Leakage around catheter Inadvertent removal of catheter

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Centers for Medicare and Medicaid Services
Urinary Incontinence and Catheters Satellite
Broadcast

• October 27, 2004

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Causes of Urinary Incontinence

• Urinary tract conditions
• Neurological disorders
• Impaired functional status
• Environmental barriers

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Potentially Reversible Causes of Urinary
Incontinence

• Acute symptomatic urinary tract infection
• Atrophic vaginitis
• Severe constipation and fecal impaction
• Conditions that cause a decrease in mobility and
  toileting ability
• Caffeine intake
• Drug side effects

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Urge Incontinence Overactive Bladder

• Involuntary Bladder Contractions
• Severe Bladder Hypersensitvity

• Signs
• Urine loss
• Urgency
• Frequency gt 8x/24 hrs

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Stress Incontinence

• Increase in intra-abdominal pressure
• Symptoms Small losses of urine when
• Coughing
• Laughing
• Exercising
• Changing positions

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Overflow Incontinence

• Urethral Obstruction
• Enlarged prostate
• Urethral Stricture
• Fecal Impaction
• Neurologic Conditions
• Diabetic Neuropathy
• Low Spinal Cord Injury
• Medications
• Anticholinergics

• Symptoms
• Bladder Distention
• Reduced Urine Flow
• Dribbling
• Frequency

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Functional Incontinence

• Conditions
• Cognitive Impairment
• Chronic Functional Disability
• Psychological Impairment
• Environmental Barriers

• Symptoms
• Inaccessible toilet or lack of staff assistance
• Nocturnal enuresis
• Combined fecal and urinary incontinence

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Objectives of the Assessment

• Identify causes and contributing conditions
• Co-morbid conditions and medications
• Degree of bother to resident
• Resident and family preferences for treatment

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Goals of Assessment

• Determine if the resident is incontinent,
• nature of lower urinary tract symptoms, and
• type of incontinence
• Determine the type of assessment conducted of the
  residents incontinence status before admission
  and any interventions
• Determine reversible factors
• Determine conditions that may require further
  evaluation
• Implement a prompted voiding trial
• Determine residents risk for complications and
  preferences for treatment

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Reversible Causes of UI

• Delirium
• Impaired mobility
• Infection
• Fecal impaction
• Frequent urination
• Medications

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Key Elements to Include in Residents History

• Duration and characteristics of the incontinence
• Precipitants
• Voiding patterns
• Previous treatment and/or management

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Factors that Increase Residents Risk for UI

• Impaired cognitive function
• Impaired mobility
• Decreased manual dexterity
• Poor upper and lower extremity strength
• Visual problems
• Neurological conditions
• Medications

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Factors that Increase Residents Risk for UI

• Medications
• Diuretics
• Narcotics
• Anticholinergics
• Psychotropics (Sedatives, Hypnotics,
  Antipsychotics)
• Calcium channel blockers

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General Physical Assessment

• Neurological conditions
• Mobility
• Cognition
• Manual dexterity

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General Physical Assessment

• Abdominal
• Bowel sounds
• Surgical incisions
• Masses
• Suprapubic bladder fullness

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General Physical Assessment

• Female Perineum
• Atrophic tissue changes
• Pelvic organ prolapse
• Perineal skin condition
• Color, odor, discharge
• Structural abnormalities

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General Physical Assessment

• Perineal assessment for men
• Determine lesions of the shaft/skin
• Inspect scrotum for lesions and size

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Additional Testing

• Urinalysis - clean catch
• Nursing home residents should not be catheterized
  to collect a urine specimen unless it is an
  urgent situation
• Testing to exclude a UTI should only be done if
  the incontinence is new or worsening, or other
  symptoms of UTI
• Post-Void Residual (PVR)
• Risk factors all men, diabetes, neurological
  disorders, medications

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How to Perform PVR

• PVR
• Conduct within a few minutes of voiding
• Record voided and PVR volume
• Done through sterile in-and-out catheterization
  or bladder ultrasound

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Behavioral Programs

• Required skills for residents
• Ability to comprehend and follow education and
  instructions
• Identify urinary urge sensation
• Learn to inhibit or control urge to void
• Kegel exercises

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Bladder Rehabilitation or Retaining

• Resident
• Should be able to resist or inhibit the urge to
  void
• Void according to a timetable
• Independent in activities of daily living
• Experience occasional incontinent episodes
• Aware of need to void
• Usually assessed as having urge incontinence

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Lower Urinary Tract

• Bladder Muscle - Detrusor
• Urethra
• Pelvic Floor Muscle

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Habit Training/Scheduled Voiding

• Requires scheduled toileting, at regular
  intervals, on a planned basis, and match the
  residents voiding habits
• Maintain record of residents voiding patterns

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Prompted voiding

• Resident
• Assessed with urge incontinence
• Cognitive impairment
• Dependent on facility staff for assistance
• Able to say name or reliably pint to one of two
  objects
• Requires training, motivation, effort

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Risk of Complications for Indwelling Urinary
Catheter

• Bacteriuria
• Febrile episodes
• Bladder stones
• Epididymitis
• Chronic renal inflammation
• Pyelonephritis

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Assessment to Determine if Indwelling Catheter is
Medically Justified

• Used for short-term decompression of acute
  urinary retention
• If used beyond 14 days, restrict to-
• Urinary retention not managed by other means
• Presence of multiple pressure ulcers for which
  healing is compromised by urinary incontinence
• Pain or impairment is compromised

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Assessment to Determine if Indwelling Catheter is
Medically Justified

• If indwelling urinary catheter is not medically
  justified-
• Remove catheter
• Complete a voiding trial
• Determine best bladder management program for
  resident

