the nurse should use clinical judgement concerning therelevance of urinary dysfunction.

A key element of the statement is that all patients should have access toappropriate toilet facilities. Concerns were raised about people inoutpatient or GP clinics who would require assistance to access the toilet,although there were no comments about the consequences for thepatients if they were denied access to toilets. The statement tries to reflectstaff concerns without accepting the conclusion that patients who cannot go to the toilet independently have two choices: to either avoidoutpatient/GP appointments or to accept the potential humiliation of anincontinent episode.

iii

iv

The original consultation indicated that some areas would prefer tocategorise patients at the outset as those who would benefit fromcontinence promotion and those assigned to incontinence containment.The original working group considered that in all cases the initial aimshould be the restoration of continence. This was confirmed by thesubsequent review of the statement. It was accepted that, followingcomprehensive assessment, this goal may need to be revised. In all cases,however, a continence care plan should be implemented and evaluated.


1

Sect

ion

1:

Pro

mo

tin

g c

on

tin

ence

aw

aren

ess

All

staf

f ar

e aw

are

of t

he e

ffect

tha

t th

eir

pra

ctic

e ca

n ha

veon

a p

atie

nt’s

con

tinen

ce s

tatu

s.

All

staf

f ar

e aw

are

of t

he e

ffect

tha

t p

erso

nal h

abits

can

have

on

cont

inen

ce s

tatu

s, a

nd s

upp

ort

pat

ient

s an

d p

ublic

by p

rovi

ding

acc

urat

e in

form

atio

n to

pro

mot

e he

alth

yp

ract

ices

.

All

staf

f ar

e aw

are

of t

he p

oten

tial f

or im

pro

vem

ent

inq

ualit

y of

life

tha

t ca

n be

ach

ieve

d by

pat

ient

s w

ithap

pro

pria

te c

ontin

ence

car

e, a

nd o

f th

e lo

w e

xpec

tatio

nsfr

om c

ontin

ence

car

e w

hich

pat

ient

s te

nd t

o ha

ve.

All

loca

l pro

cedu

re m

anua

ls in

clud

e re

fere

nce

to c

ontin

ence

diffi

culti

es,

spec

ific

to t

he r

elev

ant

spec

ialit

y, w

hich

may

be

exp

erie

nced

by

pat

ient

s.

All

disp

lays

of

pub

lic in

form

atio

n le

afle

ts in

clud

e ge

nera

lin

form

atio

n on

ap

pro

pria

te f

luid

inta

ke a

nd t

oile

ting

habi

ts,

to p

rom

ote

the

heal

thy

blad

der.

All

nurs

e/m

idw

ife t

rain

ing

initi

ativ

es r

elat

ing

to c

ontin

ence

incl

ude

info

rmat

ion

on t

he p

oten

tial f

or im

pro

vem

ent.

Stat

emen

tR

easo

ns

for

Stat

emen

tH

ow

to

Dem

on

stra

te S

tate

men

t is

Bei

ng

Ach

ieve

d

Each

nur

se/m

idw

ife w

ill h

ave

conc

erns

sp

ecifi

c to

the

irow

n ar

ea o

f ex

per

tise

(eg

atte

ntio

n to

pel

vic

floor

dur

ing

pre

gnan

cy a

nd d

eliv

ery,

initi

al c

are

of o

rtho

pae

dic

pat

ient

s, a

tten

tion

to t

oile

ting

with

con

fuse

d or

dep

ress

edp

atie

nts)

.

Peop

le o

ften

res

tric

t flu

ids

belie

ving

thi

s w

ill r

educ

eep

isod

es o

f in

cont

inen

ce.

Freq

uenc

y an

d ur

genc

y of

urin

atio

n ca

n be

agg

rava

ted

byp

eop

le v

oidi

ng f

req

uent

ly ‘j

ust

in c

ase’

– u

ltim

atel

yre

duci

ng b

ladd

er c

apac

ity.

"Sel

ecte

d p

atie

nts

in t

he c

omm

unity

hav

e sh

own

a 70

-80%

cur

e or

imp

rove

men

t ra

te"

(Roy

al C

olle

ge o

fPh

ysic

ians

199

5).

Dis

tric

t nu

rses

cite

d lo

w p

atie

nt e

xpec

tatio

n as

one

of

the

mai

n ba

rrie

rs t

o im

ple

men

ting

an e

ffect

ive

cont

inen

cem

anag

emen

t p

lan.

2

Sect

ion

2:

Acc

ess

to t

oile

tin

g f

acili

ties

* In

cer

tain

set

tin

gs (

such

as

health

cen

tres

) pati

ents

who

nee

d m

ovin

g an

d h

an

dlin

g eq

uip

men

t to

tra

nsf

er w

ill

nor

mally

have

est

abl

ishe

dco

pin

g st

rate

gies

. Whe

re a

pati

ent

requ

ires

ass

ista

nce

to

toilet

bey

ond t

hose

faci

liti

es a

vailabl

e in

hea

lth

cen

tres

or

out-pati

ent

are

as,

alter

nati

ve c

onsu

ltati

on o

pti

ons

shou

ld b

e of

fere

d.

All

pat

ient

s, a

t ev

ery

stag

e of

the

ir p

atie

nt e

xper

ienc

e, h

ave

acce

ss t

o ap

pro

pria

te t

oile

ting

faci

litie

s.A

cces

sibl

e to

ilet

faci

litie

s ar

e p

rovi

ded

with

in a

ll p

atie

ntar

eas

of h

ealth

ser

vice

pre

mis

es.

