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The Art of Incontinence Care of Elderly

Lam Mo Ching

Continence Advisor/NO

Fung Yiu King Hospital

13-7-2013

What is a normal Bladder?

Total Control = No leakage

Passing Urine < 7 times a day

< 2 times at night

No odour, No infections

Can hold 400-600ml

Desire to void ---150ml

Strong desire to void ---400ml

Peak flow 30 mi/sec (female), 20-25ml/sec (male)

Capable of bladder emptying

No dribbling

Ageing Bladder

Ageing = Incontinence ?

Elderly with Age > 65

13% in 2011

28% in 2039 (CSD 2012)

8% older people living in Recidential care home for the elderly ( RCHEs)

> 700 RCHEs in HK

> 73,000 places (private + subvented)

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Prevalence of Urinary Incontinence

Acute care Hospital 10.9%

Convalescene Hospital 37.6%

C & A Home 23.2% (Study on institutionalized elderly 1990)

Elderly Community 5% - 15%

Nursing Home 50% - 70%

Hospitalized 30% - 50%

Women is twice as common as men

28.4% over 60 years attending GP (Hong Kong Continence Society and Hong Kong College of Family

Physician, 1996).

Causes of Urinary Incontinence in the Elderly

Environment Causes

1. Unfamiliar Environment

2. Poor access to toilet

3. Lack of privacy

4. Unconducive toilet facilities

5. Negative attitudes of care-givers

Causes of Urinary Incontinence in the Elderly

Transient Causes (DIAPPERS)

D (Delirium)

I (Infection)

A (Atrophic vaginitis or urethritis)

P (Pharmaceutical)

P (Psychological disorder)

E (Endocrine disorder)

R (Restricted mobility)

S (Stool impaction)

Common types of Urinary Incontinence of Elderly

Stress Incontinence

Urge Incontinence

Overflow Incontinence

Functional Incontinence

Mixed type

Reflex Incontinence

Nursing Assessment of Urinary Incontinence

History taking

Physical examination

Diagnostic investigation

Bladder and continence chart

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Investigations

Post void residual urine volume Urinalysis: leukocytes, nitrites, blood Pad Test Urine culture / cytology Renal function tests Blood glucose, calcium Ultrasonagraphy X-ray: KUB Urodynamic study Cystoscopy

Transient causes (DIAPPERS)

Delirium

Infection

Atrophic vaginitis/urethritis

Pharmaceuticals

Psychological

Excessive urine output/Endocrine

Restricted mobility

Stool impaction

Management of Transient cause

Environmental➪ provide urinal, bed side commode, improving access to toilet

D➪ Sepsis & drug are common causes I➪ A course of antibiotics according to c/stA➪ Oral hromonal therapy/estrogen creamP➪ Try to replace the medicationP➪ Trial of antidepressant

E➪ Control DM well to control polyuriaR➪ Optimizing medical therapy & active PT/OTS➪ Stool softeners/enema/manual evacuation/

oral laxatives/ suppositories

Cranberry juice

Strategies of Bladder Management

1. Pelvic floor exercise

乾隆養生之道

耳常彈

珠常轉

鼻常揉

面常搓

齒常扣

津常嚥

肚常施

肢常伸

肛常提 pelvic floor exicise

腳常摩

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Strategies of Bladder Management

1. Pelvic floor exercise

2. Behavioural technique Bladder retraining Habit training Timed voiding Prompted voiding Deferment technique

3. Aids for social continence Intermittent catheterization External pouches/ clip collector Absorbent pads/ diapers Indwelling catheters

Bladder Training(Bladder re-education/

retraining/drill/discipline)

Bladder diary (Continence Chart)

bladder chart frequency volume chart

Education

Educate the patient regarding the mechanismof incontinence and urgency

control techniques

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Deferment technique

To suppress bladder contraction

To delay the time of toilet visit

Pelvic floor muscle contraction

Perineal pressure

Mental distraction

Penile squeeze

Breathing exercise

Methods to help reduce urgency (1)

Remove the causative stimuli e.g. turn off any running taps

Standing still and crossing legsmay be helpful.

Changing position can be useful for some people.

Methods to help reduce urgency (2)

Applied perineal pressure by sitting on something hard e.g. the arm of the chair, a rolled towel.

Contract the PFM, try to hold for 20 second.

Methods to help reduce urgency (3)

Distract your mindby thinking of some complex but possible task, e.g. the alphabet backwards or a mathematical problem, until the sensation subsides.

Methods to help reduce urgency (4)

Standing on your toes may be helpful.

Methods to help reduce urgency (5)

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Baseline voiding diaries revealing an average voiding interval of less than one hour

A shorter initial voiding interval (i.e. 30 minutes or less) may be necessary for women

Must have a normal fluid intake.

Voiding schedule (1) Voiding schedule (2)

Instruct patient to void every hourduring the day.

Must not void in between these times – either she waits or she is incontinent.

Urgency control techniques are also incorporated.

Voiding schedule (3)

When a one-hour interval is achieved, increase intervals by 15/30 minutes/week, depending on tolerance of the schedule, until a 2 to 3-hour voiding interval is achieved.

Positive reinforcement (1)

Self monitoring of voiding behaviour using a voiding diary

To determine compliance with the schedule

Evaluate progress and determine whether the voiding interval should be changed.

Clinician/Nurse should monitor progress, determine adjustments to the voiding interval and provide positive reinforcement at least weekly during the training period.

Relative’s support

Positive reinforcement (2)

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If there is no reduction in incontinence episodes after three weeks of bladder training, the patient should be reevaluated and other treatment options should be considered.

