Continence: A Matter of Dignity Care of Chronic and Complex UI

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Continence A Matter of DignityCare of
Chronic and Complex UI

• By
• Marie Mangino, MSN, CRNP, BC
• President, Vincent Healthcare, Inc.
• Consultant, Penn Nursing Consultation Service

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Acknowledgements

• Appearing in Video
• Name Appearing as
• Bob Swensen.Mr. Banks
• Ruth AlpertMrs. Banks
• Susaye Lawson Susaye
• Nate Lazowick.Mr. Williams
• Kevin Brown Carl, DCSW
• Dinnie ChildsPiano Player
• Clarese HerbertMr. Williams friend
• Man at PianoArjun Bhojwani
• Nancy WebMrs. Powell
• Eric Stewart.Mike, grandson
• Ruth LivikoffRuth, DCSW

• Name Appearing as
• Dick BrownMr. Clark
• Deanna Penn.Supervisor
• Sangeeta Bhojwani.Trainee
• Roby Jacobs..Daughter
• Charlene DuffShopper, Gift Shop
• Sheila Mitchell-AyersShopper, Gift Shop
• Marie Mangino.Trainer, as herself
• Tanisha JonesTestimonial
• Julie Cohlmer.Testimonial

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Special thanks to

• Henrietta Roberts and Sandy Bailey, of Stapeley
  in Germantown for coordination of video shoot
• All the residents and staff of Stapeley in
  Germantown, for their participation and for
  permitting video production.
• Raybourn Rusk Productions

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Review of Causes, Signs and Prevention

• The first module covered the following objectives
  as learner outcomes
• List the common causes of Urinary incontinence
  (UI)
• Describe the potentially serious effects of not
  treating UI
• Recognize signs of a UTI
• Discuss effective ways to prevent or reduce
  episodes of UI and enhance dignity

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Learning Objectives

• At the end of Care of Chronic and Complex
  Urinary Incontinence you will be able to
• List the major types of chronic UI and the common
  signs and symptoms of each
• Explain the importance of preventing constipation
  in older adults with UI
• Discuss creative approaches to more complex cases
  of older adults with UI
• Provide care to prevent or reduce episodes of UI
  and enhance dignity

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Types of Chronic UI

• Stress
• Urge /Overactive bladder
• Overflow
• Functional
• Mixed

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Stress UI

• Small amount of urine leakage
• Loss of urine with increased pressure in the
  abdomen from
• Coughing
• Sneezing
• Laughing
• Lifting
• Standing

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Stress UI How You Can Help?

• Set toileting schedule based on a log and stick
  to it
• Expect small leaks use a liner

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Stress UI How You Can Help?

• Change more frequently
• Use skin barrier
• Mrs. Levy

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Urge UI (Overactive Bladder)

• Involuntary loss of urine and a strong urge to
  urinate that occurs suddenly
• May be incontinent on the way to the bathroom
• May be incontinent of a large amount of urine
• Mrs. Powell
• w/walker

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Urge UI (Overactive Bladder)How You Can Help

• Encourage person to avoid bladder irritants
• Stick to personalized schedule
• Watch for signs of need to toilet
• Keep urinal or commode handy
• Expect heavier wetting with longer period of
  dryness

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Mrs. Powells Success
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Case of Mrs. Powell

• Remind the person to avoid bladder irritants
  (including sodas, caffeine, alcohol and
  artificial sweeteners)
• Help by establishing a toileting schedule and
  sticking to it
• Watch for signs of need to toilet

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Overflow UI

• Continuous or periodic leakage of small amounts
  of urine
• Tension in bladder forces muscles to leak small
  amounts, either continuously or off and on
• Caused by either
• Blockage at the exit of the bladder (large
  prostrate)
• Bladder, nerve or
• muscle damage
• Mr. Stanley

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Overflow UI How You Can Help

• Allow time to stand and wait
• Report complaints of discomfort
• Report inability to urinate for more than 8 hours
  or urination every hour
• Watch for signs of mental status change
• Maintain schedule for toileting

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Functional UI

• Due to chronic functional
• impairment
• Confusion
• Physical disabilities
• Combination
• Mr. Clark

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Functional UI How You Can Help

• Set toileting schedule based on the log and stick
  to it
• Encourage clothing that is easy to remove
• Assist as needed
• Praise successes and effort

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Challenging Situations

• Dementia
• Inappropriate toileting
• Denial
• Unsafe attempts to toilet
• Chronic constipation

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The Challenges of Dementia and UI

• Inappropriate toileting
• Denial of incontinence
• Mr. Clark

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Dementia and UI How You Can Help

