Urinary incontinece 12 2011


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Urinary Incontinence correction and management are essential to an individuals quality of life, sense of well being and comfort.

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Urinary incontinece 12 2011

  1. 1. Continence Management Improving Resident Outcomes www.MDSCarePlanBuilder.com
  2. 2. <ul><li>Debbie Ohl, Owner of Ohl & Associates is a Registered Nurse and Licensed Administrator, and certified facilitator. Her manuals and workshops provide cutting information and material to help long term care professionals meet the needs of their residents. </li></ul><ul><li>www.MDSCarePlanBuilder.com is absolutely one of the finest web sites for nursing facilities. It is filled with useful tips, cutting edge material, and a wealth of educational information. Send us an email letting us know what you think and what else you would like to see. </li></ul><ul><li>If you have long term care training needs contact Debbie at Ohl & Associates, www.MDSCarePlanBuilder.com </li></ul>www.MDSCarePlanBuilder.com
  3. 3. <ul><li>Understand the risk factors that contribute to Urinary Incontinence. </li></ul><ul><li>Define the types of Urinary Incontinence and management criteria for each. </li></ul><ul><li>List the steps to a workable Continent Management program. </li></ul><ul><li>Learn how to use Quality Indicators to create appropriate continence management programs and support your care planning actions. </li></ul><ul><li>Review the CAA Elements of Urinary Incontinence and Indwelling Catheters. </li></ul><ul><li>Review care planning format ideas. </li></ul>www.MDSCarePlanBuilder.com
  4. 4. <ul><li>Identify the three primary purposes for evaluating Urinary Incontinence? </li></ul><ul><li>List 5 of 10 potential causes for urinary incontinence. </li></ul><ul><li>List 4 of 7 factors needed for continence. </li></ul><ul><li>List the three most common causes of reversible incontinence. </li></ul>www.MDSCarePlanBuilder.com
  5. 5. Part 1 www.MDSCarePlanBuilder.com
  6. 6. <ul><li>Decreased bladder capacity </li></ul><ul><li>Shorter time between awareness of the need to void and symptomatic urgency </li></ul><ul><li>Incomplete emptying and increased residual volume </li></ul><ul><li>Decreased flow rate </li></ul><ul><li>Increased number of involuntary bladder contractions (detrusor instability) </li></ul><ul><li>Decreased strength of pelvic support muscles </li></ul><ul><li>Atrophic changes in urethral lining and bladder trigone in postmenopausal women </li></ul>www.MDSCarePlanBuilder.com
  7. 7. <ul><li>Bladder Continence refers to the ability to control bladder function. </li></ul><ul><li>Urinary Incontinence is the inability to control urination in a socially appropriate manner. </li></ul>www.MDSCarePlanBuilder.com
  8. 8. <ul><li>Bladder Retraining </li></ul><ul><li>The RESIDENT is the primary player. </li></ul><ul><li>Retraining demands the resident have the ABILITY to consciously delay urinating or resist the urgency to void. </li></ul><ul><li>Scheduled Toileting </li></ul><ul><li>The STAFF is the primary player. </li></ul><ul><li>The staff either takes the resident to the bathroom, hands them a urinal, or reminds them to go to the toilet. This includes habit training and/or prompted voiding. </li></ul>www.MDSCarePlanBuilder.com Key Definitions
  9. 9. <ul><li>A bladder that can hold it! </li></ul><ul><li>A urethra that can open and close properly </li></ul><ul><li>Fluid balance, integrity of spinal cord, integrity </li></ul><ul><li>of peripheral nerves. </li></ul><ul><li>Timely toilet access with or without </li></ul><ul><li>assistance. </li></ul><ul><li>Ability to adjust clothing. </li></ul><ul><li>Cognitive and social awareness. </li></ul><ul><li>Individual motivation </li></ul>www.MDSCarePlanBuilder.com
  10. 10. <ul><li>Urge Incontinence / Uninhibited Bladder </li></ul><ul><li>Bladder contracts when it shouldn't, abruptly soaking the person. </li></ul><ul><li>Can occur with or without a conscious sensation of the need to void. </li></ul><ul><li>Leakage of urine, usually in large amount. </li></ul><ul><li>Associated with </li></ul><ul><li>CNS disorders like dementia, stroke, Parkinsonism </li></ul><ul><li>Spinal cord injury </li></ul><ul><li>Cystitis, urethritis </li></ul><ul><li>Tumors </li></ul><ul><li>Stones, </li></ul><ul><li>Diverticuli </li></ul><ul><li>Overflow obstruction. </li></ul>www.MDSCarePlanBuilder.com
