American Association of Colleges of Nursing ©2010 – All Rights Reserved Transitioning to...

American Association of Colleges of Nursing ©2010 – All Rights Reserved

Transitioning to Adult-Gerontology APRN Education: Slide Library Assessment and Management of Urinary

Incontinence in Older Adults

Authors: Christine Bradway, PhD, RN, GNP-BC, University of Pennsylvania School of Nursing

Anne Marie Dowling-Castronovo, RN, MA-GNP, Wagner College, NY

Adult-Gerontology APRN Slide Library

• The APRN Slide Library is a resource of “Transitioning to Adult-Gerontology APRN Education” a project of AACN and the Hartford Institute for Geriatric Nursing 2010-2012

• The project is funded by the John A. Hartford Foundation

Adult-Gerontology APRN Slide Library"All materials are jointly copyrighted by the American Association of Colleges of Nursing (AACN) and The Hartford Institute for Geriatric Nursing, College of Nursing, New York University or are used with permission from the original source. Permission is hereby granted to reproduce, post, download, and/or distribute, this material for not-for-profit educational purposes only, provided that the American Association of Colleges of Nursing (AACN) and The Hartford Institute for Geriatric Nursing, College of Nursing, New York University are cited as the source. They may not be used for ANY commercial or other purpose."

Available at www.hartfordign.org E-mail notification of usage to: [email protected] Further information about the APRN program can be found at

www.aacn.nche.edu/APRN Gerontology.htm

http://www.hartfordign.org/

mailto:[email protected]

http://www.aacn.nche.edu/APRN

Purpose of the APRN Slide Library -UI• To provide APRNs an overview of urinary

incontinence (UI) in older adults*• To introduce APRNs to print & web resources on

assessment, diagnosis & management of UI• To provide APRN faculty with slides on UI to use in

lectures & to share with APRN students

* These slides have been modified from the those prepared for the Geriatric Education Nursing Consortium (GNEC) program (www.aacn.nche.edu)

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UI Resources

Resources to improve caregiver skill and knowledge

Wound Ostomy Continence Nurses Society National Office 15000 Commerce Parkway, Suite C, Mt. Laurel, NJ 08054 888-224-WOCN (9626) http://www.wocn.org

An international society providing a source of networking and research for nurse’s specializing in enterostomal and continence care

National Association for Continence (NAFC) P.O. Box 1010 Charleston, S.C. 29402-1019 (800) BLADDER http://www.nafc.org/

A not-for-profit profit organization dedicated to improving the lives of individuals with incontinence

http://www.americangeriatrics.org/.../the_geriatric_nursing_review_syllabus_2nd_edition/

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UI Resources

Resources to improve caregiver skill and knowledge

The Hartford Institute for Geriatric Nursing http://www.hartfordign.org/

http://www.ConsultGeriRN.org/

These web sites will bring the reader to the “Try This” series that includes a 2-page UI information sheet to share with nursing students and nursing staff at affiliated clinical sites.

Society of Urologic Nurse and Associated (SUNA), National Headquarters, East Holly Ave Box 56 Pitman, NY 08071-0056 ; (888) TAP-SUNA http://www.suna.org/

An international organization dedicated to nursing care of individuals with urologic disorders.

Source Books Specific to UI

Wein A, Newman D. (2009) Managing and Treating Urinary Incontinence, 2nd Edition, Health Professions Press

Newman D. Dzurnik MK (1999) The Urinary Incontinence Source Book. Lowell Press

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Source Books: GeriatricsAuerhahn, C., Capezuti, E., Flaherty, E., & Resnick, B. (eds.) (2007). Geriatric Nursing

Review Syllabus: A Core Curriculum in Advanced Practice Geriatric Nursing, 2nd Edition: New York: American Geriatrics Society. (3rd Edition, May, 2011)

• A concise & comprehensive text developed by the American Geriatrics Society (AGS) & the NYU Hartford Institute for Geriatric Nursing , adapted for APRNs from the AGS Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine, 6th Edition

• Authored by > 100 interdisciplinary experts in care of older adults• 59 chapters on prevailing management strategies, extensive reference, appendix with

assessment instruments, 100 case-oriented, multiple choice questions and a self-assessment tool. (www.americangeriatrics.org/.../the_geriatric_nursing_review_syllabus_2nd_edition/

Auerhahn, C. & Kennedy-Malone, L. (2010). Integrating Gerontological Content into Advanced Practice Nursing Education. New York: Springer Publishing Co.