• Never judge or disagree, accept the persons
  explanation for wet clothing
• Focus on
• Changing and cleaning
• Dignity and respect
• Prompt (remind and encourage) to use the toilet,
  assist to get there, then prompt again

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Right Time, Right Place
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Case of Mr. Clark

• Focus on
• Dignity and respect
• Changing and cleaning if needed
• Prompt (remind and encourage) to use the toilet,
  assist to get there, then prompt again

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UI and Unsafe Attempts to Toilet

• Due to
• Difficulty Walking
• Poor vision
• Poor safety judgment

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Unsafe Attempts to Toilet How You Can Help

• Use individualized toileting schedule be there
  ahead of time
• Do not rely on call bell
• Do not wait until the person tries to get up

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Unsafe Attempts to Toilet How You Can Help

• Use safe footwear
• Use proper eyeglasses when walking assist person
  wearing bifocals
• Provide a bedside commode or urinal to reduce the
  need to walk alone

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Chronic Constipation and UI

• Presence of stool in the pelvis
• Takes up room in the pelvis so bladder cannot
  fill up
• Causes need to urinate more often
• Increases incontinent episodes

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Chronic Constipation and UI How You Can Help

• Report it
• Encourage
• Fluid intake
• Activity
• Foods rich in fiber
• Avoid constipating food

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Objectives Review

• Can you now
• 1. List the major types of chronic UI and the
  common signs and symptoms of each?
• 2. Explain the importance of preventing
  constipation in older adults with UI?
• 3. Discuss creative approaches to more complex
  cases of UI in older adults?

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Closing
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Special Thanks To

• Christine W. Bradway, PhD, CRNP
• Assistant Professor of
• Gerontologic Nursing
• University of Pennsylvania
• School of Nursing
• Mary Ann Forciea, MD
• Clinical Associate Professor of Medicine
• Director, Primary Care Services
• University of Pennsylvania Health Systems
• Nicole Mangino
• Illustrator

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References and Resources

• Burgio, K. L., Robinson, J. C. Engel, B. T.
  (1986). The role of biofeedback in Kegal exercise
  training for stress urinary incontinence.
  American Journal of Obstetrics Gynecology, 154
  58-64.
•  
• Choe, J. M. (1999). Freedom regained Female
  urinary incontinence can be overcome. Columbus,
  Ohio Anadem Publishing 117-171.
•  
• Clinical practice guideline number 2 Urinary
  incontinence in adults. Rockcville Md US
  Department of Health and Human Services Agency
  for Health Care Policy and Research 1996. AHCPR
  publication 96-0682.
•  
• Gibbons, L. Choe, J. M. (2005). Helping women
  quell urinary incontinence. The Clinical Advisor,
  7 (5), 21-28.  

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References and Resources

• Langa, et al, (2002). Informal caregiving time
  and costs for UI in older individuals in the US.
  Journal of the American Geriatrics Society,
  50,(4) 733-737.
• Lee SY, Phanumus D. Fields S.D. (2000). Urinary
  incontinence a primary care guide to managing
  acute and chronic symptoms in older adults.
  Geriatrics, 55(11) 65-72.
•  
• Morkved, S. Bo, K. Fjortoft, T. (2002). Effect
  of adding biofeedback to pelvic floor muscle
  training to treat urodynamic stress incontinence.
  Obstetrics Gynecology, 100 730-739.
•  
• Multiple authors (2004). Special issue Urologic
  care of the older adult. Urologic Nursing, 24,
  247-333.
•  
• Teunissen, T.A.M., de Jonge, A., van Weel, C.,
  Lagro-Janssen, A.L.M. (2004). Treating UI in the
  elderlyconservative measures that work A
  systematic review. Journal of Family Practice, 53
  (1), 25.
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References and Resources

• Web sites
• Collaborative to Support Urinary Incontinence and
  Womens Health www.stressUI.org
• National Association for Continence www.nafc.org
• National Institute of Diabetes Digestive
  Kidney Diseases www.niddk.nig.gov

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Leadership and Staff

• Lois K. Evans, DNSc, RN, FAAN
• Series Associate Editor
• Viola MacInnes Independence
• Professor
• School of Nursing
• University of Pennsylvania
• Sangeeta Bhojwani
• Associate Director,
• Series Assistant Editor
• DVGEC
• University of Pennsylvania
• Laura Raybourn
• Sally Rusk, Consultants
• Raybourn Rusk Productions

• Kathleen Egan, PhD
• Series Editor
• DVGEC Program Administrator
• Director, DVGEC University of Pennsylvania
• Mary Ann Forciea, MD
• Series Associate Editor
• Clinical Associate Professor of Medicine
• Division of Geriatric Medicine, University of
  Pennsylvania