Patie

nts

are

able

to

cont

act

staf

f to

ass

ist

them

with

toile

ting

as r

equi

red.

*

Patie

nts

in t

heir

own

hom

es b

enef

it fr

om s

upp

ly o

feq

uip

men

t to

fac

ilita

te t

oile

ting

as r

equi

red.

Patie

nts

in r

esid

entia

l car

e se

ttin

gs h

ave

evid

ence

of

indi

vidu

al t

oile

ting

req

uire

men

ts d

ocum

ente

d in

the

ir ca

rep

lan.

Stat

emen

tR

easo

ns

for

Stat

emen

tH

ow

to

Dem

on

stra

te S

tate

men

t is

Bei

ng

Ach

ieve

d

All

pat

ient

s ha

ve t

he r

ight

to

striv

e to

mai

ntai

n/ac

hiev

eco

ntin

ence

. C

onta

inm

ent/

cath

eter

isat

ion

shou

ld n

ot b

eus

ed f

or ‘c

onve

nien

ce’ a

lone

.


3

Sect

ion

3:

Ass

essm

ent

of

urin

ary

dys

fun

ctio

n

* W

hils

t it

is

reco

gnis

ed t

hat

ther

e are

sit

uati

ons

whe

re i

t m

ay

be i

nappro

pri

ate

to

ask

qu

esti

ons

rega

rdin

g to

ilet

ing

dif

ficu

ltie

s eg

in

a t

rave

lva

ccin

ati

on c

lin

ic, i

t m

ust

als

o be

rem

embe

red t

hat

peo

ple

of

all a

ges

an

d a

biliti

es c

an

have

con

tin

ence

pro

blem

s. The

tra

veller

may

suff

erfr

om n

octu

rnal

enu

resi

s an

d d

read e

pis

odes

aw

ay

from

hom

e.

**It i

s appro

pri

ate

for

ass

essm

ent

to b

e u

nder

take

n b

y st

uden

ts i

n t

heir

pre

-reg

istr

ati

on c

onso

lidati

on p

lace

men

t an

d b

y all l

evel

s of

reg

iste

red

staff

. Hea

lth

Care

Ass

ista

nts

may

con

trib

ute

to

the

ongo

ing

pro

cess

of

con

tin

ence

ass

essm

ent

thro

ugh

gath

erin

g of

in

form

ati

on a

nd p

rovi

din

gfe

edba

ck. P

hysi

othe

rapis

ts a

nd O

ccu

pati

onal

ther

apis

ts w

ith

addit

ion

al

exper

tise

in

the

are

a m

ay

un

der

take

con

tin

ence

ass

essm

ent

inacc

ordan

ce w

ith

thei

r pro

fess

ion

al

guid

elin

es.

*Ini

tial a

sses

smen

t of

all

pat

ient

s un

derg

oing

a h

olis

ticnu

rsin

g as

sess

men

t, in

clud

es q

uest

ions

reg

ardi

ng b

ladd

erfu

nctio

n/ha

bit.

**W

here

sym

pto

ms

of u

rinar

y dy

sfun

ctio

n ar

e id

entif

ied

the

pat

ient

has

a c

omp

rehe

nsiv

e co

ntin

ence

ass

essm

ent.

The

asse

ssm

ent

is t

rans

fera

ble

acro

ss c

are

sett

ings

and

rem

ains

with

the

pat

ient

thr

ough

out

thei

r he

alth

car

eex

per

ienc

e.

Con

tinen

ce a

sses

smen

t is

cle

arly

dis

tingu

ishe

d fr

omab

sorb

ent

pro

duct

ord

ers.

Reco

rds

of a

ll ho

listic

nur

sing

ass

essm

ents

incl

ude

refe

renc

eto

con

tinen

ce s

tatu

s, a

nd a

ny c

urre

nt t

reat

men

t.

The

initi

al a

sses

smen

t of

a p

atie

nt’s

con

tinen

ce s

tatu

s, in

addi

tion

to g

ener

al in

form

atio

n ga

ther

ed,

incl

udes

the

item

s lis

ted

in F

igur

e 1,

p.4

.

All

nurs

es h

ave

acce

ss t

o in

form

atio

n on

ass

essi

ngin

cont

inen

ce a

nd a

ssoc

iate

d co

ntin

ence

car

e p

lann

ing.

All

nurs

es h

ave

acce

ss t

o an

ass

essm

ent

tool

.

Ther

e is

evi

denc

e of

a d

isch

arge

arr

ange

men

t to

for

war

dco

ntin

ence

ass

essm

ents

/car

e p

lans

thr

ough

out

the

pat

ient

’sca

re.

Con

tinen

ce a

sses

smen

t to

ols

incl

ude

info

rmat

ion

rela

ting

todi

agno

sing

the

cau

se o

f in

cont

inen

ce,

and

care

pla

nnin

g.

Stat

emen

tR

easo

ns

for

Stat

emen

tH

ow

to

Dem

on

stra

te S

tate

men

t is

Bei

ng

Ach

ieve

d

Urin

ary

inco

ntin

ence

is a

com

mon

pro

blem

affe

ctin

g up

to

10%

of

the

pop

ulat

ion

(Roe

et

al 1

996)

.3.