• Clear, user-friendly guidelines for integrating gerontological content into non-gerontological APRN programs

• Detailed lists of print resources and e-Learning materials• Utilizes a competency-based framework• “Success stories” written by APRN faculty who have integrated gerontological content into

non-gerontological courses

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Assessing, Diagnosing, and Managing Older Adults with UI: Guiding Principles for APRNs

Traditionally, health care practitioners view UI as a normal consequence of aging and recommend containment strategies UI is not a normal consequence of aging APRNs should work-up all complaints of UI as an abnormal

finding APRNs should be familiar with types of UI and appropriate

diagnostic & management strategies (e.g. pelvic floor muscle exercises [PFME] or prompted voiding)

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Incidence & Prevalence of UI

Incidence and prevalence rates of UI should be viewed cautiously due to inconsistencies with definitions and measurement limitations as well as underreporting and underassessment of UI

Dementia 11-90%

Community Dwelling 8-38%

Homebound 15-33%

Hospitalized 10.5%

Post-Hip Surgery 19-32%

Admission 36%

Additional: Hospitalized 13-42%

Risk Factors for Developing UI

Risk Factors

Modifiable Individual risk factors

Low fluid intake that contributes to bladder irritability Dementia Fecal impaction

AgeMedical conditions and comorbidities Depression Obesity


Risk Factors

Caffeine intake due to its diuretic and irritable effects on the bladder muscle

Type 2 Diabetes Mellitus (DM)

Parkinson’s disease Stroke

Arthritis and back problems Delirium

Chronic obstructive or inflammatory pulmonary conditions

Heart failure

Hearing or Visual impairment


Medications that contribute to UI Examples exacerbating UI: Calcium channel blockers DiureticsAnticholinergic drugs Alpha-adrenergic drugs Angiotension converting Narcotics enzyme inhibitors Psychoactive drugs Sedatives

Risk Factors

Smoking Environmental barriers High-impact physical activitiesChildhood Pregnancy Vaginal delivery nocturnal Episiotomy Hysterectomy enuresis Pelvic muscle Estrogen depletion weakness Prostate surgery

Additional Risk Factors

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FemalesEuropean American women have higher rates of moderate and

severe UI when compared with African-American women

Similar rates of stress UI for Hispanic, white, and Asian women

Increased rates of detrusor (bladder) overactivity; urgency with or without UI; stress UI for African-American women

Race as Risk Factor

Risk Factors for Women Developing UI

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Impact of UI on Older Adults Quality of Life

Consequences of UI may affect individuals Physically Psychosocially Economically

UI associated with Depression Poor self-rated health Poor health related quality of life (HRQoL)

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Impact of UI on Older Adults Quality of Life

Urge UI is associated with: Falls and fractures Skin irritation and infections Urinary tract infections (UTIs) Pressure ulcers Limitations of functional status

Family caregivers may suffer as well

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Definitions of UI (Expert Consensus Opinion)

UI most often defined as the involuntary loss of urine sufficient to be a problem or a bother

Two Types of UI Transient (acute) Established (chronic) UI

Hospitalized older adults are at risk of developing transient UI, and with shorter hospital stays, are also at risk of being discharged without resolution of the UI

Case Study

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Transient UICharacterized by the sudden onset of potentially reversible

symptoms Usually has a duration of less than 6 months Is most always preventable or reversible once underlying causes of UI are

identified and treated. Common causes of Transient UI include:

Delirium Infections (untreated UTI; urethritis) Medications Depression Excessive fluid intake in someone with restricted mobility stool impaction or constipation

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Established UI

Established UI: sudden or gradual onset

Healthcare providers or family caregivers may discover established UI during the course of an acute illness, hospitalization, or abrupt change in environment or daily routine

Stress Urge Mixed (defined as a

combination of stress and urge UI)

Overflow Functional UI

Types of established UI

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Stress UI

Stress UI is defined as an involuntary loss of urine associated with activities that increase intra-abdominal pressure

Symptomatically, individuals with stress UI usually present with complaints of small amounts of daytime urine loss that occurs during physical activity or with increased intra-abdominal pressure (e.g., coughing, sneezing)

MenMay experience after

prostatectomy

Womenmore common

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Urge UI

Urge UI is characterized by an involuntary urine loss associated with a preceding strong desire to void (urgency)

Signs and symptoms of urge UI most often include urinary frequency, nocturia and enuresis, and UI of moderate to large amounts

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Urge UI

An individual with an overactive bladder (OAB) may complain of urgency, with or without UI

Individuals with an OAB also may complain of frequency and nocturia

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Overflow UI Overflow UI is an involuntary loss of urine associated with over

distention of the bladder, and may be caused by an under active detrusor muscle or bladder outlet obstruction leading to over distention and urine overflow

Individuals with overflow UI often describe urine dribbling feel unable to empty the bladder

completely (urinary retention) urinary hesitancy urine loss without a recognizable urge an uncomfortable sensation of fullness or pressure in the lower

abdomen

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Functional UI

Functional UI is caused by non-genitourinary factors, such as cognitive or physical impairments that result in an inability for the individual to be independent in voiding

A cognitively impaired individual may fail to recognize environmental cues or reminders to call for assistance with toileting. This makes the voiding process overly complex resulting in a functional type of UI.

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Urine control is influenced by a myriad of anatomical, physiological, psychological, and cultural factors

Complexity of UI requires cognitive, affective, functional, physical, environmental, and motivational assessments

Despite advances in evaluation and management, UI continues to be a “Don’t ask, don’t tell” health problem

Initial History of UI

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Continence occurs when urethral pressure is equal to or greater than bladder pressure

Angulation of the urethra and pelvic muscle support play a role Continence requires

intact lower urinary tract function cognitive ability to recognize voiding signals functional ability to use a toilet or commode in a timely

manner motivation to maintain continence

Anatomy and Physiology of Micturition

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Micturition (urination) involves both voluntary and involuntary control of the bladder, urethra, detrusor muscle, and urethral sphincter

Voluntarily inhibited Urinary incontinence occurs as the

result of a disruption at any point during this process

UI is never a normal consequence of aging

When bladder volume reaches about 400 milliliters, stretch receptors of the bladder wall relay a message to the brain, which returns an impulse message for voiding back to the bladder.In response, the detrusor muscle contracts and the urethral sphincter relaxes to allow micturation.

Micturition

Anatomy and Physiology of Micturition

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First step in assessment : ask if the problem exists Elicit data in the health history Expect that many intake assessment forms used in the

acute or long-term care setting ask questions about standard medical problems (e.g. heart failure or DM ) and fail to appropriately assess a history of UI

Initial History for UI

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Ask screening questions such as “Have you ever leaked urine? If yes, how much does it bother you?”

Further questioning addresses the duration and characteristics of the urine leakage.

The Urinary Distress Inventory-6 (UDI-6) is a self-report symptom inventory for UI that is reliable and valid for identifying the type of established UI in community dwelling females

Female Patient

The Male Urinary Distress Inventory (MUDI) is a valid and reliable measure of urinary symptoms in the male population

Male Patient


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Table 2. Urogenital Distress Inventory Short Form (UDI-6)

Questions to ask on history taking and review of systems about UI

Do you experience, and, if so, how much are you bothered by:

Frequent urination This may indicate: Irritative/Overactive Bladder

Leakage related to feeling of urgency This may indicate: UI/Irritative

Leakage related to activity, coughing, or sneezing This may indicate:UI/Stress

Small amount of leakage (drops) This may indicate: UI/Stress

Difficulty emptying bladderThis may indicate Obstructive/Discomfort: Obstructive Micturation

Pain or discomfort in lower abdominal or genital area

This may indicate: Obstructive/Discomfort

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Depression Dementia Malnourishment Dependent ambulation Medications

Initial History: UI Risk factors

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Differentiate between transient and established UI because transient UI may convert to persistent UI

The seven-day bladder diary or record is the most evaluated and recommended tool to quantify UI and identify activities associated with unwanted urine loss

A three-day bladder diary may be more feasible in the clinical setting


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Resource: kidney.niddk.nih.gov/kudiseases/pubs/diary/

The bladder diary can help identify potential bladder irritants (e.g., acidic foods or fluids, aka acid-ash) that contribute to UI

The Bladder Diary

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Bladder Diary: Essential for assessing UI and developing an individualized scheduled toileting program, which mimics the patient’s normal voiding patterns Continual assessment and evaluation improves success

If the initial scheduled toileting time is set for 7 A.M., yet at 6:30 A.M. the patient consistently attempts to independently void or is noted to be incontinent, then the toileting time should be adjusted to 6 A.M.

Prompted voiding requires the caregiver to ask if the patient needs to void, offer assistance, and then offer praise for successful voiding

Example

The Bladder Diary

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Observe the patient during urination to determine ability to remove undergarments, sit on toilet etc

Abdominal exam: Determine the presence of bladder distention Determine presence of stool impaction in left

quadrant

Physical Exam for UI

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Inspect male and female genitalia

Note perineal irritation or long-standing pigmentation change, often indicative urinary leakage


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Valsalva maneuver (if not medically contraindicated) to detect pelvic prolapse (e.g., cystocele, rectocele, uterine prolapse) or urine leakage (suggestive of stress UI), as a result of increased intra-abdominal pressure with bearing down

Ask the patient to cough while observing for urinary leakage, especially important when performing a “Valsalva” maneuver is contraindicated

During the genitalia examination, instruct the patient to cough while assessing for urine leakage that may be attributed to Stress UI

Female Patient


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Look for signs of atrophic vaginitis post-menopausal women Perineal inflammation Tenderness and, on occasion, trauma as a result of

touch) Thin, pale genitalia tissues that are often friable and

prone to bleeding Perform digital rectal exam to identify constipation or

fecal impaction


Women

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Assess for “anal wink,” (contraction of the external anal sphincter) by lightly stroking the circumanal skin Indicative of intact sacral nerve routes Absence of the “anal wink” may suggest sphincter

denervation


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In men, palpate the prostate gland Typically an enlarged prostate is readily detected

and correlates with symptoms of urinary urgency, incomplete bladder emptying, decreased urinary stream or nocturia


Men

Lab Tests For UI

Urinalysis and/ urine culture and sensitivity Post void residual urine or simple bedside

urodynamics–The International Continence Society (ICS)

does not recommend urodynamic testing in the initial assessment and management of UI

Treatment vs ReferralInitiate referral if any of the following apply: Need for additional testingAbnormal U/A or culturePalpable abdominal or pelvic massElevated PVRAbnormal prostate examVaginal bleeding; obstruction; new underlying disorder; surgical candidate

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Stress UI management includes PFMEs, more commonly known as Kegel exercises

PFMEs facilitate continence by increasing strength, endurance, and contractibility of the pelvic muscles, which support the bladder neck, contribute to optimal anatomical positioning of the urethra, and facilitate neuromuscular control necessary for continence

MenDuring the rectal

examination, male patients are instructed to squeeze

the rectal muscles

WomenTeach PFMEs during the pelvic

examination

Instruct the patient to squeeze (contract) her vaginal muscles

around the examiner’s gloved hand

Management of UI: Pelvic Floor Muscle Exercizes (PFMEs) for Stress UI

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Patient should be instructed to avoid contracting abdominal, buttocks, or thigh muscles so as to not increase intra-abdominal pressure.