  11. 11. <ul><li>Need </li></ul><ul><li>Post Void </li></ul><ul><li>Residual test </li></ul><ul><li>Outcome </li></ul><ul><li>Less than 100cc </li></ul><ul><li>urine in bladder. </li></ul><ul><li>Actions </li></ul><ul><li>Candidate for timed voiding </li></ul><ul><li>Pelvic floor exercises. </li></ul><ul><li>Meds used might include anti-cholinergic, bladder relaxant, or tri-cyclic antidepressant. </li></ul>www.MDSCarePlanBuilder.com
  12. 12. <ul><li>Bladder fails to contract when it should. </li></ul><ul><li>There is a leakage of urine, usually small amounts or constant dribbling , bladder may complain about lower abdominal or pelvic pain. </li></ul><ul><li>Associated with: peripheral neuropathy secondary to diabetes mellitus, CNS lesions, fecal impaction & inadequate bowel elimination , BPH, obstruction of bladder neck. </li></ul>www.MDSCarePlanBuilder.com
  13. 13. <ul><li>Need </li></ul><ul><li>Post Void Residual Test </li></ul><ul><li>Outcome </li></ul><ul><li>Less than 400cc </li></ul><ul><li>of urine in bladder. </li></ul><ul><li>Action </li></ul><ul><li>Candidate for timed voiding. </li></ul><ul><li>Pelvic floor exercises </li></ul><ul><li>May require urologic evaluation. </li></ul>www.MDSCarePlanBuilder.com
  14. 14. <ul><li>Rare in women </li></ul><ul><li>Have increased urine loss </li></ul><ul><li>Negative stress test </li></ul><ul><li>Urethra blocked </li></ul><ul><li>Associated with </li></ul><ul><li>Obstruction of prostate </li></ul><ul><li>Stricture </li></ul><ul><li>Cystocele </li></ul><ul><li>Lack of contraction due to diabetes mellitus, spinal cord injury </li></ul><ul><li>Neurogenic bladder related to MS, spinal cord lesions. </li></ul>www.MDSCarePlanBuilder.com
  15. 15. <ul><li>Need </li></ul><ul><li>Post Void Residual Test </li></ul><ul><li>Outcome </li></ul><ul><li>Less than 100cc of urine in bladder </li></ul><ul><li>Negative stress test </li></ul><ul><li>Action </li></ul><ul><li>Urologic workup. </li></ul>www.MDSCarePlanBuilder.com
  16. 16. <ul><li>Rare in Men </li></ul><ul><li>Urethra is unable to close tight enough </li></ul><ul><li>Accompanies stress, such as coughing, sneezing, laughing, and exercising. </li></ul><ul><li>Associated with: </li></ul><ul><li>Weakness </li></ul><ul><li>Laxity of pelvic floor muscles. </li></ul><ul><li>Bladder outlet or urethral sphincter weakness. </li></ul>www.MDSCarePlanBuilder.com
  17. 17. <ul><li>Need </li></ul><ul><li>Post Void Residual </li></ul><ul><li>Stress Test </li></ul><ul><li>Outcome </li></ul><ul><li>Less than 100cc of urine in bladder </li></ul><ul><li>Positive stress test </li></ul><ul><li>Action </li></ul><ul><li>Candidate for timed voiding </li></ul><ul><li>Pelvic floor exercises </li></ul><ul><li>Perhaps medicine that will increase urethral resistance. </li></ul>www.MDSCarePlanBuilder.com
  18. 18. <ul><li>Urine loss associated with inability to toilet because of </li></ul><ul><li>impaired cognitive or </li></ul><ul><li>physical functioning, </li></ul><ul><li>Psychological issues, </li></ul><ul><li>unwillingness, or </li></ul><ul><li>environmental barriers. </li></ul><ul><li>Associated with </li></ul><ul><li>Severe dementia, and other neurologic disorders </li></ul><ul><li>psychological factors such as depression, regression, anger, & hostility </li></ul>www.MDSCarePlanBuilder.com
  19. 19. <ul><li>Need </li></ul><ul><li>Complete Incontinence RAP guidelines. </li></ul><ul><li>Determine areas of correctability/improvability & strengths. </li></ul><ul><li>Outcome </li></ul><ul><li>Develop individualized toileting program based fixability / improvability of identified problems. </li></ul><ul><li>Action </li></ul><ul><li>Complete bladder tracking & I & O to establish pattern habits. </li></ul><ul><li>Review relationship of medication to toileting habits and episodes of incontinence. </li></ul><ul><li>Check out environmental factors and needs.. </li></ul>www.MDSCarePlanBuilder.com
  20. 20. <ul><li>Stress & Urge </li></ul><ul><li>Stress (spurt of urine induced with increased pressure) </li></ul><ul><li>& </li></ul><ul><li>Urge i ncontinence (abrupt soaking) </li></ul><ul><li>Urge& Functional </li></ul><ul><li>Urge (abrupt soaking) </li></ul><ul><li>& </li></ul><ul><li>Functional incontinence (impairment prevents timely toileting, bladder function okay) </li></ul>www.MDSCarePlanBuilder.com
