Continence /ConstipationWorkshop for RNs in Long-Term Care

Participant’s Package

Supporting Implementation of the RNAO BPGs: Promoting Continence Using Prompted Voiding and

Prevention of Constipation in the Older Adult Population

May 2007

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TABLE OF CONTENTS PAGESParticipantObjectives 2

ModuleOne:Assessment 3

AssessingFluidIntake 3

WaterContentofFluids 3

ProcedureforUsingtheVoidingRecord 4

VoidingRecord 5

ToiletingSchedule 6

BristolStoolFormScale 7

BowelEliminationRecord 8

ModuleTwo:Hydration 9

Hydration,AdequateFluidIntakeCrossword 9

HydrationMiniCaseStudy 10

ModuleThree:PromptedVoiding 11

RolePlay 11

PromptedVoidingCrossword 12

PromptedVoiding:Wordsearch 14

ModuleFour:Abilities 15

AbilitiesMiniCaseStudy 15

Abilities:Crossword 16

GetupandgoCookierecipe 18

SourcesofFibre:Crossword 19

ManagementofConstipation:Wordsearch 21

ConstipationMiniCaseStudy 22

ModuleFive:Abilities 23

PersonalHygieneMiniCaseStudy 23

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Participant Objectives

1. Togainunderstandingoftheutilitzationofthevoidingrecordasatoolintheassessmentofincontinence.

2. Tolearnhowtocompletethecomponentsofthevoidingrecord.

3. Tolearnhowtoanalyzethevoidingrecordtodeterminearesident’snormalvoidingpatterns.

4. Tolearnhowtosetupanindividualizedtoiletingschedulebasedontheresident’snormalvoidingpatterns,usingatoiletingscheduletool.

5. Tounderstandtheutilizationofthebowelrecordasatoolintheassessmentofbowelfunctionandtheplanofcare.

6. TobecomefamiliarwiththeuseoftheBristolStoolCharttomonitorthequalityofbowelmovements.

7. Tounderstandtheeffectsofdementiaonolderpersons’toiletingabilities.

8. Tounderstandtheimpactoffluidintakeonurinaryincontinenceandbowelfunction.

9. Tounderstandtheeffectofcaffeineonthebladderandbowel.

10. Tolearnhowtoutilizethepromptedvoidingintervention.

11. Tounderstandtheimpactofdietaryfiberintakeonbowelfunction.

12. Torealizetheimportanceofconsistenttoiletingforabowelmovement.

13. Tounderstandtheimportanceofpersonalhygiene.

14. Tobecomeawareofappropriatecontainmentoptionsandspecificskincareproductsavailableforthespecificneedsofresidents.

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MODULE 1: ASSESSMENTAssessing Fluid Intake

CalculatingFluidIntake–pleaserecordthetime,typeoffluidandamountoffluidintakefor24hoursovertwodays.

1cupcoffeeorteaontrays=200mLfluid

*1milkcartononyourtray–250mLfluidatbreakfast,125mLatlunchandsupper

1icecreamorsherbetcup=100mL

1Jello=approx100mL

1smallbowlcannedfruit+2tablespoonsjuice=50mL

1creamerforcoffeeortea=15mL

1bowlofsoup=about200mL

1juice=125mL

*thetwodifferentsizedmilkcartonsareusedsothatmilkintakemeetstheCanada’sFoodGuidetoHealthyEatingstandard.

Water Content of liquid supplements/tube feeding products

Notethatthoughthecontainervolumeis,forexample250mLs,thatisNOTthewatercontent.

RegularEnsure–200mLwater/tin

EnsureHighProtein–180mLwater/tin

EnsurewithFibre–180mL/tin

EnsurePlus–162mL/tin

Jevity197mL/tin

JevityPlus190mL/tin

Glucerna197mL/tin

ResourceFruitBeverage–207mL/tin

NuBasicsVHP–212mL/tin

IsosourceHN203mL/tin

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Procedure for using the Voiding Record

Aurinehatisusedtocollectandmeasurearesident’surineoutput.Long-termcarestaffrecordtheamountoffluideachtimetheresidentvoidsandrecordsitinthe‘void’columnnexttothenearesthalfhour.Thetypeandamountoffluidintakeisalsodocumented.Ifpossible,wetepisodesarealsorecordedinthewetcolumn.