While there are variations on the number of PFME per day required, it is usual practice to recommend 15 PFMEs three times per day

Ideally, each PFME should consist of a contraction lasting for 10 seconds, followed by a relaxation period of 10 seconds

PFMEs

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Accurate performance of PFMEs requires some degree of performance appraisal, which may be performed with digital examination, biofeedback, or vaginal cones/weights, to verify that the incontinent individual is correctly isolating and contracting the pelvic floor muscles

Urine stream interruption test (UST) is a simple measure of pelvic floor muscle strength and provides a numerical value to supplement data collection

PFMEs

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Patients may need several weeks to note improvement in bladder control

Once patients are confident with performing PFMEs they may benefit from “The Knack”

WomenUST should be under two

seconds in women reporting significantly fewer UI

episodes

MenUST is currently being tested

in a male sample

PFMEs

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In addition to building muscle strength, PFMEs may cause neuromuscular changes that promote a decrease in the autocontractility of the bladder, thereby inhibiting the urge to urinate

There is evidence that PFMEs decrease incontinent episodes related to urge UI

PFMEs

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Other management strategies for stress UI beyond the scope of this module include: Pelvic support devices Surgical procedures

Other Management of Stress UI

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Urge inhibition is based on behavioral theory and is another recommended HBBS for treatment of urge UI although the mechanism of how urge inhibition works is not well understood

Urge inhibition includes distraction techniques relaxation techniques pelvic muscle contractions

Management of UI: Urge Inhibition

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Bladder training (re-training) is another behavioral technique used to treat urge UI and OAB. It requires a baseline bladder diary to determine the timing of voids and UI episodes

If urinary frequency is present, the patient is instructed to lengthen the time between voids in an effort to retrain the bladder

When a strong urge to void occurs, and if the patient is not in a position to empty the bladder in a socially appropriate manner, instruct the patient to quickly squeeze and relax pelvic floor muscles several times to suppress the urge to void

Management of UI: Bladder Retraining

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Anticholinergic (antimuscarinic), antispasmodic medications are commonly prescribed for urge UI and OAB because they reduce detrusor overactivity and spasm, and in turn, decrease urinary urgency, frequency, and urge UI

If prescribed, the nurse should assess the patient for common side effects

oxybutynin (Ditropan®), tolterodine (Detrol®), darifenacin (Enablex®), trospium chloride (Sanctura ®), solifenacin succinate (Vesicare ®)

Long-acting formulations, transdermal patch preparations, and lower dose preparations are available

Available Medications

Management for UI: Medications

APRN Rx of Medications & Other Treatments

Anticholinergic, antispasmodic for urge UI Be aware of side effects Follow principles of prescribing for older

adults, “start low and go slow” Alpha-agonist for Stress UInot FDA approved Referral for surgery: stress UI, pelvic organ prolapse, BPHDevices (e.g., pessary)

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Environment plays a vital role in managing functional UI Incontinent individuals are often dependent on adaptive

devices (e.g., walker) or caregivers for assistance with voiding

Many may also suffer from cognitive impairment, a significant comorbidity which causes forgetfulness to recall voiding times or loss of awareness of the need to void

Environmental Management of UI

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Strategies specific to manage overflow UI include PFMEs if it is determined that bladder outlet obstruction is due to persistent contraction of the pelvic floor muscles

Interventions to manage overflow UI: Crede’s maneuver Timed voiding Double voiding Intermittent urinary catheterization

Management: Overflow UI

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Crede’s maneuver: Cautiously used and requires manual compression over the suprapubic area during bladder emptying Avoid: If vesicoureteral reflux or overactive sphincter

mechanisms are suspected as the Crede’s maneuver would dangerously elevate pressure within the bladder

Double Void: Repositioning to void again directly after the initial void For a patient with overflow UI the APRN should evaluate if

medications may be causing urinary retention

Management: Overflow UI

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Management of UI: Containment Products