  21. 21. <ul><li>Urinary Tract Infection </li></ul><ul><li>Fecal Impaction </li></ul><ul><li>Delirium </li></ul><ul><li>Lack of Toilet Access </li></ul><ul><li>Immobility </li></ul><ul><li>Depression </li></ul><ul><li>Congestive Heart Failure or Pedal Edema </li></ul><ul><li>Recent Stroke </li></ul><ul><li>Diabetes Mellitus </li></ul><ul><li>Medications </li></ul>www.MDSCarePlanBuilder.com
  22. 22. Part 2 Regulations www.MDSCarePlanBuilder.com
  23. 23. <ul><li>A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary track infections and restore as much bladder function as possible . </li></ul>www.MDSCarePlanBuilder.com
  24. 24. <ul><li>To ensure that the facility develops, implements, and evaluates continence care programs that include systematic approaches to identify and routinely assess each resident who resides in the facility who are incontinent of urine to: </li></ul><ul><ul><li>Improve or restore bladder function, where possible. </li></ul></ul><ul><ul><li>Ensure treatment and services to assist the resident to maintain their highest level of continence status. </li></ul></ul><ul><ul><li>Address and minimize the risk of potential negative outcomes related to urinary incontinence. </li></ul></ul>www.MDSCarePlanBuilder.com
  25. 25. www.MDSCarePlanBuilder.com Physical Mental Social Emotional
  26. 26. <ul><li>Comprehensive Assessment </li></ul><ul><li>Comprehensive Care Plans </li></ul><ul><li>Maintain or improve abilities </li></ul><ul><li>Neglect </li></ul><ul><li>Dignity </li></ul>www.MDSCarePlanBuilder.com
  27. 27. <ul><li>FAILURE TO ACCURATELY ASSESS . </li></ul><ul><li>MAKING ASSUMPTIONS RATHER THAN EVALUATING. </li></ul><ul><li>Bladder tracking to establish/negate a pattern </li></ul><ul><li>Assess for reversibility, causes and contributing factors, and type(s) of incontinence. </li></ul>www.MDSCarePlanBuilder.com
  28. 28. <ul><li>FAILURE TO DEVELOP A CARE PLAN </li></ul><ul><li>OR </li></ul><ul><li>FAILURE TO APPROPRIATELY TREAT THE PROBLEM. </li></ul><ul><li>Plan does not address the specific problem or need and/or identify resident strengths. </li></ul><ul><li>Specific goals to manage and/or correct the incontinence, and prevent risk factors from materializing are not present. </li></ul><ul><li>Clear, appropriate interventions and approaches are not identified or fail to identify who is responsible for implementation. </li></ul><ul><li>Target dates are absent or inappropriate. </li></ul>www.MDSCarePlanBuilder.com
  29. 29. <ul><li>FAILURE TO IMPLEMENT THE PLAN </li></ul><ul><li>Written and not used </li></ul><ul><li>Written and not known. </li></ul><ul><li>Written and not followed or not followed consistently. </li></ul><ul><li>Lacks individualization. </li></ul><ul><li>Inappropriate interventions. </li></ul>www.MDSCarePlanBuilder.com
  30. 30. <ul><li>FAILURE TO </li></ul><ul><li>REVIEW PLAN </li></ul><ul><li>FOR </li></ul><ul><li>EFFECTIVENESS </li></ul><ul><li>AND </li></ul><ul><li>OUTCOMES. </li></ul><ul><li>When is the last time you discussed incontinence status or outcomes at care conference? </li></ul>www.MDSCarePlanBuilder.com
  31. 31. <ul><li>NEGATIVE OUTCOMES THAT SHOULD HAVE BEEN AVOIDABLE OR THAT LACKED CLINICAL DOCUMENTATION OF AVOIDABILITY OR SUBSTANTIATION OF NEED. </li></ul><ul><li>accidents </li></ul><ul><li>use of restraints </li></ul><ul><li>use of psychoactive drugs </li></ul><ul><li>urinary track infections </li></ul><ul><li>dehydration </li></ul><ul><li>behavior problems </li></ul><ul><li>depression, mood or behavior problems </li></ul><ul><li>Isolation & withdraw </li></ul><ul><li>pressure ulcers, skin problems </li></ul><ul><li>resident right violations </li></ul>www.MDSCarePlanBuilder.com
  32. 32. <ul><li>Resident was appropriately assessed. </li></ul><ul><li>The care plan was developed and reflective of status, risk, measurable, appropriate, do-able goals with reasonable time frames. </li></ul><ul><li>Care was implemented consistently in keeping with standards of practice </li></ul><ul><li>Resident outcomes were reviewed & care plan revised as needed. </li></ul>www.MDSCarePlanBuilder.com