8% o

f p

eop

le o

ver

40 b

oth

exp

erie

nce

sym

pto

ms

ofur

inar

y p

robl

ems

and

wan

t he

lp (

Perr

y 20

00).

"Urin

ary

inco

ntin

ence

is a

sym

pto

m n

ot a

dia

gnos

is…

..as

sess

men

t is

of

cruc

ial i

mp

orta

nce

as e

ffect

ive

man

agem

ent

is d

eter

min

ed b

y ac

cura

te d

iagn

osis

of

the

typ

e of

inco

ntin

ence

" (C

heat

er e

t al

199

9 p

2).

The

emba

rras

smen

t fe

lt by

pat

ient

s, in

dis

cuss

ing

thei

rco

ntin

ence

nee

ds,

is m

inim

ised

by

new

pro

fess

iona

lco

ntac

ts a

lread

y ha

ving

the

info

rmat

ion

avai

labl

e. P

atie

nts

reco

gnis

e th

ere

is in

suffi

cien

t lia

ison

bet

wee

n p

rofe

ssio

nals

(AC

A 2

000)

.

It is

rec

ogni

sed

that

con

tinen

ce ‘a

sses

smen

ts’ a

t p

rese

ntar

e of

ten

little

mor

e th

an a

n or

der

form

for

abs

orbe

ntga

rmen

ts (

Aud

it C

omm

issi

on 1

999)

.

4

Tab

le 1

: In

itia

l ass

essm

ent

of

urin

ary

dys

fun

ctio

n

(This

tab

le r

epre

sents

a c

onse

nsu

s of

the

work

ing

group. I

t w

as d

evel

oped

by c

om

par

ison o

f co

ntinen

ce a

sses

smen

t to

ols

subm

itte

dfr

om

acr

oss

Sco

tlan

d.)

Mai

n co

mp

lain

t

Inco

ntin

ent

epis

odes

Toile

t Pa

tter

n C

apac

ity

Effe

ct o

n q

ualit

y of

life

Ons

et o

f p

robl

em

Patie

nt e

xpec

tatio

ns

Prev

ious

ass

essm

ent/

trea

tmen

t

Envi

ronm

enta

l inf

luen

ces

Mob

ility

/dex

terit

y

Urin

ary

sym

pto

ms

Flui

d in

take

/out

put

Die

t

Con

ditio

n of

ski

n

Urin

alys

is

Med

icat

ion

Med

ical

/sur

gica

l his

tory

Smok

ing

Giv

es a

gen

eral

imp

ress

ion

of t

he p

atie

nt’s

vie

w o

f w

hat

need

s to

be

reso

lved

Volu

me,

fre

que

ncy

and

timin

g –

use

char

t fo

r cl

ear

pic

ture

Patie

nt m

ay b

e co

ntin

ent

but

only

due

to

exce

ssiv

ely

freq

uent

toi

letin

g ➜

redu

ced

blad

der

Incr

ease

d la

undr

y, r

educ

ed s

ocia

l act

iviti

es,

emp

loym

ent,

intim

acy

May

be

indi

cativ

e of

cau

se/t

ype

of in

cont

inen

ce

Patie

nt p

artic

ipat

ion

grea

tly im

pro

ved

if ai

min

g fo

r co

mm

on g

oals

Wha

t w

orke

d? W

hat

didn

’t?

Why

?

Barr

iers

to

toile

ting:

sea

ting,

dis

tanc

e, s

tairs

, do

ors,

sta

ff/ca

rer

avai

labi

lity

Part

icul

arly

with

ref

eren

ce t

o dr

essi

ng,

undr

essi

ng a

nd t

oile

ting

Such

as:

fre

que

ncy,

urg

ency

, dy

suria

, vo

lum

e of

leak

age

and

void

ing

diffi

culti

es

Too

little

➜co

ncen

trat

ed u

rine

➜irr

itate

d bl

adde

r; t

oo m

uch

➜bl

adde

r co

mp

lianc

e p

robl

ems

Effe

cts

on b

owel

hab

it/ur

inar

y p

H

Prob

lem

s du

e to

inco

ntin

ence

/ina

pp

rop

riate

con

tain

men

t

Sym

pto

mat

ic U

TI,

diab

etes

, co

ncen

trat

ed u

rine,

pH

, m

icro

scop

ic h

aem

atur

ia,

pro

tein

uria

Revi

ew f

or s

ide

effe

cts,

as

wel

l as

cont

inen

ce t

reat

men

t

Part

icul

arly

with

ref

eren

ce t

o p

elvi

c, a

bdom

inal

, sp

inal

and

neu

rolo

gica

l pro

blem

s

Chr

onic

cou

gh/p

erip

hera

l neu

rop

athy

/bla

dder

can

cer

Top

icFo

cus

for

Que

stio

nin

g /

In

vest

igat

ion


5

Obs

tetr

ic h

isto

ry

Men

opau

sal s

tatu

s

Men

tal h

ealth

Beha

viou

ral d

iffic

ultie

s

Patie

nt’s

cop

ing

stra

tegy

Bow

el H

abit

Faec

al in

cont

inen

ce

Poss

ibili

ty o

f p

elvi

c flo

or d

amag

e, d

ysp

areu

nia

Falli

ng o

estr

ogen

leve

ls ➜

dry

vagi

na/u

reth

ral m

ucos

a

Awar

enes

s/ef

fect

on

self

care

and

sel

f es

teem

Man

ipul

atio

n us

ing

toile

ting

beha

viou

r, w

ettin

g or

soi

ling

Alte

rnat

ives

to

toile

t (s

uch

as e

xces

sive

fre

que

nt t

oile

ting/

cont

ainm

ent)

use

d

His

tory

of

stra

inin

g, c

onst

ipat

ion

or f

aeca

l im

pac

tion

Patie

nt m

ay b

e re

luct

ant

to m

entio

n fa

ecal

pro

blem

s de

spite

dis

cuss

ing

urin

ary

inco

ntin

ence

Top

icFo

cus

for

Que

stio

nin

g /

In

vest

igat

ion

6

Sect

ion

4.

