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NICHE Online Connect Webinars | 2016 1

When Laughing is No Longer Funny Managing Transient Urinary Incontinence in

Hospitalized Elderly Women

Grace Umejei, BSN, RN, CWOC.

Texas Health Presbyterian Hospital Dallas


Objectives

• Identify Transient Urinary Incontinence (TUI) and discuss outcomes on the Healthcare System

• Discuss the effectiveness of behavioral modification therapy (BMT) in reducing TUI episodes

• Review the outcome of management of TUI in elderly female patients.

Mechanism of Urination

• bladder, the muscular wall

• nerve

• the brain

• urethral closure muscle

Classification and Types of Incontinence

Categories of UI

• Transient Incontinence –incontinence with reversible causes.

• Established Incontinence – when transient cause have been addressed and incontinence persists


Urinary Incontinence (UI)

• Stress – Occurs with increased abdominal pressure.

• Urge – sudden overwhelming need to urinate without ability to control

urine flow, when urinary sphincter fails as a result of pelvic floor weakness to support uterus, bladder, and other pelvic organs.

• Overflow – involuntary leakage of urine small amounts, associated with incomplete bladder emptying mechanical forces on distended bladder

• Functional – contributing factors outside urinary system not

characterized by bladder dysfunction. Inability to get to the bathroom, cognition impairment.

Facts About Urinary Incontinence

• People > 65 years are the reason for a growing hospital population.

• This segment of the population have the greatest need for health care.

• Acute hospital settings 20% to 42% of older adult patients are affected by UI

• 42.5% of UI patients have some type of skin injury.

TUI Background

• Involuntary urine loss with reversible causes.

• Negatively impacts patient outcomes, e.g.

independence, mood, falls, and skin integrity

• Affects 80% of hospitalized patients and

75% of females >60 years of age

• Cost of managing TUI is $26 billion annually


Gertrude’s Story

Literature ReviewEvidence based practice (EBP) TUI interventions

include:

• BMT, i.e. bladder training and lifestyle

modifications based on TUI assessments and

causation

• Daily bladder diary (BD) to track

continence/incontinence episodes/toileting

behaviors

• Staff education on use of BD and BMT strategy

• Patient education and counseling

PICOT Question

Is BMT (including a BD) more effective than

passive TUI care in reducing TUI episodes

in elderly hospitalized female patients on a

rehabilitation unit?


Change Strategy

• Inter-professional team formed

• Educated inter-professional team on treatment plan and management strategies

• Inter-professional team used the BD to establish toileting schedule/assess BMT effectiveness

• Incontinence episodes tracked with use of BD

• Patients queried prior to discharge on BMT satisfaction and use of incontinence protection (i.e. adult briefs)

Inter-Professional Team

• Nurses

• Patient Care Technician

• Chaplain

• Occupational Therapist (OT), Physical Therapist (PT)

• Wound Ostomy and Continence Nurse

• Physicians

• Dietary Staff

Behavioral Modification Therapy

Foundation for behavioral intervention

• Bladder Training – Skills to control symptoms of bladder dysfunction.

• Lifestyle Modification– Healthy bladder habits that will alleviate bladder symptom, enhance

function and promote bladder health


Behavioral Modification Therapy

Detection

• Identify transient causes of UI and individual patient risk factors.

• Determine the actual or potential effect of incontinence on patient’s quality of life and functional statues.

• Anticipate and address potential complications based on established causes.

• Develop a set of interventions that target the risk factors and causes for each patient through consistent approach to evaluation. May Utilize Urinary Incontinence Assessment for Older Adults (Hartford Institute for Geriatric

Nursing, New York University, College of Nursing)

Bladder Diary

Key:

D –Diaper BSC-Bedside Commode

P- Bed Pad BP-Bed pan

PU- Pull Ups

T- Toilet

DIAPPERS Tools for Determining TUI

D Delirium Acute confusion alters one’s ability to

anticipate and meet own needs. Delirium

may occur from drugs, surgery, or acute

illness.

I Infection Urinary tract infection

A Atrophy Thin dry, friable vaginal and urethral

mucosa due to Hypo-estrogenization in

older female is associated with irritating

symptoms (burning on urination, urgency,

frequency)

P Pharmaceuticals Drugs including sedatives, hypnotics,

alcohol, anticholinergic, antihistamine,

narcotics, loop diuretics.

P Psychological

condition

Depression impairs one’s motivation and

desire to manage self-care or be

concerned about incontinence.

Fear of odor, embarrassment, obvious

leakage, and unpredictable urine leakages

can lead to marked alternation in social

activities, relationships with others, and

loss of social support.