  33. 33. <ul><li>Quality of Life Deficiency Physical, mental, social, emotional status declined, was not maintained or enhanced as it could have been based on a comprehensive review and assessment. </li></ul>www.MDSCarePlanBuilder.com
  34. 34. <ul><li>Evaluation of the incontinence requires appropriate classification by history, examination, and testing. </li></ul><ul><li>Residents who are likely to benefit from behavioral therapy for urinary incontinence can be easily identified. </li></ul><ul><li>Residents who show a response to a simple, non-invasive assessment consisting of 3-day trial of prompted voiding have potential to show long term benefit in control of their incontinence. </li></ul><ul><li>Comprehensive assessment should include an evaluation of the residents: </li></ul><ul><ul><li>Prior history of urinary incontinence, including previous treatment or management. </li></ul></ul><ul><ul><li>Physical exam </li></ul></ul><ul><ul><li>Individual risk factors </li></ul></ul>www.MDSCarePlanBuilder.com
  35. 35. <ul><li>Voiding Patterns </li></ul><ul><li>Type of Incontinence </li></ul><ul><li>Results of PVR or Ultra sound for residents at risk of retention. </li></ul><ul><li>Presence or absence of UTI’s, persistent or recurrent, urine culture if symptomatic. </li></ul><ul><li>Environmental factors and assistive devices such as grab bars raised toilets, bed rails, restraints, etc. </li></ul><ul><li>Type and frequency of physical assistance needed to access toilet. </li></ul><ul><li>Cognitive status and behaviors that may affect continence status. </li></ul><ul><li>Functional impairments that can impede ability to maintain continence. </li></ul><ul><li>Significant alteration or impairment in patterns of fluid intake & hydration status including constipation & impaction. </li></ul><ul><li>Medications that may affect continence, including those with anticholinergic properties </li></ul>www.MDSCarePlanBuilder.com
  36. 36. <ul><li>Resident was appropriately assessed. </li></ul><ul><li>The care plan was developed and reflective of status, risk, measurable appropriate, do-able goals with reasonable time frames. </li></ul><ul><li>Care was implemented consistently in keeping with standards of practice. </li></ul><ul><li>Resident outcomes were reviewed & care plan revised as needed. </li></ul>www.MDSCarePlanBuilder.com
  37. 37. Part 3 www.MDSCarePlanBuilder.com
  38. 38. <ul><li>Quality Indicator </li></ul><ul><li>Facility Profile </li></ul><ul><li>Provides facility status </li></ul><ul><li>report in percentile ranking </li></ul><ul><li>format for each of the 24 </li></ul><ul><li>MDS based Quality </li></ul><ul><li>Indicators as compared to a </li></ul><ul><li>peer group of the facilities </li></ul><ul><li>in the State or Nation. </li></ul><ul><li>Resident Level </li></ul><ul><li>Summary Report </li></ul><ul><li>Provides the specific Quality Indicators triggered for EACH resident using the most current MDS . </li></ul><ul><li>Promotes a clinical thought map for determining cause and effect relationships of one indicator to another. </li></ul>www.MDSCarePlanBuilder.com
  39. 39. www.MDSCarePlanBuilder.com HOW TO READ PROFILE REPORT Domain Indicator # in QI Total Poss. NF Avg. State Avg. Percentile Rank Elimination /Incontinence Prevalence of bowel or bladder incontinence 37 64 57.8 53.8% 60% High Risk Low Risk 17 20 17 47 100% 42.6% 91.6% 40.4% 100% 54% Prevalence of occasional or frequent incontinence without a toileting plan 8 19 42.1% 48.1% 45%
  40. 40. <ul><li>Bladder or Bowel Incontinence : </li></ul><ul><li>Frequently or always incontinent. </li></ul><ul><li>Denominator excludes comatose or indwelling catheters or ostomy </li></ul><ul><li>Risk Adjusted: </li></ul><ul><li>High risk severe cognitive impairment or t otally dependent in mobility. </li></ul><ul><li>Low Risk all others. </li></ul>www.MDSCarePlanBuilder.com
  41. 41. <ul><li>Resident Based </li></ul><ul><li>Note if incontinence is frequent or always. </li></ul><ul><li>If high risk why? </li></ul><ul><li>If low risk why? Identify the type of incontinence. </li></ul><ul><li>Correlate relationships with other triggered indicators. </li></ul><ul><li>Determine cooperation. </li></ul><ul><li>Identify best program. </li></ul><ul><li>Create or review care plan . </li></ul><ul><li>Facility Based </li></ul><ul><li>Split residents into high or low risk group. </li></ul><ul><li>List residents as frequently or always using RLSR. </li></ul><ul><li>Identify if cooperative. </li></ul><ul><li>Start program adjustments using the low risk, frequent and cooperative resident. </li></ul><ul><li>Make educated assumption on type of incontinence and proceed accordingly. </li></ul><ul><li>Identify causal relationship with other indicators. </li></ul>www.MDSCarePlanBuilder.com
