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  • Slide 38 With urge UI and/or an overactive bladder, patients have severe urgency and frequency and usually cannot hold or postpone urination! Detrusor overactivity is a common cause of urge incontinence. This instability causes uninhibited bladder contractions, increasing the urge to void. Uninhibited detrusor contractions due to neurologic conditions are referred to as detrusor hyperreflexia. Detrusor hyperactivity with impaired bladder contractility (DHIC) is more common in the elderly. Overactive bladder is a common term that describes all those conditions listed under urge. Common causes include:     Local genitourinary conditions such as cystitis, urethritis, atrophic vaginitis, tumors, stones, diverticula, outflow obstruction, UTI, impaired contractility     Central nervous system disorders such as stroke, Parkinsonism, Alzheimer’s disease, brain tumor or aneurysm, and spinal cord injury.     Medical conditions such as diabetes mellitus, inadequate fluid intake, habitual frequent voiding.     A number of frail, elderly incontinent residents will have involuntary bladder contractions, but not empty their bladder completely. This can cause chronic urinary retention. That is one reason why the MDS requires bladder assessment of all residents with UI. These residents have an absence of normal bladder urge sensations. Many times this is referred to as reflex incontinence.
  • SLIDE 35    The two most common causes of SUI are: Urethral hypermobility or significant displacement of the urethra and bladder neck during physical exertion when abdominal pressure is increased Intrinsic sphincter deficiency (ISD) is significant failure of the sphincter due to urothelial, myogenic or neurogenic dysfunction of the outlet. ISD may be seen with and without hypermobility of the urethra. Etiology         sphincter dysfunction, due to relaxation and weakness of the pelvic floor muscles and reduction in urethral resistance       in women, especially those with multiple childbirths, estrogen deficiency, or trauma to the external urinary sphincter in men due to pelvic trauma or sphincter damage during prostatectomy       obesity       smoking with chronic coughing can contribute to stress UI.
  • SLIDE 41 - Overflow incontinence occurs when the bladder cannot empty normally and becomes overdistended, leading to frequent, sometimes nearly constant urine loss. Urine loss is usually in small amounts and patients will report dribbling or being unable to “empty my bladder”. Causes include neurologic abnormalities that impair detrusor contractile capacity, including spinal cord lesions, neuropathies (e.g. Diabetes) and any factor that obstructs outflow, e.g., medications, tumors, constipation/fecal impaction, urethral strictures, and prostatic hyperplasia or cancer.
  • Slides (Power Point)

    1. 1. Centers for Medicare and Medicaid Services Urinary Incontinence and Catheters Satellite Broadcast October 27, 2004
    2. 2. Causes of Urinary Incontinence <ul><li>Urinary tract conditions </li></ul><ul><li>Neurological disorders </li></ul><ul><li>Impaired functional status </li></ul><ul><li>Environmental barriers </li></ul>
    3. 3. Potentially Reversible Causes of Urinary Incontinence <ul><li>Acute symptomatic urinary tract infection </li></ul><ul><li>Atrophic vaginitis </li></ul><ul><li>Severe constipation and fecal impaction </li></ul><ul><li>Conditions that cause a decrease in mobility and toileting ability </li></ul><ul><li>Caffeine intake </li></ul><ul><li>Drug side effects </li></ul>
    4. 4. Urge Incontinence “Overactive Bladder” <ul><li>Signs : </li></ul><ul><li>Urine loss </li></ul><ul><li>Urgency </li></ul><ul><li>Frequency > 8x/24 hrs </li></ul><ul><li>Involuntary Bladder Contractions </li></ul><ul><li>Severe Bladder Hypersensitvity </li></ul>