Co

nti

nen

ce C

are

Plan

nin

g

The

nurs

e an

alys

es t

he in

form

atio

n ga

ther

ed a

nd u

sing

clin

ical

judg

emen

t, f

orm

ulat

es a

dia

gnos

is a

nd d

evel

ops

aca

re p

lan.

The

aim

is r

esto

ratio

n of

con

tinen

ce.

Con

tinen

ce m

anag

emen

t p

lans

are

dev

elop

ed t

hat

are

rele

vant

to

the

typ

e of

inco

ntin

ence

iden

tifie

d.

The

effe

ct o

f th

e co

ntin

ence

man

agem

ent

pla

n is

eval

uate

d at

reg

ular

inte

rval

s.

Follo

win

g a

com

pre

hens

ive

cont

inen

ce a

sses

smen

t th

ep

atie

nt’s

nur

sing

not

es s

how

evi

denc

e of

con

tinen

ce c

are

pla

nnin

g.

All

nurs

es h

ave

acce

ss t

o in

form

atio

n on

the

typ

es a

ndca

uses

of

inco

ntin

ence

and

the

rel

evan

t m

anag

emen

tst

rate

gies

.(F

igur

e 2,

p.6

pro

vide

s p

relim

inar

y in

form

atio

n).

All

nurs

es h

ave

the

opp

ortu

nity

to

regu

larly

up

date

the

irkn

owle

dge.

All

area

s w

hich

pro

vide

ong

oing

car

e fo

r p

atie

nts

have

an

arra

ngem

ent

to u

nder

take

reg

ular

rev

iew

s of

con

tinen

cest

atus

and

con

tinen

ce m

anag

emen

t p

lans

.

Patie

nts

who

are

rec

eivi

ng c

ontin

ence

car

e ar

e re

gula

rlyre

view

ed t

o de

tect

and

add

ress

cha

nges

in t

heir

cond

ition

.

Follo

win

g re

view

the

pat

ient

’s m

anag

emen

t p

lan

isam

ende

d as

ap

pro

pria

te.

Stat

emen

tR

easo

ns

for

Stat

emen

tH

ow

to

Dem

on

stra

te S

tate

men

t is

Bei

ng

Ach

ieve

d

Clin

ical

gov

erna

nce

mea

ns n

ot o

nly

conf

orm

ing

totr

eatm

ent

stan

dard

s, b

ut a

lso

ensu

ring

that

tre

atm

ent

isof

fere

d to

any

one

for

who

m it

wou

ld b

e be

nefic

ial

(Con

tinen

ce F

ound

atio

n 20

00).

Ther

e is

con

side

rabl

e ev

iden

ce t

hat

indi

vidu

alis

edm

anag

emen

t p

lans

can

res

tore

con

tinen

ce o

r gr

eatly

imp

rove

the

qua

lity

of li

fe f

or p

atie

nts

livin

g w

ithin

cont

inen

ce (

Butt

on e

t al

199

8).

Ass

essm

ent

and

care

pla

nnin

g do

es n

ot g

uara

ntee

imp

rove

men

t. T

he p

atie

nt’s

pro

gres

s m

ust

alw

ays

bem

onito

red.

A p

atie

nt’s

hea

lth w

ill c

hang

e in

rel

atio

n to

man

y fa

ctor

san

d th

is c

hang

e m

ay im

pac

t on

con

tinen

ce s

tatu

sre

qui

ring

a ne

w a

sses

smen

t an

d m

anag

emen

t p

lan.


7

Tab

le 2

: B

asic

gui

dan

ce f

or

con

tin

ence

car

e p

lan

nin

g

The

follo

win

g pag

es h

ave

bee

n a

dap

ted f

rom

the

Continen

ce F

oundat

ion "co

ntinen

ce m

anag

emen

t" w

hee

l (1

992)

, ava

ilable

in t

he

Continen

ce F

oundat

ion’s

"Continen

ce R

esourc

e Pa

ck".

Thes

e ta

ble

s pro

vid

e bas

ic info

rmat

ion t

o lin

k d

ata

gath

ered

at

initia

las

sess

men

t w

ith t

he

man

agem

ent

options

avai

lable

to n

urs

es. F

urt

her

rea

din

g is

incl

uded

at

the

end o

f th

e se

ctio

n.

2a.

Fun

ctio

nal

In

con

tin

ence

Trig

ger

que

stio

ns(o

bser

vatio

n of

pat

ient

ess

entia

l)

Und

erly

ing

Cau

se

Con

trol

affe

cted

by

Che

ck f

or:

Nur

sing

man

agem

ent

Sig

ns/

Sym

pto

ms

Un

able

/un

will

ing

to

use

to

ilet

Do

you

have

diff

icul

ty g

ettin

g to

the

toi

let?

Do

you

know

how

to

call

for

help

(if

req

uire

d) t

o ta

ke y

ou t

o th

e to

ilet?