Timed Voiding (1)

Timed voiding (2)

Method

A fixed voiding schedule that remains unchanged throughout treatment. (Rigid regime)

To prevent incontinence by providing regular opportunities for bladder emptying prior to incontinence.

Timed Voiding (3)

Recommended for patients who cannot participate in independent toileting.

In institutional settings and passive toileting assistance programmes

Need a motivated care-giver takes the patient to void every 2-4 hours including at night.

Habit Training (1) Habit training (2)

Method

The same rationale as timed voiding method

except that the voiding scheduletries to match the individual voiding habits so as to prevent incontinence episodes.

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Habit Training (3)

An initial monitoring period is used to determine the patient’s specific incontinence profile and individual schedule is then defined.

Prompted voiding

The patient is asked if he/she wants to void at regular interval- only taken to toilet if response is positive

An effective behavioural modification for the correction of urge and functional incontinence in institutional patients with mental and physical disabilities

Need motivated staff to help

Strategies of Bladder Management

1. Pelvic floor exercise

2. Behavioural technique Bladder retraining Habit training Timed voiding Prompted voiding Deferment technique

3. Aids for social continence Intermittent catheterization External pouches/ clip collector Absorbent pads/ diapers Indwelling catheters

Catheter Care

Catheter insertion

Avoid catheterization

Only trained personnel or trainee under supervision

Using aseptic technique and sterile equipment

Single-use packet of lubricant jelly

Sterile water for balloon inflation 5-10ml of water

Female: Size 12-16 Ch.

Male: Size 12-18 Ch.

Catheter Care

Avoid kinking if catheter and collecting tube.

Urine bag should always keep below level of bladder.

Avoid outlet of urine bag touching the floor.

Frequency of changing drainage bag

Secure indwelling catheter

Strap catheter onto the thigh for ambulatory people, but strap onto lower abdomen only for bed bound client.

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Catheter Care

Do not allow the catheter to touch any surface

Inflate the catheter balloon with 5-10ml sterile water.

Connect the catheter to a urinary drainage bag.

Secure the catheter properly.

Hang the urinary bay below the level of bladder.

Problems & Complications of

Indwelling Catheter (1)

Urethral pain or discomfort

Possible causes Management

Too large catheter or

balloon

Blocked catheter

Urethral trauma or

lesion

Unstable bladder

contraction

Treat the cause

accordingly

High Fluid intake

Problems & Complications of

Indwelling Catheter (2)

Catheter-associated UTI & Colonization

Possible causes Management

Bacteriuria (Colonization ) is

inevitable after 2-4 weeks

Too large balloon size

Insufficient fluid intake

Broken the closed system

? Aseptic technique not

satisfactory

Insufficient handwashing

Antibiotic is indicated

only when symptomic

Maintain closed drainage

system

Catheter need to changed if

UTI

Strict aseptic technique

Sufficient handwashing

Problems & Complications of

indwelling catheter(3)

Leaking of urine

Possible causes Management

Blocked catheter

Drainage bag above level

of bladder

Unstable bladder

contraction (ie: detrusor

hyper-reflexia too large

catheter or big balloon )

Change blocked catheter

Change to small catheter

with 5-10ml balloon

Remove kinks or twists

Use anti-cholenergic drugs

for unstable contraction due

to detrusor hyper-reflexia

Problems & Complications of

Indwelling Catheter ( 4)Non- deflating balloon

Possible causes Management

Catheter shaft being clamped

cause collapse of inflating

channel

Catheter materials swelled up

leading the valve to stick

Using wrong solution ( not

sterile water ) for inflation

Avoid clamping to the catheter

shaft

Use syringe and needle to

aspirate directly through the

inflation channel

Consult surgeon for

puncture balloon via

abdominal under X-ray/ USG

guided

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Clean Intermittent Catheterization (CIC)

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Clean Intermittent Catheterization (CIC)

Introduce a catheter into the bladder to drain urine, the catheter is removed afterward

Leaving the patient catheter-free between catherization

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Speedicath Compact Male

SpeediCath

SpeediCath control

SpeediCath Compact

SpeediCath Complete

Absorbent pads/ diapers

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Skin Care

Immobile: at major risk for skin breakdown.

Good hygiene and skin care can prevent skin breakdown and maintain skin integrity.

Perineal skin condition and integrity should be assessed regularly.

Thorough cleansing of the entire genital area should be done at least twice a day.

Gentle cleansing of the skin after each soiling

Avoid force and friction during cleansing.

Skin Care

After cleansing, the skin should be gently but thoroughly patted dry with a soft towel

Avoid using talcum powder as it can irritate and tend to form lumps when dampened by urine causing encrustations in the groin skin folds.

Absorbent incontinent product should be replaced frequently to keep skin dry.

Avoid using plastic pants

If the skin is becoming sore, factors other than the incontinence should be investigated:

sensitive to the materials of incontinent pad or appliance, e.g. latex of a penile sheath

the pad may be too rough

appliance may be too tight

plastic in contact with wet skin

candida infection

Minimizing skin injury caused by friction or shearing forces through proper positioning, turning and transfer techniques.

A moisturizing lotion or cream may be applied for dry skin.

If skin irritation is present or at risk, a moisture barrier

product (e.g. Zinc or castor oil) should be used. The moisture

barrier should be re-applied after each incontinent episode

and every 12-24 hours.

No Sting Barrier Film

Timely intervention on continence problems

regenerates Older persons’ quality of life

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THANK YOU