    5. 5. Stress Incontinence <ul><li>Increase in intra-abdominal pressure </li></ul><ul><li>Symptoms: Small losses of urine when: </li></ul><ul><ul><li>Coughing </li></ul></ul><ul><ul><li>Laughing </li></ul></ul><ul><ul><li>Exercising </li></ul></ul><ul><ul><li>Changing positions </li></ul></ul>
    6. 6. Overflow Incontinence <ul><li>Urethral Obstruction </li></ul><ul><ul><li>Enlarged prostate </li></ul></ul><ul><ul><li>Urethral Stricture </li></ul></ul><ul><ul><li>Fecal Impaction </li></ul></ul><ul><li>Neurologic Conditions </li></ul><ul><ul><li>Diabetic Neuropathy </li></ul></ul><ul><ul><li>Low Spinal Cord Injury </li></ul></ul><ul><li>Medications </li></ul><ul><ul><li>Anticholinergics </li></ul></ul><ul><li>Symptoms </li></ul><ul><li> Bladder Distention </li></ul><ul><li> Reduced Urine Flow </li></ul><ul><li>Dribbling </li></ul><ul><li>Frequency </li></ul>
    7. 7. Functional Incontinence <ul><li>Conditions: </li></ul><ul><li>Cognitive Impairment </li></ul><ul><li>Chronic Functional Disability </li></ul><ul><li>Psychological Impairment </li></ul><ul><li>Environmental Barriers </li></ul><ul><li>Symptoms: </li></ul><ul><li>Inaccessible toilet or lack of staff assistance </li></ul><ul><li>Nocturnal enuresis </li></ul><ul><li>Combined fecal and urinary incontinence </li></ul>
    8. 8. Objectives of the Assessment <ul><li>Identify causes and contributing conditions </li></ul><ul><li>Co-morbid conditions and medications </li></ul><ul><li>Degree of bother to resident </li></ul><ul><li>Resident and family preferences for treatment </li></ul>
    9. 9. Goals of Assessment <ul><li>Determine if the resident is incontinent, </li></ul><ul><li>nature of lower urinary tract symptoms, and </li></ul><ul><li>type of incontinence </li></ul><ul><li>Determine the type of assessment conducted of the resident’s incontinence status before admission and any interventions </li></ul><ul><li>Determine reversible factors </li></ul><ul><li>Determine conditions that may require further evaluation </li></ul><ul><li>Implement a prompted voiding trial </li></ul><ul><li>Determine resident’s risk for complications and preferences for treatment </li></ul>
    10. 10. Reversible Causes of UI <ul><li>Delirium </li></ul><ul><li>Impaired mobility </li></ul><ul><li>Infection </li></ul><ul><li>Fecal impaction </li></ul><ul><li>Frequent urination </li></ul><ul><li>Medications </li></ul>
    11. 11. Key Elements to Include in Resident’s History <ul><li>Duration and characteristics of the incontinence </li></ul><ul><li>Precipitants </li></ul><ul><li>Voiding patterns </li></ul><ul><li>Previous treatment and/or management </li></ul>
    12. 12. Factors that Increase Resident’s Risk for UI <ul><li>Impaired cognitive function </li></ul><ul><li>Impaired mobility </li></ul><ul><li>Decreased manual dexterity </li></ul><ul><li>Poor upper and lower extremity strength </li></ul><ul><li>Visual problems </li></ul><ul><li>Neurological conditions </li></ul><ul><li>Medications </li></ul>
    13. 13. Factors that Increase Resident’s Risk for UI <ul><li>Medications: </li></ul><ul><li>Diuretics </li></ul><ul><li>Narcotics </li></ul><ul><li>Anticholinergics </li></ul><ul><li>Psychotropics ( Sedatives, Hypnotics, Antipsychotics ) </li></ul><ul><li>Calcium channel blockers </li></ul>
    14. 14. General Physical Assessment <ul><li>Neurological conditions </li></ul><ul><li>Mobility </li></ul><ul><li>Cognition </li></ul><ul><li>Manual dexterity </li></ul>
    15. 15. General Physical Assessment <ul><li>Abdominal: </li></ul><ul><li>Bowel sounds </li></ul><ul><li>Surgical incisions </li></ul><ul><li>Masses </li></ul><ul><li>Suprapubic bladder fullness </li></ul>
    16. 16. General Physical Assessment <ul><li>Female Perineum: </li></ul><ul><li>Atrophic tissue changes </li></ul><ul><li>Pelvic organ prolapse </li></ul><ul><li>Perineal skin condition </li></ul><ul><li>Color, odor, discharge </li></ul><ul><li>Structural abnormalities </li></ul>
    17. 17. General Physical Assessment <ul><li>Perineal assessment for men: </li></ul><ul><li>Determine lesions of the shaft/skin </li></ul><ul><li>Inspect scrotum for lesions and size </li></ul>