Afterfourdays,LTCstaffareleftwithadetailedrecordoftheresident’svoidingpatternsandtypeandamountoffluidintake.Thiscompletedrecordwillassistthestaffinsettingupanindividualizedtoiletingschedulebasedontheresident’svoidingpatterns.Itwillalsohelpthestafftorecognizefactorsthatcontributetourinaryincontinence.Forexample,theamountoffluidintake(i.e.toomuch,toolittle,amountofcaffeinetheresidentconsumes)andtherelationshipbetweenthesecontributingfactorsandtheincontinentepisodes.

TIP: It may be useful to develop a cue card of typical amounts of fluid offered at each meal. This will help staff to calculate the amount of fluid taken by the resident.

EvaluationandtheVoidingRecord

Repeatingthevoidingrecordsafterafewweeksofthepromptedvoidinginterventionshoulddemonstrateanincreasednumberofsuccessfulvoidsanddecreasednumberofwetepisodes.Thereshouldalsobeademonstrableincreaseinfluidintake.

RNAO’sBestPracticeGuidelineswebsitehasmanyfreeimplementationresources tosupportuptakeofthecontinenceandconstipationguideline,andmanyothers. Visitwww.rnao.org/bestpracticetoview

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EVESHIFT DAYSHIFT NIGHTSHIFT

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The Bristol Stool Form Scale

Type 1

Type 2

Type 3

Type 4

Type 5

Type 6

Type 7

Separatehardlumps,likenuts(hardtopass)

Sausage-shapedbutlumpy

Likeasausagebutwithcrackesonitssurface

Likeasausageorasnake,smoothandsoft

Softblobswithclear-cutedges,(passedeasily)

Fluffypieceswithraggededges,amushystool

Watery,nosolidpiecesENTIRELYLIQUID

ReproducedbykindpermissionofDrKWHeaton,ReaderinMedicineattheUniversityofBristol.ProducedbyNorgineLimited,manufacturedofMovicol®.

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Bowel Elimination Record

Date: Date:

Nights

BMHrContinentNature (Type)AmountToiletFluid intake24-hour intakeFibre intakeTreatment

Referrals/Consults

Total # of BMs#Episodes ofConstipation/fecal stainingInitials

Legend: BM (Bowel Movement): � Enter time Continent: � = Continent I = IncontinentAmount: S = small ( <250 ml); M = normal ( >250 - < 500 ml); L = large ( > 500 ml); FO = oozing; FS = stainingNature: Bristol Stool Chart TypeToilet: T = toilet; C = commode; B = bedpan; SL = side lyingFluid intake: Record actual amount consumed per shift. Calculate 24-hour intake.Fibre intake: Record number of fibre items consumed.Treatments: PRN laxatives, suppositories, enemas, rectal stimulation. Enter time treatment given and initials.Regularly prescribed laxatives are recorded on Medication Administration Record (MAR).Referrals: D = Dietitian; NCA = Nurse Continence Advisor; OT = Occupational Therapy; P= Pharmacy; PT = PhysiotherapyEnter total # of BMs:

Enter total episodes of constipation/fecal soiling

Registered Nurses Association of Ontario (2005). Prevention of Constipation in the OlderAdult Population. (Revised). Toronto, Canada: Registered Nurses Association of Ontario. Trial#1068

415157 (Rev. 2005.07.26

NightsDays DaysEvenings Evenings

Nights NightsDays DaysEvenings Evenings

Date: Date:

Patient/Resident Name:

A D D R E S S O R G R A P H

BMHrContinentNature (Type)AmountToiletFluid intake24-hour intakeFibre intakeTreatment