  42. 42. <ul><li>Occasional or Frequent Bladder or Bowel Incontinence without Toilet Plan: </li></ul><ul><li>Prevalence of Indwelling Catheters </li></ul><ul><li>Prevalence of Fecal Impaction </li></ul>www.MDSCarePlanBuilder.com
  43. 43. <ul><li>Resident Based </li></ul><ul><li>Is reason acute & reversible? </li></ul><ul><li>If not why & make educated assumption on type of incontinence and proceed accordingly. </li></ul><ul><li>Identify if occasional or frequent. </li></ul><ul><li>Remember to consider resident strengths. </li></ul><ul><li>Facility Based </li></ul><ul><li>Split into occasional and frequent using RLSR. </li></ul><ul><li>Identify residents who self manage. </li></ul><ul><li>Determine why no program is in place. </li></ul><ul><li>Look for negative relationships to other indicators. </li></ul>www.MDSCarePlanBuilder.com
  44. 44. <ul><li>A resident who enters a facility without an indwelling catheter is not catheterized unless the resident’s clinical record demonstrates catherization was necessary. </li></ul>www.MDSCarePlanBuilder.com
  45. 45. <ul><li>Physical </li></ul><ul><li>Psychosocial </li></ul><ul><li>Cross check to UTI, dehydration, and pressure ulcer QI's for possible correlation. </li></ul><ul><li>Determine cause affect scenario. </li></ul>www.MDSCarePlanBuilder.com
  46. 46. <ul><li>Evaluate if coding error related to staff misunderstanding of what is and is not an impaction. </li></ul><ul><li>If it is true impaction evaluate for causative factors. </li></ul><ul><li>Is it food, fluid or mobility related or exacerbated? What actions has or could the facility take to improve this? If not, why not, and be sure the reasons are recorded in the medical record. </li></ul><ul><li>Is it med related or exacerbated? If so, can a different med be substituted? If not, why not, and record in chart, as well as care plan complication / risk and interventions. </li></ul><ul><li>Is it a result of disease process? If so, request physician address as such in progress notes periodically and / or summarize in your assessment notes. Care plan complication / risk and interventions. </li></ul><ul><li>Was the risk for impaction recognized? Was it care planned? If the goals were not met was residents reassessed and care plan revised? </li></ul><ul><li>Is impaction or constipation a cause or contributor to urinary incontinence? </li></ul>www.MDSCarePlanBuilder.com
  47. 47. <ul><li>Check medical record. Is their supporting documentation to indicate UTI did occur within 30 days of assessment reference date window? </li></ul><ul><li>For each resident determine if UTI’s are more than an isolated event. If so, have you evaluated the causes? Is it something you can reverse or minimizing? Was care planning in place? Was it followed? Is revision needed? </li></ul><ul><li>Review your infection control program for monitoring and investigating to be sure you are in compliance. I.e. tracking by site, source, organism, unit, care givers, etc. </li></ul><ul><li>Does the chart support presence of a true UTI? I.e. Positive cultures and symptoms were present. If not, evaluate if this was an isolated issue or a systemic problem related to facility policies or practices, including the need for staff training. </li></ul>www.MDSCarePlanBuilder.com
  48. 48. Part 4 Types of Programs www.MDSCarePlanBuilder.com
  49. 49. www.MDSCarePlanBuilder.com Continence Management Treatment Options Management Program Requirements : Schedule Habit Training <ul><li>Resident is cooperative </li></ul><ul><li>There is NO discernible voiding pattern. </li></ul><ul><li>Able to be mobilized </li></ul>Fixed. Scheduled Toileting Prompted <ul><li>Resident is cooperative </li></ul><ul><li>There is a discernible voiding pattern. </li></ul><ul><li>Voiding frequency greater than two hours. </li></ul><ul><li>Resident is cooperative </li></ul><ul><li>Some awareness some of the time </li></ul><ul><li>Mobilizes without help </li></ul>Individualized, tailored to identified voiding pattern.