UI management presented here avoided a detailed discussion of containment products

This was intentional as this module focuses on evidence-based management strategies beyond traditional containment

Note: If absorbent products are used, studies emphasize individualization in choosing absorbent products

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Priority Setting: Avoiding UI Complications

Goal of incontinence management may not be to have the patient be totally dry but to decrease the number of UI episodes

Realistic goal for UI evaluation and management includes interdisciplinary collaboration and the inclusion of the patient, and in many instances, the caregiver or significant other

In the acute care setting, new onset of UI needs to be closely assessed and appropriately managed

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Appropriate assessment and management of UI is often overlooked in the hospital setting due to patients’ acuity level or short length of stay UI is often managed with the use of temporary indwelling

urinary catheterization Justification for this intervention revolves around the

patient’s inability to access toilet facilities independently, including use of a bedpan or urinal due to voicelessness from intubation or other mechanical, life-sustaining devices

Priority Setting: Avoiding UI Complications in the Hospital

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Detailed presentation of how long-term care processes - Resident Assessment Instruments, the Minimum Data Set, and resident care plans – are utilized in the provision of quality incontinence assessment and management, which are now a focus of state surveyors in response to Tags F315 and F316.

Prochoda Admission to a skilled nursing

setting (e.g., an assisted living or a nursing home) should trigger an accurate assessment of UI including:

Review of medical records Speaking to the hospital

discharge primary nurse or physician

Priority Setting: Avoiding UI Complications in LTC

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AHRQ UI Clinical Practice Guideline

1988: National Institute for Health (NIH) led a multidisciplinary Consensus Panel to examine the state of knowledge regarding adult UI Examined available research in a directed effort to answer

specific trigger questions Agenda for future research and practice

1988 NIH AHRQ’s UI clinical practice guidelines

2008: NIH State of Science: Prevention of fecal and urinary incontinence

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AHRQ UI Clinical Practice Guidelines

Few outcome studies have evaluated the AHRQ UI guidelines

Most studies have examined UI evaluation and management in the LTC setting

Most studies show that AHRQ guideline use in LTC have not produced positive outcomes in bladder health

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AHRQ UI Clinical Practice Guidelines

Studies show that containment products are the primary strategy employed in LTC settings to manage UI LTC setting incontinent residents not adequately assessed for UI

only 2% of women having a pelvic examinations less than 15% receiving a rectal examination less than 1% being assessed for characteristics of

established UI - stress, urge, mixed, overflow, functional

LTC LTC

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Research on UI

Research in UI in the acute care setting has predominantly focused on incidence, prevalence, and risk factors of UI

Most research in UI has been conducted in long-term and community care settings

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UI Outcome Indicators Research regarding UI outcome indicators has used the “If…then…”

approach

IF an individual has involuntary urine loss THEN a focused history is performed and documented

Nurses will find that North American Nursing Diagnosis Association (NANDA), Nursing Interventions Classifications (NIC), and Nursing Outcomes Classification (NOC) provide structure for planning and evaluating UI assessment and management

Example

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UI Outcome Indicators in the Community Setting

In the community setting, performance quality indicators for continence management include:

evidence of screening all older adults for UI at initial health encounters and then yearly

evidence of performing a focused health history, including characteristics of voiding, ability to toilet self, any previous treatment for UI, degree of bother, and mental status assessment

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In the community setting, performance quality indicators for continence management include (continued):

evidence of a urinalysis and post-void residual evidence that HBBS, as well as pharmacological and

surgical options were appropriately reviewed with the incontinent individual

Bladder diaries continue to be the predominant clinical outcome indicator measure to determine if continence management interventions are effective.

UI Outcome Indicators in the Community Setting

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UI Outcome Indicators in LTC

In the LTC setting, state surveyors audit for evidence of: an assessment for UI the presence and implementation of a continence

management plan the appropriate use of indwelling urinary catheters in

response to the F315 Tag.