Referrals/Consults

Total # of BMs#Episodes ofConstipation/fecal stainingInitials

Bowel Elimination Record

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MODULE 2: HYDRATION

Hydration Adequate Fluid Intake: Crossword

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4 Thebesttypeoffluidtodrinkandanaturalstoolsoftener.(1word)

8 Aninterventioneverytimeyouareintheresident’sroom.(3words)

9 2litresoffluidintakein24hoursisconsideredtobe(1word)

11 Whatmakeswatertastebetterforsomepeople?(1word)

12 Acaffeinatedbeverage.(1word)

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1 Whattypeoffluidhasadehydratingeffectandisnotconsideredintotalfluidintakecalculation?Itiscalculatedseparatelyasatotalamount.(1word)

2 Acaffeinatedbeverage.(1word)

3 Acomponentoffluidintakerecordedonthevoidingrecord.(1word)

7 Acaffeinatedbeverage.(1word)

10 Acomponentoffluidintakerecordedonthevoidingrecord.(1word)

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Hydration Adequate Fluid Intake: Crossword (answers)

Hydration Mini Case StudyMrs. Smith states that she does not like drinking water. She takes sips of water, only with her medications. She drinks only tea with all her meals, and has soup occasionally. She sometimes has a small cup of ginger ale in the afternoon.

Whatisyourassessmentofherfluidintake?

a)Belowminimumadequate

b)Minimumadequate

c)Adequate

G I V E F L U I D O F T E N

W A T E R

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MODULE 3: PROMPTED VOIDINGRole-playScript:ApproachingtheResidentaboutPromptedVoiding

1.Contacttheresidentfollowingtheindividualizedtoiletingschedule.(basedontheirnormalvoidingpatterns).PROMPT

2.Focustheirattentiononvoidingbyaskingthemwhethertheyarewetordry.MONITOR

3.Checkthemforwetness,recordonvoidingrecordandgivefeedbackonwhethertheyarecorrectorincorrect.MONITOR

4.Whetherwetordry,asktheresidentiftheywouldliketousethetoilet,bedpanorurinal.PROMPT

If“Yes”

a)Assistthem.PROMPT

b)Recordtheresultsonthevoidingrecord.MONITOR

c)Givethempositivereinforcementbyspendinganextraminuteortwotalkingwiththem.PRAISE

If“No”

a)Promptandencouragethemtotoilettwomoretimes.PROMPT

Ifresidentcontinuestosayno,tellthemwhenyouwillbebackandrequestthattheytrytodelayvoidinguntilthen.

5.Offertheresidentadrinkoffluidbeforeleaving.HYDRATION

6.Iftheresidentspontaneouslyrequeststoiletassistance,provideitandrecordtheresultsonthevoidingrecord.Givetheresidentpositivereinforcementbyspendinganextraminuteortwotalkingwiththem.PROMPTOffertheresidentadrinkoffluidbeforeleaving.HYDRATION

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Prompted Voiding: Crossword

ACROSS

5 Reinforcement(1word)

8 Oneofthethreestrategiestosupportpromptedvoiding(1word)

9 Thebestindicatorofsuccessisa(1word)

DOWN

1 Thetypeoftoiletingschedule(1word)

2 Theresident’snormalvoiding(1word)

3 Onefthethreestrategiestosupportpromptedvoiding(1word)

4 Onefthethreestrategiestosupportpromptedvoiding(1word)

6 Verbal(1word)

7 Typeofrecord

8 ProtectiveUnderwear(1word)

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PROMPTED VOIDING (answers)

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Prompted Voiding: Word Search

Findthewordsinthegrid.Wordscangohorizontally,vertiacallyanddiagonallyinalleightdirections.