  50. 50. www.MDSCarePlanBuilder.com Management Program Requirements : Schedule Bladder Retraining <ul><li>Resident has ability to be taught to : </li></ul><ul><li>Consciously delay urinating or </li></ul><ul><li>Resist the urgency to void. </li></ul>Void on a predetermined schedule. Check & Change <ul><li>Not cooperative </li></ul><ul><li>Not a restorative program </li></ul>Based on assessment risk
  51. 51. Part 5 Continence Management Protocol Components of Documentation www.MDSCarePlanBuilder.com
  52. 52. <ul><li>Any resident identified as incontinent of urine will be evaluated for causal factors and appropriate actions undertaken to obtain the most effective results. </li></ul><ul><li>Outcomes will be focused on attaining independent, dependent, social continence or a combination of these, dependent on the source and cause of the incontinence. </li></ul><ul><li>Management strategies might include toileting programs, use of prescribed medications, fluid and dietary management, exercise, external collection devices, environmental modifications, and use of absorbent products. The choice of interventions will be dependent on assessment findings. </li></ul>www.MDSCarePlanBuilder.com
  53. 53. <ul><li>Initiate bladder tracking and intake / output every for 2-3 days . </li></ul><ul><li>Complete the Incontinence CAA analyzing the data collected. </li></ul><ul><li>Develop the care plan. </li></ul><ul><li>Educate caregivers and resident. </li></ul><ul><li>Initiate the Care Plan. </li></ul><ul><li>Monitor effectiveness of the plan. </li></ul><ul><li>Review and modify the plan as needed. </li></ul>www.MDSCarePlanBuilder.com
  54. 54. Bladder Tracker www.MDSCarePlanBuilder.com 1 2 3 Taken /prompted/voided. Unaware of need. 4 Self control, voided. Taken /prompted/did not void. Unaware of need. 5 Self control, Requires assistance. Taken, dry, Then incontinent in this time period. 6 Self control, did not need to void in this time period. Day 1 Code In-take Out-put Day 2 Code In-take Out put Day 3 Code In-take Out-put 7 AM to 9 AM 9 AM to 11 AM 11 AM to 1 PM 1 PM to 3 PM
  55. 55. <ul><li>Use the </li></ul><ul><li>Incontinence CAA </li></ul><ul><li>to determine : </li></ul><ul><ul><li>Reversible causes </li></ul></ul><ul><ul><li>Contributing factors </li></ul></ul><ul><ul><li>Compounding problems </li></ul></ul><ul><li>Identify key issues impacting on the status. </li></ul><ul><li>Relationship of mobility, transfer, ADL abilities/needs to Incontinence as causes or contributors. </li></ul><ul><li>Identify cognitive status including ability to recognize urges, respond to urges, & cooperate with a toileting program </li></ul><ul><li>Identify remaining capabilities of resident. </li></ul><ul><li>Include resources available. </li></ul>www.MDSCarePlanBuilder.com
  56. 56. <ul><li>Functional Impairments </li></ul><ul><li>Cognitive function </li></ul><ul><li>No awareness of urges </li></ul><ul><li>Some awareness </li></ul><ul><li>Can respond to urges </li></ul><ul><li>Can cooperate </li></ul><ul><li>Able to find the toilet </li></ul><ul><li>Mobility </li></ul><ul><li>Transferring, requires assistance </li></ul><ul><li>Locomotion, requires assistance </li></ul><ul><li>Distance problems getting to toilet </li></ul><ul><li>Access problems to toilet </li></ul><ul><li>Use of restraint/side rails </li></ul>www.MDSCarePlanBuilder.com
  57. 57. <ul><li>Difficulty/inability </li></ul><ul><li>Communicating need </li></ul><ul><li>Seeing/hearing </li></ul><ul><li>Managing clothing </li></ul><ul><li>With hygienic needs i.e. wiping self, washing hands, etc. </li></ul><ul><li>Risk Factors Present </li></ul><ul><li>Abnormal labs influencing continence </li></ul><ul><ul><li>High calcium </li></ul></ul><ul><ul><li>High blood glucose </li></ul></ul><ul><ul><li>High BUN/Creatinine </li></ul></ul><ul><ul><li>Positive urine culture </li></ul></ul><ul><li>Signs of depression </li></ul><ul><li>Edema </li></ul><ul><li>Excessive fluid intake </li></ul><ul><li>Excessive caffeine </li></ul><ul><li>Wears pads/briefs </li></ul><ul><li>Chemo/radiation therapy </li></ul><ul><li>Other : </li></ul>www.MDSCarePlanBuilder.com