    18. 18. Additional Testing <ul><li>Urinalysis - clean catch </li></ul><ul><ul><li>Nursing home residents should not be catheterized to collect a urine specimen unless it is an urgent situation </li></ul></ul><ul><ul><li>Testing to exclude a UTI should only be done if the incontinence is new or worsening, or other symptoms of UTI </li></ul></ul><ul><ul><li>Post-Void Residual (PVR) </li></ul></ul><ul><ul><li>Risk factors: all men, diabetes, neurological disorders, medications </li></ul></ul>
    19. 19. How to Perform PVR <ul><li>PVR: </li></ul><ul><li>Conduct within a few minutes of voiding </li></ul><ul><li>Record voided and PVR volume </li></ul><ul><li>Done through sterile in-and-out catheterization or bladder ultrasound </li></ul>
    20. 20. Behavioral Programs <ul><li>Required skills for residents: </li></ul><ul><li>Ability to comprehend and follow education and instructions </li></ul><ul><li>Identify urinary urge sensation </li></ul><ul><li>Learn to inhibit or control urge to void </li></ul><ul><li>Kegel exercises </li></ul>
    21. 21. Bladder Rehabilitation or Retaining <ul><li>Resident: </li></ul><ul><li>Should be able to resist or inhibit the urge to void </li></ul><ul><li>Void according to a timetable </li></ul><ul><li>Independent in activities of daily living </li></ul><ul><li>Experience occasional incontinent episodes </li></ul><ul><li>Aware of need to void </li></ul><ul><li>Usually assessed as having urge incontinence </li></ul>
    22. 22. <ul><ul><li>Bladder Muscle - Detrusor </li></ul></ul><ul><ul><li>Urethra </li></ul></ul><ul><ul><li>Pelvic Floor Muscle </li></ul></ul>Lower Urinary Tract
    23. 23. Habit Training/Scheduled Voiding <ul><li>Requires scheduled toileting, at regular intervals, on a planned basis, and match the resident’s voiding habits </li></ul><ul><li>Maintain record of resident’s voiding patterns </li></ul>
    24. 24. Prompted voiding <ul><li>Resident: </li></ul><ul><li>Assessed with urge incontinence </li></ul><ul><li>Cognitive impairment </li></ul><ul><li>Dependent on facility staff for assistance </li></ul><ul><li>Able to say name or reliably pint to one of two objects </li></ul><ul><li>Requires training, motivation, effort </li></ul>
    25. 25. Risk of Complications for Indwelling Urinary Catheter <ul><li>Bacteriuria </li></ul><ul><li>Febrile episodes </li></ul><ul><li>Bladder stones </li></ul><ul><li>Epididymitis </li></ul><ul><li>Chronic renal inflammation </li></ul><ul><li>Pyelonephritis </li></ul>
    26. 26. Assessment to Determine if Indwelling Catheter is Medically Justified <ul><li>Used for short-term decompression of acute urinary retention </li></ul><ul><li>If used beyond 14 days, restrict to- </li></ul><ul><ul><ul><li>Urinary retention not managed by other means </li></ul></ul></ul><ul><ul><ul><li>Presence of multiple pressure ulcers for which healing is compromised by urinary incontinence </li></ul></ul></ul><ul><ul><ul><li>Pain or impairment is compromised </li></ul></ul></ul>
    27. 27. Assessment to Determine if Indwelling Catheter is Medically Justified <ul><li>If indwelling urinary catheter is not medically justified- </li></ul><ul><ul><ul><li>Remove catheter </li></ul></ul></ul><ul><ul><ul><li>Complete a voiding trial </li></ul></ul></ul><ul><ul><ul><li>Determine best bladder management program for resident </li></ul></ul></ul>
    28. 28. Risk Factors for Urinary Tract Infections <ul><li>Fecal incontinence </li></ul><ul><li>Urinary retention </li></ul><ul><li>Diabetes </li></ul><ul><li>Structural abnormalities of the lower urinary tract </li></ul><ul><li>Atrophic vaginitis in women </li></ul>
    29. 29. Asymptomatic Bacteriuria <ul><li>Common in geriatric population </li></ul><ul><li>Should not be treated </li></ul><ul><ul><ul><li>Unnecessary risks of antibiotic therapy </li></ul></ul></ul><ul><ul><ul><li>Excess costs </li></ul></ul></ul><ul><ul><ul><li>Potential to develop multi-drug resistant bacteria </li></ul></ul></ul>