Obs

erve

pat

ient

acc

essi

ng t

oile

t, e

nsu

reth

ey c

an u

ndre

ss,

sit

on t

oile

t, a

nd r

edre

ss.

Esse

ntia

l on

hom

e vi

sits

/prio

r to

disc

harg

e

Redu

ced

mob

ility

/dex

terit

yU

nava

ilabl

e/un

will

ing

care

rsC

onfu

sion

/dis

orie

ntat

ion

Lack

of

mot

ivat

ion/

dep

ress

ion

Com

mun

icat

ion

diffi

culti

es

Att

itude

/ava

ilabi

lity

of c

arer

sD

ehyd

ratio

nPo

lyp

harm

acy

Seda

tion

Diu

retic

s A

nti-d

epre

ssan

ts

Abi

lity

to u

se t

oile

tD

ehyd

ratio

nFa

ecal

imp

actio

n/co

nstip

atio

n

Op

timis

e en

viro

nmen

tSi

gnp

ost

toile

t fa

cilit

ies

Rehy

drat

eC

lear

fae

cal i

mp

actio

n/no

rmal

ise

bow

el h

abit

Imp

lem

ent

indi

vidu

alis

ed t

oile

ting

regi

me/

blad

der

retr

aini

ng p

rogr

amm

eM

otiv

ate

both

pat

ient

and

car

ers

8

Team

dis

cuss

ion

Onw

ard

refe

rral

Sig

ns/

Sym

pto

ms

Un

able

/un

will

ing

to

use

to

ilet

Staf

f at

titud

esRe

view

med

icat

ion

Occ

upat

iona

l the

rap

y/Ph

ysio

ther

apy

inp

ut

Psyc

hiat

ric a

sses

smen

t as

ap

pro

pria

te


9

2b.

Str

ess

urin

ary

inco

nti

nen

ce

Trig

ger

que

stio

ns(p

ositi

ve r

esp

onse

indi

cativ

e of

str

ess

inco

ntin

ence

)

Und

erly

ing

Cau

se

Con

trol

affe

cted

by

Che

ck f

or:

Nur

sing

man

agem

ent

Team

Dis

cuss

ion

Onw

ard

refe

rral

Sig

ns/

Sym

pto

ms

Smal

l sp

urt

of

urin

ary

leak

age

wit

h e

xert

ion

gen

eral

ly le

adin

g t

o d

amp

un

der

wea

r

Do

you

leak

whe

n yo

u co

ugh/

snee

ze/l

ift?

Do

you

leak

if y

ou r

un e

g fo

r a

bus?

Do

you

leak

if y

ou w

alk

dow

nhill

?D

o yo

u le

ak w

hen

you

rise

from

a c

hair?

Do

you

leak

with

out

feel

ing

the

need

to

emp

ty y

our

blad

der?

Whe

n yo

u le

ak d

o yo

u w

et y

our

unde

rwea

r on

ly?

Inco

mp

eten

t ur

ethr

al s

phi

ncte

rW

eak

pel

vic

floor

mus

cles

Hig

h flu

id in

take

Chr

onic

cou

gh (

+/-s

mok

ing)

Hea

vy li

ftin

g (e

.g.

at w

ork)

Ath

letic

life

styl

e (h

urdl

ing/

tram

pol

ine)

Preg

nanc

yC

onst

ipat

ion

Redu

ced

oest

roge

n p

rodu

ctio

n (p

re-m

enst

rual

/pos

t-m

enop

ausa

l)

Ap

pro

pria

te f

luid

inta

ke/v

oidi

ng p

atte

rnC

onst

ipat

ion

Vagi

nal p

rola

pse

Atr

ophi

c ch

ange

s

Nor

mal

ise

fluid

inta

ke/t

oile

t p

atte

rnA

dvis

e re

sm

okin

gN

orm

alis

e bo

wel

hab

it

Trea

t co

ugh

Pelv

ic f

loor

exe

rcis

es +

/- m

edic

atio

n as

ap

pro

pria

tePo

st m

enop

ausa

l vag

inal

sym

pto

ms

Spec

ialis

t p

hysi

othe

rap

y as

sess

men

t an

d ad

vice

re

pel

vic

floor

re-

educ

atio

nU

rolo

gica

l/gy

naec

olog

ical

op

inio

n

10

2c.

Urg

e in

con

tin

ence

Trig

ger

que

stio

ns(p

ositi

ve r

esp

onse

indi

cativ

e of

urg

e in

cont

inen

ce)

Und

erly

ing

Cau

se

Con

trol

affe

cted

by

Che

ck f

or:

Nur

sing

man

agem

ent

Team

dis

cuss

ion

Onw

ard

refe

rral

Sig

ns/

Sym

pto

ms

Un

con

tro

llab

le u

rgen

t d

esir

e to

vo

id,

oft

en r

esul

ts in

wet

clo

thin

g

Do

you

feel

tha

t yo

u ar

e su

dden

ly d

esp

erat

e fo

r th

e to

ilet

and

unab

le t

o ho

ld o

n?D

oes

your

bla

dder

sta

rt t

o em

pty

whe

n yo

u p

ut t

he k

ey in

the

doo

r/re

ach

the

toile

t?D

o yo

u fe

el y

our

blad

der

emp

tyin

g?W

hen

you

leak

are

you

r cl

othe

s w

et?