  58. 58. <ul><li>CONCURRENT MEDICAL PROBLEMS </li></ul><ul><li>Acute confusion </li></ul><ul><li>Diabetes </li></ul><ul><li>CHF </li></ul><ul><li>CVA </li></ul><ul><li>TIA </li></ul><ul><li>Cancer </li></ul><ul><ul><li>Brain </li></ul></ul><ul><ul><li>Bladder </li></ul></ul><ul><ul><li>Prostate </li></ul></ul><ul><ul><li>Spine </li></ul></ul><ul><li>Benign prostatic hypertrophy </li></ul><ul><li>Recurrent UTI </li></ul><ul><li>Parkinson’s disease </li></ul><ul><li>Neurological disorder </li></ul><ul><li>Developmental disability </li></ul><ul><li>Mood or Behavior Disorder </li></ul><ul><li>Other: </li></ul><ul><li>MEDICATIONS (can promote urge incontinence/urinary retention or overflow incontinence) </li></ul><ul><ul><li>Diuretic </li></ul></ul><ul><ul><ul><li>Urine Output greater than 1 liter/day </li></ul></ul></ul><ul><ul><ul><li>Urine Output less than liter/day </li></ul></ul></ul><ul><ul><li>Anticholenergics </li></ul></ul><ul><ul><li>Antipsychotic </li></ul></ul><ul><ul><li>Antianxiety/hypnotic </li></ul></ul><ul><ul><li>Antidepressants </li></ul></ul><ul><ul><li>Antihistamine </li></ul></ul><ul><ul><li>Antispasmodics </li></ul></ul><ul><ul><li>Parkinson’s med </li></ul></ul><ul><ul><li>Disopyramide </li></ul></ul><ul><ul><li>Narcotics </li></ul></ul><ul><ul><li>Sympathomimetics </li></ul></ul><ul><ul><li>Beta Blockers </li></ul></ul><ul><ul><li>Calcium Channel Blockers </li></ul></ul>www.MDSCarePlanBuilder.com
  59. 59. <ul><li>The following actions have been completed or are in progress </li></ul><ul><li>Urinary Tract Infection Ruled Out </li></ul><ul><li>Bowel Impaction Ruled Out </li></ul><ul><li>Pelvic exam (rule out atrophic vaginitis / prolapse/etc.) </li></ul><ul><li>Urological testing and/or consultation </li></ul><ul><li>BLADDER TRACKING </li></ul><ul><li>Not done: </li></ul><ul><li>In progress </li></ul><ul><li>Voiding pattern present </li></ul><ul><li>No voiding pattern established </li></ul>www.MDSCarePlanBuilder.com
  60. 60. <ul><li>SUSPECTED TYPE OF INCONTINENCE </li></ul><ul><li>Stress (spurts of urine when coughing/laughing caused by increased intra-abdominal pressure) </li></ul><ul><li>Urge (abrupt loss caused by involuntary bladder contraction) </li></ul><ul><li>Mixed (loss caused by a combination of stress and urge incontinence) </li></ul><ul><li>Overflow/Obstruction (loss when bladder holding capacity exceeded /dribbles urine) </li></ul><ul><li>Neurogenic bladder ( uncontrolled or continuous leakage) </li></ul><ul><li>Functional (restricted mobility/dexterity, vision, hearing, speech loss, inability to communicate) </li></ul><ul><li>Resident/Family/Sig. Other Input </li></ul><ul><li>Questions and concerns: </li></ul><ul><li>Preferences /Suggestions </li></ul><ul><li>Interviewer Comments </li></ul><ul><li>Questions and concerns: </li></ul><ul><li>Preferences /Suggestions </li></ul><ul><li>Interviewer Comments </li></ul>www.MDSCarePlanBuilder.com
  61. 61. <ul><li>Do Not Proceed </li></ul><ul><ul><li>Self manages continence needs </li></ul></ul><ul><ul><li>Other </li></ul></ul><ul><li>Proceed </li></ul><ul><ul><li>Functional compromise and concurrent medical problems require intervention </li></ul></ul><ul><ul><li>Continence status may be improved with toileting plan </li></ul></ul><ul><ul><li>Continence may be restored with re-training program </li></ul></ul><ul><ul><li>Teaching plan is indicated </li></ul></ul><ul><ul><li>Other: </li></ul></ul>www.MDSCarePlanBuilder.com
  62. 62. <ul><li>Criteria for use </li></ul><ul><li>Terminal illness </li></ul><ul><li>Stage III or IV pressure ulcer </li></ul><ul><li>Need for exact urine measurement </li></ul><ul><li>Poor fluid intake and output </li></ul><ul><li>History of inability to void after catheter removal </li></ul><ul><li>Neurogenic/atonic bladder </li></ul><ul><li>Untreatable urinary blockage (inoperable related to diagnosis/medical condition) </li></ul><ul><li>Obesity prevents adequate toilet/skin care </li></ul><ul><li>Debilitating illness </li></ul><ul><li>PROBLEM FACTORS to CONSIDER </li></ul><ul><li>Treated for UTI in absence of symptom </li></ul><ul><li>Treated for UTI with active symptoms </li></ul><ul><li>Hx of Hospitalization for septicemia, bacteria/pylonephritis </li></ul><ul><li>Fluid intake less than 500cc per day </li></ul><ul><li>Irrigation of bladder for other than blockage </li></ul><ul><li>Catheter tube placement problems: </li></ul><ul><li>Tube anchoring system is used </li></ul><ul><li>Other: </li></ul>www.MDSCarePlanBuilder.com