    30. 30. Symptomatic Urinary Tract Infections (UTIs) <ul><li>Residents without an indwelling urinary </li></ul><ul><li>catheter include at least three of the following: </li></ul><ul><ul><li>Fever of at least 2.4 degrees Fahrenheit above the resident’s baseline temperature </li></ul></ul><ul><ul><li>New or increased incontinence, burning or pain on urination, frequency or urgency </li></ul></ul><ul><ul><li>New flank pain or tenderness </li></ul></ul><ul><ul><li>Change in character of urine such as blood, new pyuria or hematuria </li></ul></ul><ul><ul><li>Worsening of mental or functional status </li></ul></ul>
    31. 31. Symptomatic Urinary Tract Infections (UTIs) <ul><li>Residents with an indwelling urinary </li></ul><ul><li>Catheter include at least two of the </li></ul><ul><li>following : </li></ul><ul><ul><li>Fever of at least 2.4 degrees Fahrenheit above the resident’s baseline temperature </li></ul></ul><ul><ul><li>New flank pain or tenderness </li></ul></ul><ul><ul><li>Change in character of urine such as blood, new pyuria or hematuria </li></ul></ul><ul><ul><li>Worsening of mental or functional status </li></ul></ul>
    32. 32. Assessment for Absorbent Products <ul><li>Assess resident’s; </li></ul><ul><li>Functional ability to ambulate, toilet, disrobe, use of assistive devices </li></ul><ul><li>Ease in self-toileting </li></ul><ul><li>Assess product for: </li></ul><ul><li>Contain urinary leakage </li></ul><ul><li>Comfort </li></ul><ul><li>Ease of application/removal </li></ul>
    33. 33. Bladder Rehabilitation/Retraining <ul><li>Goal is to achieve a normal voiding pattern, or </li></ul><ul><li>Achieve the longest possible interval </li></ul><ul><li>Resident should be able to hold urine until reaching the toilet </li></ul>
    34. 34. Prompted Voiding <ul><li>Three components: </li></ul><ul><li>regular monitoring with encouragement </li></ul><ul><li>prompting the resident to toilet on a scheduled </li></ul><ul><li>basis </li></ul><ul><li>praise and positive feedback when the resident </li></ul><ul><li>is continent and attempts to toilet. </li></ul>
    35. 35. Prompted Voiding (PV) <ul><li>Predictors of responsiveness to PV </li></ul><ul><ul><li>Resident’s response to a therapeutic trial of PV </li></ul></ul><ul><ul><li>Normal bladder capacity (>200 and <700cc) </li></ul></ul><ul><ul><li>Recognizes need to void </li></ul></ul><ul><ul><li>Baseline incontinence < 4 times/12hours </li></ul></ul><ul><ul><li>Maximum voided volume > 150 cc </li></ul></ul><ul><ul><li>Post void residual < 100 cc </li></ul></ul><ul><ul><li>Able to void successfully when given toileting assistance </li></ul></ul><ul><ul><li>Evidence from properly designed and implemented controlled trials by University of Iowa Gerontology Nursing Intervention Research Center </li></ul></ul>
    36. 36. Habit Training/Scheduled Voiding <ul><li>Goal is to prevent incontinence from </li></ul><ul><li>Occurring: </li></ul><ul><li>Provide access to the toilet based on the </li></ul><ul><li>resident’s voiding pattern </li></ul>
    37. 37. Key Considerations for Medication Therapy for Urge Incontinence and Overactive Bladder <ul><li>Identify residents with symptoms known to be responsive to medication therapy </li></ul><ul><li>Ongoing incontinence despite treatment of reversible causes </li></ul><ul><li>Risk for anticholinergic side effects </li></ul><ul><li>Costs </li></ul>
    38. 38. Anticholinergic Medications <ul><li>Side Effects: </li></ul><ul><ul><li>Dry mouth </li></ul></ul><ul><ul><li>Constipation </li></ul></ul><ul><ul><li>Development or exacerbation of gastroesophageal reflux </li></ul></ul><ul><ul><li>Urinary retention </li></ul></ul><ul><ul><li>Impaired cognitive function </li></ul></ul><ul><ul><li>Delirium </li></ul></ul>
