1. Overview of Urinary Incontinence in the Long Term Care Setting
Management Strategies for the Nursing Assistant
Ann M. Spenard RN, C, MSN
Courtney Lyder ND, GNP

2. Learning Objectives Describe common types of incontinence
Describe how to complete the 3 day voiding diary
Describe the techniques in bladder training
Will be able to facilitate pelvic muscle (Kegel) exercises
Identify the steps to facilitating urinary incontinence

3. Steps to Continence 1. Complete Physical Assessment and History Form
2. Determine the type of urinary incontinence
3. Complete Algorithm

4. Prevalence of Urinary Incontinence (UI)
Estimated 10% to 35% of adults
> 50% of 1.5 million nursing home residents
A conservative estimated cost of $5.2 billion per year for urinary incontinence in nursing homes
Estimated that approximately 10% to 35% of all adults in the United States suffer from bladder control problems.
The highest prevalence occurs in the elderly in both community and institutional settings.
50% of 1.5 million nursing home residents are urinary incontinent.

5. Impact on Quality of Life
Loss of self-esteem
Decreased ability to maintain independent lifestyle
Increased dependence on caregivers for activities of daily life
Avoidance of social activity and interaction
Restricted sexual activity
Although urinary incontinence is classified as a medical disease, it most importantly affects:
quality of life
self-esteem
social activities
alters daily functioning

6. Consequences of UI An increased risk of falls
Most hip fractures in elders can be traced to nocturia (night time voiding) especially if combined with urgency
Risk of hip fracture increases with
physical decline from reduced activity
cognitive impairments that may accompany a UTI
medications often used to treat incontinence
loss of sleep related to nocturia
Falls and hip fractures are very common in the elderly population and are often the reasons for prolonged hospitalization and admission to a long term care facility.
Rushing to the bathroom is frequently the cause of a fall.
Nocturia is defined as getting up to the bathroom more than twice during the night.

7. Risk Factors Aging Medication side effects High impact exercise
Menopause
Childbirth
There are many different things that put a person at risk for incontinence.
These are risks for incontinence, not causes.

8. Factors Contributing to Urinary Incontinence
Diet
Caffeine
Alcohol
Chocolate
Acidic fruit or juices
(OJ,pineapple)
Spicy foods
Nutrasweet products
Tomatoes, spaghetti sauce
Medications
Bowel Irregularities
Constipation
Fecal Impaction
Side effects of many medications can significantly contribute to bladder control problems, along with irritants such as caffeine.
antihypertensives include medications such as calcium channel blockers, beta adrenergics, and diuretics.
hypnotics include psycatropic and psychoactive, in addition to drugs with adrenergic side effects.
Some foods that are thought to contribute to bladder leakage include:
alcoholic beverages
carbonated beverages (with or without caffeine)
milk or milk products
coffee or tea (even decaffeinated)
citrus juices and fruits
tomatoes
highly spicy foods
sugar and honey
chocolate, corn syrup and artificial sweeteners

9. Age Related Changes in the Urinary Tract
Majority of urine production occurs at rest
Bladder capacity is decreased
Quantity of urine left in the bladder after urinating is increased
Bladder contractions without warning
Desire to void is delayed
Normal changes that occur with the aging process can also put a person at risk for bladder control problems.
Residual urine is the amount of urine left in the bladder after a void.
normally less than 100cc.
many elderly people have larger amounts left in the bladder after a void, even though they demonstrate no signs of this. That is, they do not feel full or uncomfortable, that have good urine output, and do not seem to have a large bladder by palpation or percussion.

10. Several Types of Urinary Incontinence
Stress: Leakage of small amounts of urine as a result of increased pressure on the abdominal muscles (coughing, laughing, sneezing, lifting)
Urge: The strong desire to void but the inability to wait long enough to get to a bathroom
Stress incontinence
can also occur when a resident is being moved, for example when transferring from chair to bed, or wheelchair to toilet.
it is caused by weakness or damage to the pelvic floor or urethra.
Urge incontinence
caused by detrusor muscle weakness, damage, or hyperactivity.

11. Several Types of Urinary Incontinence (continued)
Mixed: A combination of two types, stress and urge
Overflow: Occurs when the bladder overfills and small amounts of urine spill out (The bladder never empties, so it is constantly filling)
Total: Complete loss of bladder control
Mixed incontinence
most common in the elderly.
Overflow incontinence
caused by neurological factors or obstruction, such as benign prostatic hypertrophy (BPH).
obstruction can also occur in females due to prolapse of the uterus.