Individualized

Monitor

Pattern

Praise

Prompt

Schedule

Toileting

Voiding

I N D I V I D U A L I Z E D

T K N G Z N E Q K R L K Q C

T R V B N L L S G T K B P V

D S T K H C K Z I K W P R H

N C D O B H C P P A R V D G

N H F G I X J K P O R W K N

B E R J C L D L M V N P D I

J D K R Q D E P T R D P N D

N U K R R T T T E Z F X H I

T L P P D M N T I L Z T N O

T E X H R L T T N N Z M J V

N R T B J A H Q T K G N N X

N M W T P B L D Q Y R N W N

R O T I N O M C Q L V R M C

I N D I V I D U A L I Z E D

T K N G Z N E Q K R L K Q C

T R V B N L L S G T K B P V

D S T K H C K Z I K W P R H

N C D O B H C P P A R V D G

N H F G I X J K P O R W K N

B E R J C L D L M V N P D I

J D K R Q D E P T R D P N D

N U K R R T T T E Z F X H I

T L P P D M N T I L Z T N O

T E X H R L T T N N Z M J V

N R T B J A H Q T K G N N X

N M W T P B L D Q Y R N W N

R O T I N O M C Q L V R M C

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MODULE 4: ABILITIES Abilities Mini Case StudyMr. Brown is aware of the need to pass urine, but he cannot find the toilet, or he has forgotten that the toilet is the socially appropriate place to pass urine. Staff observe him passing urine in strange places, like the garbage pail and behind the door in his room. His situation dem-onstrates significant excess disabilities (Dawsonetal.,1986) related to his capacity to successfully void in a toilet with staff interventions. He has retained his ability to respond to his name and he is able to follow one-step instructions. He is able to feed and dress himself.

Do you think the Mr. Brown will respond to the prompted voiding intervention?

a)Yes,Mr.Brownwouldlikelyrespondwelltopromptedvoiding.

b)No,Mr.Brownwouldnotlikelyrespondwelltopromptedvoiding.

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Abilities: Crossword

ACROSS

2 Understandingreminders(1word)

4 Motivationtobecontinent(1word)

7 Attentiondeficitsandconversation(1word)

8 Voluntaryandpurposefulmovement.Specialorientation(2words)

10 Identifyingtheurgetovoid(1word)

11 Recognitionandrecall(1word)

12 Rememberinghowtorespond(2words)

DOWN

1 Sittingonthetoilet(2words)

3 Voluntaryandpurposefulmovement(2words)

5 Askingforassistance(1word)

6 Comprehensionandexpression(1word)

9 Rememberinghowtorespondandlocatethetoilet(1word)

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Abilities: Crossword (answers)

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Get Up and Go Cookies½cupmargarineorbutter

1cupbrownsugar

½cupprunepuree

1egg

1cupapplesauce-anyflavour

2cupsbrancereal

1½cupsflour

½teaspoonbakingsodaand1teaspoonofcinnamonoryourfavoritespice

Optional:½to1cupraisins,orchocolatechips,sunflowerseeds,nuts,whateveryoulikeincookies.

Directions:Inalargebowl,creammargarinewithsugar.Addegg,thenprunepuree,thenapplesauceandmixwell.Adddryingredients.Mixwell.Dropbyspoonfulsonto3cookiesheets-12cookiesasheet.Bakein350oovenforabout15minutes.Coolonpansforafewminutesandthenremove.Freezecookiesandbegineating2cookiesaday.

Prune pureeIngredients:375grambag=about50prunes.

Dirrections:Putinsmallpotwith1cupofwater.Heatonstovetopuntilhot.Coolandmash.Storeunusedpureeinfridge.Youcanaddgratedlemonrindwhilecookingforaddedflavour.Alternatively,youcanmashpittedprunesfromcanwithsomeofthejuice,orusebabyfoodprunepuree.

Eachcookie=80.6calories,2.8gramoffat,1.67gramsoffibrepercookie.