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Patient Education: AHRQ UI Clinical Practice Guidelines Majority of patients delay seeking health care for UI because of

inadequate knowledge, embarrassment, feelings that symptoms were “normal” or advice-seeking from non-health care providers

Continence policies and research add an important contribution in understanding what is known about translating continence guidelines into practice

United Kingdom

general practitioners

hospital services

nurse

Learned UI from

40.0

28.0

8.0

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UI Health Promotion and Risk Reduction

Continence experts recommend prevention of UI in adults using population-based strategies

little evidence pertaining to the benefits of primary prevention of UI for older women, and for preventing childbirth related UI

Case Study

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Regardless of the type of established UI, be aware of and teach HBBS to patients, family & staff

Prior to instituting HBBS, assess the motivation of the patient, informal caregiver, and/or nursing staff, since behavior management is a premise of HBBS

Patient Education: Healthy Bladder Behavior

Skills (HBBS)

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Work closely with older adults who fear that unwanted urine loss results from increased fluid intake

Focus education on the adverse consequence of inadequate fluid intake such as volume depletion, or potential for dehydration.

Emphasize that too little fluid intake causes urine to become concentrated which in turn, leads to increased bladder contractions and feelings of urinary urgency

To manage and limit nocturia, advise to limit fluid intake a few hours before bedtime

Patient Education: Fluid Intake

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Examine and discuss medications contributing to UI with the prescribing health care provider

Determine the necessity of the medication or ideal scheduling to promote continence

Patient Education: Medications

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Staff Education: Appropriate Use of Indwelling Urinary Catheters

Indwelling urinary catheters, typically used for diagnostic reasons or, often inappropriately, for containment of UI, are not recommended for treatment of UI

141 hospitals demonstrated that catheter-associated UTI was present in over 60 percent of nosiocomial UTI cases

European study

UTI incidence of 10 percent associated with indwelling catheter use resulting in an increased length of hospital stay and decreased opportunities for nursing staff to identify continence as a problem

Dowd and Campbell (’95)

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Appropriate indications for indwelling urinary catheter use include: Severe acute illness Urinary retention uncontrollable by other interventions

(including medication management and sterile intermittent catheterization)

UI management for patients with Stage III-IV pressure ulcers of the trunk

Sterile intermittent catheterization may result in a lower incidence of infection and may be a viable alternative to placement of an indwelling urinary catheter

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When an indwelling urinary catheter is indicated it is recommended that the smallest lumen size catheter is used Sterile water is used to inflate the catheter balloon with

balloon volume assessment every two weeks or as clinically indicated

Catheter be secured to the patient’s thigh There is no evidence supporting routine collection of urine

for collection nor for routine timing of catheter changes


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Examples of Teaching Pedagogies for Urinary Incontinence in Older Adults

Teaching Pedagogies for Urinary Incontinence in Older Adults

Content Area: Topic Recommended Teaching Pedagogy

Recognition/Screening for UI

List & discuss 5 clinical problems that can lead to UI in an older adult

Review the medical record of an older adult with multiple co-morbidities and identify potential medications that can have adverse side effects of urinary incontinence.

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Assessment of Older Adults with UI

Describe the components of assessment of an older adult with new onset of UI.

Critically analyze “why” the older adult has a new onset of UI. What are important historical questions and physical examination techniques to be performed with a new onset of UI?

Describe the components of assessment of an older adult with chronic UI.

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Assessment of Older Adults with UIReview and respond to a case study on UI

Management of Older Adults with UI

Review a clinical case whereby a indwelling urinary catheter is used for the chronic management of UI. Ask the student to select a patient from their caseload and to respond/determine on a case-by-case basis why a indwelling urinary catheter is used?

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How long has it been used?

What were the presenting symptoms leading to use of the indwelling urinary catheter if any.

What are the major risks associated with the use of a indwelling urinary catheter and what are realistic alternatives to management other than a indwelling urinary catheter?

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Outline the basic components of a toileting program. What are some issues that impact the success of a toileting program?

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