12. Remember...
Urinary incontinence can be treated even if the resident has dementia!!

13. Stress Incontinence vs. Urge Incontinence: System Check List

14. Symptoms of Overactive Bladder
Urgency to void
Frequency in voiding
Nocturia (getting up two or more times at night to void) and/or urge incontinence
ANY COMBINATION

15. Causes of Mixed Urinary Incontinence
Combination of bladder spasms and stress incontinence
One type of symptom (e.g., urge or stress incontinence) often predominant
Mixed incontinence is very common in the geriatric population.

16. Reversible or Transient Conditions that may Contribute to UI
“D” Delirium (Sudden or increased confusion)
Dehydration
“R” Restricted mobility
Retention
“I” Infection
Inflammation
Impaction
“P” Pharmaceuticals (Drugs)

17. Continence Treatment Behavioral Medications Surgery
Pelvic Muscle Rehabilitation (PMR) - for strengthening or relaxation
Urge Inhibition Training - reduce or control urgency
Bladder and/or Bowel Training - reduce frequency
Treatment of Bowel Dysfunction
Medications
Surgery

18. Behavioral Treatments
Fluid management
Voiding frequency
Toileting assistance
Scheduled toileting
Prompted voiding
Bladder training
Pelvic floor muscle exercises

19. Bladder Training & Urgency Inhibition Training
Bladder Training - Techniques for postponing voiding
Urge Inhibition Training - Techniques for resisting or stopping the feeling of urgency
Bladder Training & Urge Inhibition training - Strongly recommended for urge and mixed incontinence and is recommended for management of stress incontinence

20. Behavioral Treatments
Pelvic Muscle (Kegel) exercises
Goal: To strengthen the muscle that controls the release of urine
Proper identification of muscle (if able to stop urine in mid stream)
Planned active exercise (hold for 10 seconds then relax do this times per day for a minimum of 8 weeks)

21. Biofeedback
Very helpful in assisting residents in identifying and strengthening pelvic muscles
Give positive feedback for bladder training, habit training and/or Kegels

22. Summary
With correct diagnosis of UI, expect more than 80% improvement or cure rate without surgery!!

23. Case Study 1
Mrs. Martin:
She was admitted to a skilled nursing facility following a hospitalization for surgical repair of a fractured hip which occurred when she fell on the way to the bathroom.

24. Prior to Admission: She was living at home with her daughter.
Her medical history included high blood pressure and thinning of the bones. Mrs. Martin’s daughter reported that her mother frequently rushed to get to the bathroom on time and often got out of bed 4 to 5 times per night to urinate.

25. Upon Admission to the Nursing Home:
Mrs. Martin’s transfer status was assist of one with a walker.
Nursing staff implemented an every 2 hour toileting schedule.
This resident was frequently incontinent.

26. Upon Admission to the Nursing Home: (continued)
Mrs. Martin stated that she knew when she needed to void but could not wait until the staff could take her to the bathroom. She could feel the urine coming out but could not stop her bladder from emptying. Mrs. Martin felt embarrassed about wearing a brief but felt it was better than getting her clothing wet. Her incontinence was sudden, in large volumes and accompanied by a strong sense of urgency.

27. Problem Identification
The problems identified by the staff during the first case conference included urge incontinence and impaired mobility.

28. What can we do to help Mrs. Martin?
Help her get stronger in walking.
Help her resist the urge to urinate frequently.
Check her at night frequently and offer to take her to the bathroom as needed.
Respond as quickly as possible.
Give positive feedback when she is able to get to the bathroom in time.
The doctor may order medication.

29. Voiding Diary, Why Use Them?
People are not born with bladder control, it is a learned behavior.
As people involuntarily lose urine they sometimes retrain their bladder by going to the bathroom too frequently.
A voiding diary helps us to see if a new toileting pattern will help keep a person dry or if a simple reminder at a certain time will help that person get to the bathroom on time.

30. Voiding Diary, Why Use Them? (continued)
Your help in completing these diaries is as important as many of the medications or treatments that the nurse may give !!!
The information that you collect (including your comments) is vital for the development of an individualized plan of care for the resident.

31. What Information Do We Need?
Time a person toileted (did the resident request or was it offered).
Did the resident void in the bathroom or were they wet?
Small or large incontinent episode.
Reason for the incontinent episode.

32. How Long Do You Complete A Voiding Diary?
The voiding diary is completed for 3 days across all three shifts.

33. What Effect Will This Program Have For the Resident & Staff?
Improved quality of life for the resident
Reduce the number of residents needing Q2 hour toileting.
All residents will have an individualized plan for scheduled toileting or prompted voiding that meets their needs.
Less briefs and clothing to change because of incontinence.
Overall, less time spent toileting and providing incontinence care, leaving more quality time to be spent with your residents.