Lowerfatrecipe•use¼cupmargarineandincreaseapplesauceto1¼cups•use2eggwhitesoreggreplacementproductssuchasEggbeaters®insteadof1wholeegg

Eachcookie=68.6calories,1.4gramsoffat,1.67gramsoffibrepercookie

Lowersugarrecipe•use1cupofSugarTwin®brownorwhitesugar•useunsweetenedapplesauce

Eachcookie=62.6calories,1.4gramsoffat,1.67gramsoffibrepercookie

Highfibrerecipe•use¾cupwholewheatflourwith¾cupwhiteflour

•use½cupwholewheatwith½cupwhitewith½cupoatmeal.Youmayneedtoincreaseapplesauceby¼to½cuptomakethemmorechewy.

Eachcookie=89.4calories,2.8gramoffat,1.97gramsoffibrepercookie.

Remember:Fibreabsorbswatertosoftenstool.Youneedtodrinkplentyofwater,ifyourdietallows,tohelpthesecookiestowork.

©1997ContinenceProgram,St.Joseph’sHealthcare,Hamilton,OntarioPD3432

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WEBACTIVITY:

Visit: www.dhhs.tas.gov.au/healthyliving/nutrtion/documents/quick-fibre-quiz.pdfwww.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/quiz_fibre?open

forquizzesonsourcesoffibre.

Sources of Fibre: Crossword1

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5 Freshvegetables(1word)

9 Freshfruit(1word)

10 1.5litresto2litresfluidintakein24hoursbeforeaddingfibresources.(3words)

11 Atypeofbreadwithfibre(2words)

DOWN

1 Theindigestablepartsofplants.Itpreventsconstipationbybulkingupthestools.(1word)

2 Nuts(1word)

3 Gramsoffibreperday.(2words)

4 Afibresupplement(2words)

6 Atypeofcerealwithfibre(2words)

7 Beans(1word)

8 Fibreisintroduced

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Sources of Fibre: Crossword (answers)

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B R O C C O L I

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A D E Q U A T E F L U I D I N T A K E

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Managing Constipation: Word search

Findthewordsinthegrid.Wordscangohorizontally,verticallyanddiagonallyinalleightdirections

Caffeine

Exercise

Fibre

Fluid

Privacy

Squat

Toileting

G E S I C R E X E

N N N K W G N Q E

I F I B R E P N P

T D F Z G T I L R

E I S F T E V G I

L U B Q F P R K V

I L B F U N W R A

O F A W V A N D C

T C R R W X T Y Y

G E S I C R E X E

N N N K W G N Q E

I F I B R E P N P

T D F Z G T I L R

E I S F T E V G I

L U B Q F P R K V

I L B F U N W R A

O F A W V A N D C

T C R R W X T Y Y

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Constipation Mini Case StudyMs. Purdy is an 83 year old resident recently admitted to a long-term care facility. She has recent onset constipation and has now been placed on a bowel routine consisting of laxatives and suppositories. She was experiencing easy to pass stools at home. She is frustrated about not toileting as she has been used to at home. She is worried about privacy as she now shares a room with another resident. She feels rushed and experiences embarrassment due to a lack of privacy. She is not able to relax and take the time necessary to have a bowel movement.

Ms. Purdy is also a bit depressed about adjusting to her new living arrangements. She is not eating or drinking much, except for tea with every meal. She likes prunes and bran cereal, but has not had these on her tray. She is also not getting outside for walks as before.

Which of the following factors could be contributing to Ms. Purdy’s constipation?

•Lowfluidintake

•Caffeineintake

•Lowfibreintake

•Decreasedphysicalexercise

•Emotionaldistress

•Lackofprivacy

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MODULE 6: PERSONAL HYGIENE Personal Hygiene Mini Case StudyMs. Birkshire has experienced multiple symptomatic urinary track infections since her admission to the long-term care home. She has been using soap to wash and has a hard time cleaning front to back after having a bowel movement.

What product would you suggest she use for personal hygiene?

How will you assist her with personal hygiene ensuring that this care is provided, especially following a bowel movement?