Ove

ract

ive

blad

der

– bl

adde

r co

ntra

cts

durin

g fil

ling

pha

se

Caf

fein

e in

take

Low

flu

id in

take

Diu

retic

med

icat

ion

Urin

ary

trac

t in

fect

ion

Redu

ced

mob

ility

/dex

terit

yA

nxie

ty

Urin

ary

trac

t in

fect

ion

Con

stip

atio

nN

euro

logi

cal d

isea

sePo

st v

oid

resi

dual

urin

eD

iabe

tes

mel

litus

Nor

mal

ise

fluid

inta

ke

Trea

t ur

inar

y tr

act

infe

ctio

nN

orm

alis

e bo

wel

hab

itIn

divi

dual

ised

toi

letin

g p

rogr

amm

e/bl

adde

r re

trai

ning

Redu

ce c

affe

ine

inta

ke if

ap

pro

pria

te

Ant

i-mus

carin

ic t

hera

py

– un

less

larg

e p

ost-

void

res

idua

l (si

gnifi

cant

>150

mls

)Pe

lvic

flo

or e

xerc

ises

Po

st m

enop

ausa

l vag

inal

sym

pto

ms

Spec

ialis

t p

hysi

othe

rap

y as

sess

men

t an

d ad

vice

Uro

logi

cal a

sses

smen

t


11

2d.

Mix

ed u

rge

and

str

ess

inco

nti

nen

ce

Trig

ger

que

stio

ns

Und

erly

ing

Cau

se

Con

trol

affe

cted

by

Che

ck f

or:

Nur

sing

man

agem

ent

Team

dis

cuss

ion

Onw

ard

refe

rral

Sig

ns/

Sym

pto

ms

Co

mb

inat

ion

of

smal

l sp

urt

urin

ary

leak

age

on

exe

rtio

n a

nd

wh

ole

bla

dd

er e

mp

tyin

gas

soci

ated

wit

h u

rgen

cy

As

for

stre

ss a

nd u

rge

but

givi

ng a

mix

ture

of

pos

itive

res

pon

ses

Ove

ract

ive

blad

der

and

inco

mp

eten

t ur

ethr

al s

phi

ncte

r/w

eak

pel

vic

floor

mus

cles

Caf

fein

e in

take

Low

/hig

h flu

id in

take

Urin

ary

trac

t in

fect

ion

Anx

iety

Obe

sity

Chr

onic

cou

ghLo

w o

estr

ogen

leve

ls (

pre

-men

stru

al/

pos

t-m

enop

ausa

l)

Ap

pro

pria

te f

luid

inta

ke/v

oidi

ng p

atte

rnU

rinar

y tr

act

infe

ctio

nC

onst

ipat

ion

Vagi

nal p

rola

pse

Atr

ophi

c ch

ange

sN

euro

logi

cal d

isea

seD

iabe

tes

mel

litus

Redu

ce c

affe

ine

inta

keN

orm

alis

e flu

id in

take

Trea

t U

TIN

orm

alis

e bo

wel

hab

itIn

divi

dual

ised

toi

letin

g p

rogr

amm

e/bl

adde

r re

trai

ning

Adv

ise

re w

eigh

t lo

ss/s

mok

ing

Ant

i-mus

carin

ic t

hera

py

- un

less

larg

e p

ost-

void

res

idua

l (si

gnifi

cant

>150

mls

)Pe

lvic

flo

or e

xerc

ises

Tr

eat

coug

hPo

st m

enop

ausa

l vag

inal

sym

pto

ms

Spec

ialis

t p

hysi

othe

rap

y as

sess

men

t an

d ad

vice

Uro

dyna

mic

ass

essm

ent

whe

re:

•fir

st li

ne m

easu

res

have

not

res

olve

d th

e p

robl

em•

surg

ical

inte

rven

tion

is b

eing

con

side

red

12

2e.

Inco

mp

lete

bla

dd

er e

mp

tyin

g

Trig

ger

que

stio

ns(p

ositi

ve r

esp

onse

indi

cativ

e of

ove

rflo

w in

cont

inen

ce)

Und

erly

ing

Cau

se

Con

trol

affe

cted

by

Che

ck f

or:

Nur

sing

man

agem

ent

Team

dis

cuss

ion

Onw

ard

refe

rral

Sig

ns/

Sym

pto

ms

Hes

itan

cy,

po

or

stre

am,

pas

sive

dri

bb

le,

freq

uen

cy,

urg

ency

, n

oct

uria

, n

oct

urn

al e

nur

esis

,fe

elin

g o

f in

com

ple

te e

mp

tyin

g.

Rec

urre

nt

UTI

Whe

n yo

u ha

ve p

asse

d ur

ine

do y

ou f

eel t

here

is s

till m

ore

to p

ass?

Do

you

have

diff

icul

ty s

tart

ing

to p

ass

urin

e?D

o yo

u ha

ve t

o st

rain

to

pas

s ur

ine?

Do

you

have

to

retu

rn t

o th

e to

ilet

min

utes

aft

er h

avin

g p

asse

d ur

ine?

