Continence Management Script

Transcription

1 Note: This script may vary from the recording. Continence Management Script Slide 2 Segment 1 Index Slide 3 Definition Continence is the voluntary control of passing urine or faeces. It can also be applied to ejaculation of sperm so essentially it is the ability the body to voluntarily restrain passing body fluid. Being continent or in-continent is important to our self esteem and our dignity. It is something that we learn from a young age. Loosing control of ones bodily functions can be very demoralizing and degrading for a person. Slide 4 Things to know about incontinence Being incontinent is not a disease but rather a sign of other problems. However the cause can be the result of a disease. As we will see later on when we discuss reasons and causes for continence problems. Slide 5 Organs involved There are two organs involved in incontinence and they are the bladder bowels and Slide 6 What causes urine incontinence Urine Incontinence This is caused through problems that occur with the muscles and nerves in the bladder. Slide 7 The urinary system You will see on this slide how the urine is manufactured in the kidneys and travels down to the bladder where it is excreted via the urethra. The kidneys are responsible for the body s water balance, regulating blood pressure and blood electrolytes and help regulating the body s acid base balance. It also helps with the production of Vitamin D as well as the excretion of wastes products and toxins from drugs and chemicals we ingest. As people get older, their kidneys do not function so well and are not able to concentrate the urine. This means older people appear to pass more urine at night. While is may appear that they are passing more urine, in fact they are not. It is the inability to concentrate urine that makes it seem like they pass more urine Slide 8 The bladder structure The bladder is a small bag made up of smooth muscle that holds the urine. A normal bladder can hold mls but it is usually when the capacity reaches mls that you get the urge of wanting to empty the bladder. Slide 8 The Bladder This slide shows what a normal bladder looks like with 600 mls in it. You can also see the smooth muscle I mentioned in the previous slide. Essentially it is a small bag that expands and contracts to hold and discharge urine. Slide 10 Functions of the Bladder So the bladder has two main functions. That is to store urine, until it reaches a point in which the bladder needs to empty and to expel or discharge urine. It is as simple as that. Slide 11 How the bladder works? So how does the bladder work? 1

2 Once the bladder reaches the level of feeling full, say around mls the nerve impulses are stimulated and a message is sent to the brain that it wants to empty or discharge the contents of the bladder. Once you get to the toilet you then have the control to relax the external sphincter or the opening at the bottom of the bladder. The muscles the wall of the bladder then receive the message to contract or get tighter and force the urine out of the bladder through the urethra, the external opening. All of this most people have control over. When a person has not or restricted control over this process they become incontinent. Slide 12 Normal bladder control For most all of us the production of urine is involuntary. That means it is going to form regardless of what we do. As humans we have the ability to know when our bladder is full as I mentioned in the previous slide. You will all have experienced this as most of us have control over when and where we pass urine. This is monitored or controlled by the messages sent to the brain by the nerves in our bladder as I said before. So it stands to reason that if a person has a condition that interferes with the message getting to the brain, they are going to have problems knowing when or maybe even where to pass urine. Side 13 Urethra The urine is expelled from the bladder through a small tube called the urethra. It connects the bladder to genitals or the external meatus as it is called. In the female the urethra is very short around 3.8 cm or 1 ½ inches and finishes just above the vaginal opening. You will see this when we discuss the female anatomy. In a male however it is much longer as it has to travel down the length of the penis. On average the urethra is around 20 cm long or 8 inches from the opening in the bladder to the end of the penis in a male. Slide 14 Types of incontinence It is estimated that 1 in 10 people over the age of 65 will have some continence problems. There are many forms of incontinence and not everyone has the same type. Incontinence problems are classified into 6 different types Urge Incontinence: This is when the urge to pass urine is strong and often sudden. People with this problem find they have to suddenly get up and go to the toilet. You may even hear it referred to an overactive bladder. This is caused by a problem with the muscles and nerves in the bladder. Most people make it to the toilet in time but some people have trouble and start to pass some or all of the contents of their bladder into their pants or pads before they get to the toilet. For some people his can happen regardless to how much urine is in the bladder. For others it may happen intermittently for example if a person has a urinary infection they may have this urge to pass urine all the time which is extremely uncomfortable. It is one of the first signs of a Urinary Tract Infection or a UTI as it is often referred to. It is a clue for you when looking after people. If a person in your care keeps running to the toilet or tells you they keep wanting to go to the toilet when they don t usually have a problem then there is a possibility they may have a urinary infection. For men with an enlarged prostate they too can want to pass urine frequently because the enlarge prostate prevent them from fully emptying their bladder. We will talk more about this further in the slide. Stress Incontinence: 2

