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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”
Signs: • Urine loss Urine loss • Urgency Urgency • Frequency > 8x/24 hrsFrequency > 8x/24 hrs
• Involuntary Bladder Contractions
• Severe Bladder Hypersensitvity
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Stress IncontinenceStress Incontinence
Increase in intra-abdominal pressureIncrease in intra-abdominal pressure
Symptoms: Symptoms: Small losses of urine when:Coughing LaughingExercisingChanging positions
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Overflow Incontinence Urethral Obstruction
Enlarged prostateUrethral StrictureFecal Impaction
Neurologic ConditionsDiabetic NeuropathyLow Spinal Cord Injury
MedicationsAnticholinergics
Symptoms Bladder Distention Reduced Urine Flow
Dribbling Frequency
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Functional Incontinence
Conditions:Conditions:
Cognitive ImpairmentCognitive Impairment
Chronic Functional Chronic Functional DisabilityDisability
Psychological Psychological ImpairmentImpairment
Environmental Environmental BarriersBarriers
Symptoms:Symptoms:
Inaccessible toilet Inaccessible toilet or lack of staff or lack of staff assistanceassistance
Nocturnal enuresisNocturnal enuresis
Combined fecal Combined fecal and urinary and urinary incontinenceincontinence
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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 Assessment1. Determine if the resident is incontinent,
nature of lower urinary tract symptoms, and type of incontinence
2. Determine the type of assessment conducted of the resident’s incontinence status before admission and any interventions
3. Determine reversible factors4. Determine conditions that may require further
evaluation5. Implement a prompted voiding trial6. Determine resident’s 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 Resident’s History Duration and characteristics of the
incontinence Precipitants Voiding patterns Previous treatment and/or
management
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Factors that Increase Resident’s 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 Resident’s 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 RetainingResident: 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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22
Bladder Muscle - Detrusor
Urethra
Pelvic Floor Muscle
Lower Urinary Tract
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Habit Training/Scheduled Voiding
Requires scheduled toileting, at regular intervals, on a planned basis, and match the resident’s voiding habits
Maintain record of resident’s voiding patterns
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Prompted voidingResident: 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 resident’s 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 resident’s 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 resident’s; Functional ability to ambulate, toilet,
disrobe, use of assistive devices Ease in self-toiletingAssess 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
Resident’s response to a therapeutic trial of PV
Normal bladder capacity (>200 and <700cc) Recognizes need to void Baseline incontinence < 4 times/12hours Maximum voided volume > 150 cc Post void residual < 100 cc Able to void successfully when given
toileting assistanceEvidence 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 fromOccurring:
Provide access to the toilet based on the
resident’s 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 resident’s
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.shtml
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/incontinence.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/