Out

flow

obs

truc

tion

eg e

nlar

ged

pro

stat

eU

nder

activ

e bl

adde

r m

uscl

eBl

adde

r m

uscl

e co

ntra

ctio

n an

d ur

ethr

al s

phi

ncte

r re

laxa

tion

not

co-o

rdin

atin

g du

ring

void

ing

Ant

i-mus

carin

ic m

edic

atio

n ca

n in

crea

se r

eten

tion

by r

elax

ing

the

blad

der

mus

cle

UTI

Post

-voi

d re

sidu

al u

rine

(sig

nific

ant>

150m

ls)

Faec

al im

pac

tion/

cons

tipat

ion

Neu

rolo

gica

l dis

ease

His

tory

of

pro

stat

ic e

nlar

gem

ent

Drib

blin

g du

e to

poo

ling

of u

rine

in m

ale

uret

hra

Vagi

nal p

rola

pse

Trea

t sy

mp

tom

atic

UTI

Cle

ar f

aeca

l im

pac

tion/

norm

alis

e bo

wel

hab

itA

llow

pea

ce a

nd p

rivac

y to

voi

dEd

ucat

e re

cor

rect

voi

ding

pos

ition

Mal

e –

man

ual u

reth

ral e

mp

tyin

g p

ost-

void

if p

oolin

g of

urin

eIn

term

itten

t se

lf-ca

thet

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Glossary

anti-muscarinic medication which reduces bladder spasm

assessment a thorough review of the patient’s condition, by

questioning, observation and physical examination

constipation emptying the bowels less frequently than the patient’s

normal habit

containment means of preventing urinary leakage onto

clothing/furniture

continence being able to control the passing of urine

diuretic medication which increases urine production

dysfunction not working properly

dyspareunia pain during sexual intercourse

dysuria pain on passing urine

faecal impaction solid faecal matter blocking the bowel

functional wetting due to being unable or unwilling to access a

incontinence toilet

gynaecological related to health of women’s reproductive system

haematuria blood in the urine

management plan a description of the patient’s future treatment

nocturia passing urine at night

nocturnal enuresis uncontrolled passing of urine at night

oestrogen a female hormone

pelvic floor the sling of muscles which supports the bladder

peripheral disease of the nerves outwith the spine and brain

neuropathy

polypharmacy multiple medicines

post-void residual volume of urine left in the bladder immediately

following bladder emptying

proteinuria protein in the urine

reflex passage of urine as a result of completion of spinal

incontinence reflex arc, outwith brain control

stress leakage of urine, on exertion, due to weak pelvic floor

incontinence

toilet habit usual individual routine for emptying bladder/bowel.

toileting assistance or equipment required to facilitate emptying

requirements of bladder/bowel.

urethral sphincter small circular muscle around the entrance to the

bladder which tightens to hold urine in and relaxes to

allow passage of urine

15

16

urge incontinence leakage of urine, due to uncontrollable bladder spasm

urinalysis testing of urine specimen with a ‘dipstick’ - for sugar,

protein etc.

urinary tract infection of bladder, ureters or kidneys

infection

urogynaecological related to health of women’s urinary and reproductive

systems

voiding passing urine


References:

1 ACA (2000). Survey of patients: national care audit. London:Association for Continence Advice. www.aca.uk.com

2 Audit Commission (1999). First Assessment. London: Audit Commission.

3 Brocklehurst JC (1993) Urinary incontinence in the community -analysis of a MORI poll: British Medical Journal 306: 832-4

4 Button, D. Roe, B. Webb, C. Frith, T. Colin-Thome, D. Gardner, L. (1998).Continence: promotion and management by the primary health careteam. London: Whurr.

5 Brown JS, Vittinghoff E, Wyman JF, Stone KL, Nevitt MC, Ensrud KE, etal (2000) Urinary Incontinence: does it increase risk of falls andfractures? Study of Osteoporotic Fractures Research group. Journalof American geriatric Society; 48 (7): 721-5

6 Cheater, F. Lakhani, M. Cawood, C. (1999). Assessment of patients withurinary incontinence: evidence-based audit protocol for primaryhealth care teams.

7 Department of General Practice and Primary Health Care: Universityof Leicester. Protocol CT15 Assessment of Patients with UrinaryIncontinencewww.le.ac.uk/cgrdu/protocol.html

8 Continence Foundation, (1996). The Continence Resource Pack.London: The Continence Foundation. www.continence-foundation.org.uk

9 Continence Foundation, (2000). Making the case for an integratedcontinence service. London: The Continence Foundation.www.continence-foundation.org.uk/

10 Perry, S. Shaw, C. Assassa, P. Dallosso, H. Williams, K. Brittain, K R.Mensah, F. Smith, N. Clarke, M. Jagger, C. Mayne, C. Castleden, C M.Jones, J. McGrother, C., (2000). An epidemiological study to establishthe prevalence of urinary symptoms and felt need in the community.Journal of Public Health Medicine, 22 (3)

11 Roe, B. Wilson, K. Doll, H. Brooks, P. (1996). An evaluation of healthinterventions by primary health care teams and continence advisoryservices on patient outcomes related to incontinence. Department ofPublic Health and Primary Care: University of Oxford. (Summaryvolume available from the Continence Foundation)

17

18

12 Royal College of Physicians (1995). Incontinence: causes managementand provision of services. London: Royal College of Physicians.www.rcplondon.ac.uk/pubs/brochures/pub_print_pc.htm

13 Scottish Intercollegiate Guidelines Network (SIGN) December 2004SIGN Guideline 79 Management of urinary incontinence in primarycare Dec 2004 [updated Sept 2005}. Edinburgh SIGNwww.sign.ac.uk/guidelines/published/index.html accessed 09/11/05

Recommended reading:

Button, D. Roe, B. Webb, C. Frith, T. Colin-Thome, D. Gardner, L. (1998).Continence: promotion and management by the primary health careteam. London: Whurr.