    39. 39. Determination of Urinary Tract Infection <ul><li>Review several test results in combination with </li></ul><ul><li>clinical findings: </li></ul><ul><li>Microscopic urinalysis showing the presence of pyuria; or </li></ul><ul><li>Positive urine dipstick test for leukocyte esterase (indicating significant pyuria) or </li></ul><ul><li>Nitrites (indicating the presence of Enterobacteriaceae) </li></ul>
    40. 40. Determination of Urinary Tract Infection <ul><li>Nonspecific symptoms, look for: </li></ul><ul><li>Hematuria, </li></ul><ul><li>Fever or </li></ul><ul><li>Evidence of pyuria </li></ul>
    41. 41. Urinary Tract Infection Prevention Strategies <ul><li>Infection control policies and procedures </li></ul><ul><li>Identification of high risk residents </li></ul><ul><li>Perineal hygiene, especially for women with fecal incontinence </li></ul><ul><li>Hydration </li></ul><ul><li>Treatment of atrophic vaginitis </li></ul>
    42. 42. Complications of Indwelling Catheters <ul><li>Urinary Tract Infections </li></ul><ul><li>Encrustations </li></ul><ul><li>Leakage around catheter </li></ul><ul><li>Inadvertent removal of catheter </li></ul>
    43. 43. Catheter Related Urinary Tract Infections <ul><ul><li>Risk </li></ul></ul><ul><ul><ul><li>method and duration of catheterization </li></ul></ul></ul><ul><ul><ul><li>quality of catheter care </li></ul></ul></ul><ul><ul><ul><li>host susceptibility </li></ul></ul></ul><ul><ul><li>Most common complication seen with long-term use of indwelling catheters </li></ul></ul><ul><ul><ul><li>MRSA </li></ul></ul></ul><ul><ul><li>E-coli most common organism </li></ul></ul><ul><ul><li>Urosepsis –results from frequent and repeated UTIs </li></ul></ul>
    44. 44. Encrustations <ul><li>Risk factors: </li></ul><ul><ul><li>alkaline urine </li></ul></ul><ul><ul><li>poor mobility </li></ul></ul><ul><ul><li>decreased fluid intake </li></ul></ul>
    45. 45. Leakage Around Catheter <ul><li>Contributing factors: </li></ul><ul><ul><li>Detrusor (bladder) overactivity </li></ul></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><li>Urethral/catheter obstruction </li></ul></ul><ul><ul><li>Catheter or balloon size too large </li></ul></ul><ul><ul><li>Constipation or fecal impaction </li></ul></ul>
    46. 46. Other Care Practices to Reduce Complications <ul><li>Educating the resident or responsible party on the risks and benefits of catheter use; </li></ul><ul><li>Recognizing and assessing for symptoms of complications; </li></ul><ul><li>Attempts to remove the catheter; </li></ul><ul><li>Monitoring for post void residual; and </li></ul><ul><li>Keeping the catheter anchored to prevent urethral tensions </li></ul>
    47. 47. Skin Problems Related to Urinary Incontinence <ul><li>Early: </li></ul><ul><li>Irritant dermatitis </li></ul><ul><li>Inflammation </li></ul><ul><li>Caused by prolonged contact with moisture </li></ul><ul><li>Advanced: </li></ul><ul><li>Blistering </li></ul><ul><li>Erosion </li></ul><ul><li>Exudate </li></ul>
    48. 48. Decline or Lack of Improvement in Continence <ul><li>Practices that prevent or minimize a </li></ul><ul><li>decline or lack of improvement: </li></ul><ul><ul><li>Assessment and documentation of the resident’s </li></ul></ul><ul><ul><li>baseline continence status </li></ul></ul><ul><ul><li>Interventions to improve functional abilities </li></ul></ul><ul><ul><li>Environmental modifications </li></ul></ul><ul><ul><li>Treatment of the underlying cause </li></ul></ul><ul><ul><li>Adjustment of medications </li></ul></ul><ul><ul><li>Fluid management program </li></ul></ul>
    49. 50. Websites <ul><li>Qualidigm Medicare Information </li></ul><ul><li>AHRQ National Guideline Clearinghouse </li></ul><ul><li> </li></ul><ul><li>National Institute of Diabetes and Digestive and </li></ul><ul><li>Kidney Diseases (NIDDK) incontine nce.asp </li></ul><ul><li>Society of Urologic Nurses and Associates </li></ul><ul><li> </li></ul><ul><li>National Association for Continence </li></ul><ul><li> </li></ul><ul><li>The Simon Foundation for Continence </li></ul><ul><li> </li></ul>