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Risk Factors for Urinary Tract Infections

• Fecal incontinence
• Urinary retention
• Diabetes
• Structural abnormalities of the lower urinary
  tract
• Atrophic vaginitis in women

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Asymptomatic Bacteriuria

• Common in geriatric population
• Should not be treated
• Unnecessary risks of antibiotic therapy
• Excess costs
• Potential to develop multi-drug resistant
  bacteria

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Symptomatic Urinary Tract Infections (UTIs)

• Residents without an indwelling urinary
• catheter include at least three of the following
• Fever of at least 2.4 degrees Fahrenheit above
  the residents baseline temperature
• New or increased incontinence, burning or pain on
  urination, frequency or urgency
• New flank pain or tenderness
• Change in character of urine such as blood, new
  pyuria or hematuria
• Worsening of mental or functional status

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Symptomatic Urinary Tract Infections (UTIs)

• Residents with an indwelling urinary
• Catheter include at least two of the
• following
• Fever of at least 2.4 degrees Fahrenheit above
  the residents baseline temperature
• New flank pain or tenderness
• Change in character of urine such as blood, new
  pyuria or hematuria
• Worsening of mental or functional status

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Assessment for Absorbent Products

• Assess residents
• Functional ability to ambulate, toilet, disrobe,
  use of assistive devices
• Ease in self-toileting
• Assess product for
• Contain urinary leakage
• Comfort
• Ease of application/removal

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Bladder Rehabilitation/Retraining

• Goal is to achieve a normal voiding pattern, or
• Achieve the longest possible interval
• Resident should be able to hold urine until
  reaching the toilet

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Prompted Voiding

• Three components
• regular monitoring with encouragement
• prompting the resident to toilet on a scheduled
• basis
• praise and positive feedback when the resident
• is continent and attempts to toilet.

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Prompted Voiding (PV)

• Predictors of responsiveness to PV
• Residents response to a therapeutic trial of PV
• Normal bladder capacity (gt200 and lt700cc)
• Recognizes need to void
• Baseline incontinence lt 4 times/12hours
• Maximum voided volume gt 150 cc
• Post void residual lt 100 cc
• Able to void successfully when given toileting
  assistance
• Evidence from properly designed and
  implemented controlled trials by University of
  Iowa Gerontology Nursing Intervention Research
  Center

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Habit Training/Scheduled Voiding

• Goal is to prevent incontinence from
• Occurring
• Provide access to the toilet based on the
• residents voiding pattern

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Key Considerations for Medication Therapy for
Urge Incontinence and Overactive Bladder

• Identify residents with symptoms known to be
  responsive to medication therapy
• Ongoing incontinence despite treatment of
  reversible causes
• Risk for anticholinergic side effects
• Costs

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Anticholinergic Medications

• Side Effects
• Dry mouth
• Constipation
• Development or exacerbation of gastroesophageal
  reflux
• Urinary retention
• Impaired cognitive function
• Delirium

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Determination of Urinary Tract Infection

• Review several test results in combination with
• clinical findings
• Microscopic urinalysis showing the presence of
  pyuria or
• Positive urine dipstick test for leukocyte
  esterase (indicating significant pyuria) or
• Nitrites (indicating the presence of
  Enterobacteriaceae)

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Determination of Urinary Tract Infection

• Nonspecific symptoms, look for
• Hematuria,
• Fever or
• Evidence of pyuria

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Urinary Tract Infection Prevention Strategies

• Infection control policies and procedures
• Identification of high risk residents
• Perineal hygiene, especially for women with fecal
  incontinence
• Hydration
• Treatment of atrophic vaginitis

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Complications of Indwelling Catheters

• Urinary Tract Infections
• Encrustations
• Leakage around catheter
• Inadvertent removal of catheter

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Catheter Related Urinary Tract Infections

• Risk
• method and duration of catheterization
• quality of catheter care
• host susceptibility
• Most common complication seen with long-term use
  of indwelling catheters
• MRSA
• E-coli most common organism
• Urosepsis results from frequent and repeated
  UTIs

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Encrustations

• Risk factors
• alkaline urine
• poor mobility
• decreased fluid intake

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Leakage Around Catheter

• Contributing factors
• Detrusor (bladder) overactivity
• Infection
• Urethral/catheter obstruction
• Catheter or balloon size too large
• Constipation or fecal impaction

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Other Care Practices to Reduce Complications

• Educating the resident or responsible party on
  the risks and benefits of catheter use
• Recognizing and assessing for symptoms of
  complications
• Attempts to remove the catheter
• Monitoring for post void residual and
• Keeping the catheter anchored to prevent urethral
  tensions

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Skin Problems Related to Urinary Incontinence

• Early
• Irritant dermatitis
• Inflammation
• Caused by prolonged contact with moisture
• Advanced
• Blistering
• Erosion
• Exudate

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Decline or Lack of Improvement in Continence

• Practices that prevent or minimize a
• decline or lack of improvement
• Assessment and documentation of the residents
• baseline continence status
• Interventions to improve functional abilities
• Environmental modifications
• Treatment of the underlying cause
• Adjustment of medications
• Fluid management program

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Websites

• Qualidigm Medicare Information
  http//www.ctmedicare.org/qip_med_nursing_res.shtm
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• AHRQ National Guideline Clearinghouse
• http//www.guideline.gov/
• National Institute of Diabetes and Digestive and
  
• Kidney Diseases (NIDDK)
  http//kidney.niddk.nih.gov/kudiseases/topics/inco
  ntinence.asp
• Society of Urologic Nurses and Associates
• http//www.suna.org/
• National Association for Continence
• http//www.nafc.org/
• The Simon Foundation for Continence
• http//www.simonfoundation.org/html/