Norton, C. (1996). Nursing for Continence. London: Beaconsfield.


Appendix 1

Best practice statement audit tool

Continence care –

adults with urinary dysfunction

This audit tool is also available at www.nhshealthquality.org

In some sections the audit tool provides lists of data to be recorded. Best practice suggests 100% of information should be recorded. It is for eachuser to agree what percentage would count as meeting the criteria.

This audit tool is intended to be used as part of the audit cycle. This can bedescribed as the use of audit to identify areas for improvement, drawing up aplan and implementing improvements in these areas, and re-auditing toevaluate and define areas for further improvement. This should raise thestandard expected with each cycle of audit.

This tool may be used by organisations to audit their continence service oradapted by individuals to audit their own practice.

19

20

Best practice statement audit tool Date of audit …….........

Continence care Name of auditor ………

Criteria to be audited Yes No Action

Do local procedure manuals include reference to continence difficulties, specific to your speciality, which may be experienced by patients?Is continence training provided for staff?What % of nursing/care staff have attended continence care training in the previous 12 months?Do all displays of public information leaflets include general information on appropriate fluid intake and toileting habits, to promote the healthy bladder?Are accessible toilet facilities provided within all patient areas of your service premises?Are patients able to contact staff to assist them with toileting as required? Does your service use a continence assessment tool?Is the patient’s continence care plan transferred through all care areas?

No of No %records meeting meetingaudited criteria criteria

Do all patients have evidence of individual toileting requirements documented in their care plan (to enable continence)?Do all individuals with continence problems have a personal continence care plan taking into account:

• individual’s perception of problem/solution

• individual’s own coping strategies

• environmental influences

• mental health

• fluid intake

• urinalysis

• frequency/volume of incontinent episodes

• condition of skin

• diet/bowel habit

• medication effects/side effects

• previous assessments/treatments

Is consideration given to any other risk factors eg:

• reduced mobility/dexterity

• infection control issues

• moving and handling issues

• acute illnessFor individuals for whom continence problems have been identified, is there evidence within the personal continence care plan of a proactive approach to regain continence rather than containment (pads/sheaths/catheters) as the sole solution?For individuals who have a continence care plan is there evidence of the plan being evaluated and revised as appropriate?


21

Appendix 2

Who was involved in developing and reviewing thestatement?

Project leader:

Linda Morrow, Team Leader, Care Commission

Working group:

Helen Arnold* Physiotherapist NHS LothianMary Ballantyne* Clinical Nurse Specialist NHS Greater GlasgowJane Campbell Continence Advisor NHS Ayrshire & ArranHelen Cheyne Research Fellow Nursing Research

Initiative ScotlandNorma Craig* Continence Advisor NHS TaysideSuzanne Hagan Programme Leader Nursing Research

Initiative ScotlandChris Harris* Urology Nurse Specialist NHS LothianAnne Jamieson* Continence Advisor NHS Dumfries &

GallowayCathy McKerrell* Support Network Manager Incontact.Anita Neilson* Lecturer University of PaisleyRosemary Noon* Continence Advisor NHS Argyll & ClydeJim Torrance* Continence Advisor NHS BordersPamela White Continence Advisor NHS Ayrshire & ArranHilary Wright* Clinical Nurse Specialist NHS Lothian

Reference group

Patrick Beausang Consultant, Dept. of NHS Forth ValleyAgeing and Health

Jo Booth Nurse Consultant NHS Forth Valley(older people’s services)

Mary Brown District Nurse NHS LothianPeter Cartwright Lead Nurse (mental health) NHS Argyll & ClydeVeronica Cornet District Nurse NHS LothianCarolyn Hall Clinical Nurse Specialist NHS Highland

(urology)Ellen Hudson Lead Nurse NHS Argyll & ClydeJoan Kay Ward Sister NHS BordersAnnette Lobo Clinical Midwifery NHS Fife

Services Co-ordinator

22

Laurence Stewart Consultant Urologist NHS LothianPat Tyrell Lead Nurse NHS Argyll & ClydeEdna Watson Nursing Development NHS Shetland

Officer

Statement review 2005

The reference group provided consultation to the original documentdeveloped by the working group, and it was then sent out for widerconsultation across Scotland. The statement was reviewed by reconveningmembers from the original working group. Those marked * took part inthe review process, updating the statement and by further consultationwith relevant specialists across Scotland.

Support from NHS QIS

Penny Bond Practice Development Professional OfficerRosemary Hector Practice Development Project Co-ordinator

© NHS Quality Improvement Scotland 2005

ISBN 1-84404-285-5

First published May 2002Updated November 2005

You can copy or reproduce the information in this document for use within NHSScotland and foreducational purposes. You must not make a profit using information in this document.Commercial organisations must get our written permission before reproducing this document.

www.nhshealthquality.org

Best Practice Statement ~ November 2005

Continence - adults with urinarydysfunction

NHS Quality Improvement ScotlandEdinburgh Office Glasgow OfficeElliott House Delta House8-10 Hillside Crescent 50 West Nile StreetEdinburgh EH7 5EA Glasgow G1 2NP

Phone: 0131 623 4300 Phone: 0141 225 6999Textphone: 0131 623 4383 Textphone: 0141 241 6316

Email: [email protected]: www.nhshealthquality.org

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