E Excess urine

output

Excess urine output resulting large fluid

intake, caffeinated beverages endocrine

problems CHF, Peripheral edema

R Restricted mobility Poor mobility, arthritic pain, poor use of

assistive device

S Stool Impaction Narcotic use can lead to severe

constipation and fecal impaction that

obstruct the bladder neck, leading to urine

retention and/or overflow incontinence

Transient Causes of

Urinary Incontinence

and other contributing

factors


Incontinence Training-NursingAssessment

• Focused Assessment

• Determine Cause

Intervention• Develop individualized plan of care using data obtained from the history and

physical examination, and in collaboration with other team members

Evaluation of Outcome• Bladder Diary

• Follow up assessment

Nursing Education

Patient assessment.• Perform Comprehensive Assessment

• Focused Urinary Incontinence assessment

• Determine Neurological Status

• Identify Mobility and Activity Level

Incontinence Training-Patient

Counseling

Intervention

• BMT

Evaluation

• Follow up patient questionnaire


Bladder Re -Training

• Progressive voiding schedule, using relaxation and distraction techniques together with multicomponent behavioral training which patient has to learn.

• Positively affects mobility, behavior, skin integrity, urinary tract infection and bowel function.

Goal• Increase amount of time between emptying your urinary bladder and amount of

urine your bladder can hold.• Diminish leakage and sense of urgency associated with incontinence

• Determine fixed voiding schedule that corresponds to patients’ assessment

Bladder Re-Training

Prompted Voiding• Neurologically Intact

• Responsibility of RN/PCT/Patient and interdisciplinary team

• Description– Prompt patient on a schedule of every three hours during the day and every

four hours at night as time allows.

– Report continence status and to assist to the toilet

– Provide positive feedback for maintenance of continence.

• Goal– To keep the patient dry and to increase the patient’s awareness of

incontinence status and participation in bladder program

Bladder Re- Training Cont.

Scheduled Voiding

• Patients with Cognitive Impairment• unable to accurately determine wetness or dryness

• unable to take responsibility for self-toileting but able to follow instructions

with assistance.

• Responsibility - RN/PCT/Patient and interdisciplinary team

• Description• Every two hours while awake – every four hours at night the patient is taken

to the toilet (or bedside commode) on schedule and cued to void

• Goal• Prevent over-distention of bladder and keep the patient dry by toileting

frequently enough to prevent incontinence.


Bladder Re Training cont.,

• URGE Suppression Techniques – Freeze, Squeeze, Breathe or Distraction.

• If urge cannot be suppressed and you must go slowly

• DOUBLE Voiding

Lifestyle Modification

Habits that may be modified to alleviate bladder symptoms or

promote bladder health

Dietary

• Ensure adequate fluids

• Avoid caffeinated beverages

• Promote high-fiber diet for bowel regularity

• Promote a regular voiding schedule, about every 3 hours

Pharmacology

• Monitor poly-pharmacy, drug interactions

Life style Modification Cont.

Mobility• OT, PT. to assist with gait or transfer training, assistive devices, develop

toilet skills to promote independence.

• Utilize clothing that is easy to undo to promote independence in toileting.

• Monitor for transient causes of urinary incontinence and treat quickly.

Social Environment• Promote a positive approach to continence.

• Promote socialization.

• Assist with toileting if needed

• Recognize urinary incontinence as medical syndrome that is abnormal, promote the desire to maintain urinary continence.


Lifestyle Modification cont.

Environmental Modifications• Physical Environment

• Ensure good lighting in room, bathroom, call light within reach

• Obtain bedside commode, promote independence.

• Non-skid sock, non-glare floor also cord free floors

Smoking cessation• Optimal treatment outcome changes

• Adhering to these changes will require significant behavioral changes from the patient.

Results

0.2

3.3

0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5

Post-

BMT

Pre-BMT

Mean # Incontinence Episodes in 24 Hours

Reduction of Incontinence Episodes

Pre & Post Behavioral Modification

Therapy (BMT)

(n = 10 patients)

Mean

Range 1-5

Mean

Range 0-1

Results (cont.)

• Mean age 81.2 years (range 68-90)

• Days on BMT, mean 8.1 days (range 9-

11)

• All patients (n=10) reported they were

able to wear fewer adult briefs (cost

reduction = $10 per day/per patient)

• 100% reported satisfaction with BMT


Conclusion

• BDs are effective TUI management tools;

maintaining documentation is challenging.

• BMT is a cost-effective EBP intervention

Summary

• Increase of elderly patients with UI.

• Behavioral modification interventions can significantly improve symptoms of TUI when education, counselling, support and encouragement are applied.

• Need to implement BMT in acute care setting in order to reverse the current practice of focusing TUI management on UI consequences rather than treating underlying causes of UI.

Thank you!


References

DuBeau, C. E., Kuchel, G. A., Johnson II, T., Palmer, M. H., & Wagg, A. (2010). Incontinence in the frail elderly: Report from the 4th international consultation on incontinence. Neurology and Urodynamic, 29, 165-178.

Melville, J.L., Katon, W., Delaney, K., Newton, K. (2005). Urinary incontinence in US women: A population-based study. Archive Internal Medicine, 165(5) 537-542.

Shamliyan, T., Wyman, J., Kane, R.L. (2012) Nonsurgical treatments for urinary incontinence in adult women: Diagnosis and comparative effectiveness. Agency for Healthcare Research and Quality, 36.

Wyman, J.F., Burgio, K.I., Newman, D.K. (2009). Practical aspects of lifestyle modifications and behavioral interventions in the treatment of overactive bladder and urgency urinary incontinence. International Journal of Clinical Practice, 63(8), 1177-1191.

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