  63. 63. <ul><li>Other Considerations </li></ul><ul><li>Assessment for continuing need done within past 3-6 months by urologist </li></ul><ul><li>Trial without catheter tried </li></ul><ul><ul><li>In progress </li></ul></ul><ul><ul><li>Yes, results </li></ul></ul><ul><ul><li>No, reason </li></ul></ul><ul><li>Resident/Family/Sig. Other Input </li></ul><ul><li>Questions and concerns: </li></ul><ul><li>Preferences /Suggestions </li></ul><ul><li>Interviewer Comments </li></ul><ul><li>Questions and concerns: </li></ul><ul><li>Preferences /Suggestions </li></ul><ul><li>Interviewer Comments </li></ul>www.MDSCarePlanBuilder.com
  64. 64. <ul><li>Proceed </li></ul><ul><ul><li>Catheter is short time until condition stabilizes. </li></ul></ul><ul><ul><li>Catheter use is long term based on irreversible factors, risk plan is indicated. </li></ul></ul><ul><ul><li>Teaching is indicated. </li></ul></ul><ul><ul><li>Other: </li></ul></ul>www.MDSCarePlanBuilder.com Indwelling Catheters CAA
  65. 65. <ul><li>Consider MDS 3.0 Triggering Items </li></ul><ul><li>Identify Key Issues / Problems </li></ul><ul><li>Resident Strengths </li></ul><ul><li>Risk Factors / Potential Complications </li></ul><ul><li>Refer to Related / Linked CAA’s…… </li></ul><ul><li>Care Panning Decision: Proceed Do Not Proceed </li></ul><ul><ul><li>Potential for Improvement </li></ul></ul><ul><ul><li>Improve Current Status </li></ul></ul><ul><ul><li>Maintain </li></ul></ul><ul><ul><li>Slow Decline </li></ul></ul><ul><ul><li>Minimize/Prevent Complication </li></ul></ul><ul><li>Referrals to </li></ul><ul><li>Nursing Social Service Dietary Activities Therapy Physician Other </li></ul>www.MDSCarePlanBuilder.com
  66. 66. <ul><li>Independent Continence </li></ul><ul><li> Able to maintain continence without assistance. </li></ul><ul><li>Dependent Continence </li></ul><ul><li>Kept dry through the efforts of others; for </li></ul><ul><li>physically or mentally impaired. </li></ul><ul><li>Social Continence </li></ul><ul><li>Dependent on absorbent products & other measures to contain urine leakage. Social continence means clean, dry, and odor free. </li></ul>www.MDSCarePlanBuilder.com
  67. 67. <ul><li>Gain resident agreement if resident is cognitively able. </li></ul><ul><li>Discuss with responsible party </li></ul><ul><li>Instruct caregivers. </li></ul><ul><li>Monitor compliance. </li></ul>www.MDSCarePlanBuilder.com
  68. 68. To see complete care plans go to: http://www.hcmarketplace.com/prod-8700/MDS-30-Care-Plans-Made-Easy.html Problem/need Related to Risks/challenges ❏ Occ. incontinence ❏ Frequent incontinence ❏ Always incontinent Bladder incompetence: ❏Abrupt loss of urine ❏ Urine loss with stress ❏ Uncontrolled leakage Physical limitation: ❏ Compromised mobility ❏ Inability to manage clothing ❏ Inability :wipe self, wash hands Medical condition: ❏Diabetes ❏ Multiple sclerosis ❏ CVA ❏ Quadriplegia ❏ Depression ❏ Seizure disorder ❏ Constipation ❏ Impaction ❏ Catheter use Medication: ❏ Diuretic ❏ Narcotic use ❏ Falls ❏ Skin irritation ❏ Urinary tract infections ❏ Social isolation ❏ Socially inappro.behavior ❏ Behavior outburst ❏ Embarrassment ❏ Curtailment of fluids ❏ Curtailment of activities
  69. 69. To see complete care plan for all CAA’s go to: http://www.hcmarketplace.com/prod-8700/MDS-30-Care-Plans-Made-Easy.html Problem/need Related to Risks/challenges Urinary incontinence resulting in the need for: —— Indwelling catheter —— Suprapubic catheter <ul><li>Urinary retention unresolved by other interventions </li></ul><ul><li>Terminal illness </li></ul><ul><li>Uncomfortable or disruptive bed and clothing changes </li></ul><ul><li>Stage 3 or 4 pressure ulcers on the resident’s trunk </li></ul><ul><li>❏ The resident’s preference when failing to respond to more specific treatments </li></ul><ul><li>❏ The resident’s preference after being informed of the attendant risks </li></ul><ul><li>❏ Monitoring the adequacy of fluid intake and output </li></ul>❏ Chronic bacteria ❏ Symptomatic infection ❏ Septicemia, pylonephritis ❏ Abscesses ❏ Leakage around the catheter ❏ Urethral and bladder neck trauma ❏ Urinary calculi
  70. 70. <ul><li>www.MDScarePlanBuilder.com </li></ul><ul><li>www.ThinkTheThoughts.com </li></ul><ul><li>http://www.galaxyhosted.com/clinical.html </li></ul><ul><li>www.hcmarketplace.com/prod-8700/MDS-30-Care-Plans-Made-Easy.html </li></ul>www.MDSCarePlanBuilder.com