3 This is the most common form of incontinence. It most frequently occurs when people laugh, cough. This may be something that happens to you or you may see some of your friends rush off to the toilet you are laughing and having fun. It also happens during exercise, sneezing lifting heavy objects or any type of activity that puts pressure on the bladder. People who are more at risk of stress incontinence are Being female although it does happen in men. This is mainly due to our anatomy how our urinary system and all supporting structures are designed. Childbirth is another very common reason because the pressure of the baby on the pelvic floor and childbirth itself weakens the pelvic floor muscles. Women are encouraged to do exercises after the baby to strengthen these muscles and bring them back to normal. The pelvic floor is just a term used to describe all the muscles that sit in the pelvic area of the body. It does not mean a person has to get on the floor to do the exercises. Chronic coughing for people chronic bronchitis and asthma or even smokers the continuous coughing puts stress on the pelvic muscles which will eventually make them weak so that every time they cough a little bit of urine escapes. Getting older while age itself is not a cause of continence problems the fact is an increase in risk factors. These include loss of estrogen after menopause in women, development of physical and mental disabilities, some medications people take, decreased sensation in the bladder, decreased capacity of the bladder, and a loss of muscle tone do all contribute to continence problems Obesity in a number of studies of severely obese women over 60% complained of stress incontinence Smoking Cigarette smokes is known as a bladder irritant meaning that the bladder can become inflamed and sore. Overflow Incontinence This happens when there is a problem with the bladder capacity or a person has been unable to go to the toilet for some reason. The pressure builds up in the bladder and the bladder struggles to hold the amount of urine produced causing some of the urine to leak out as it cannot hold on to the excess urine. Mixed Incontinence This is most commonly a combination of both urge and stress incontinence but it can be a combination of any types of incontinence. You may well know of people with a combination or you may even suffer from it yourself? Functional Incontinence This when a person has a medical condition that prevents them from getting to the toilet in time to urinate. They may be unable to undo their pants in time due to arthritis or they may have Parkinson s disease which makes it difficult to not only get in the door to the toilet but also to get their pants down. The more agitated and fearful of wetting themselves can make the tremors worse which make it even more difficult for them to get to the toilet. A person with dementia may know they want to go to the toilet but have forgotten what a toilet looks like. This may cause them to urinate in inappropriate places. Total incontinence This is when the bladder cannot hold urine and leaks all the time. This is where a person has no voluntary control over the sphincter that allows urine out through urethral sphincter because of damage causing loss or weakness of the muscles and nerves. It is common in people with spinal cord injury. It can happen in women after childbirth and in men with prostate problems. For this condition devices or pads are used which we will talk about in later slides. Slide 15 Summary So let s summarize continence Incontinence is caused by problems with the muscles and nerves in the bladder 3

4 The function of the bladder is to store and expel urine When the bladder reaches around mils the a person will get the urge to go to the toilet There are many different types of continence problems and you cant treat all people the same So to understand continence it is really helpful to understand how the body works. Knowing this will make it easier for you to understand the person in your care and indeed yourself, so the appropriate care or intervention is given to the person. Segment 2 Slide 1 Female and Male Incontinence Slide 2 Female anatomy Firstly lets look at the female. As you can see from this slide of a female anatomy, the ureter, vagina, bowel and anus are all very close together. Their proximity or closeness of the organs contributes to urinary problems in women. As mentioned early one of the common causes urinary problems in women is caused through pregnancy and childbirth. It is easy to see how the extreme pressure that gets put on the pelvic floor, or the lower part of the body can cause damage to the muscles and ligaments. This is why stress and urge incontinence so prevalent in women. Urine leakage in women is very common. In fact it is twice as more common in women than in men. Slide 3 Causes of urinary problems in women Structure and anatomy is the major contributing factor as mentioned earlier. The most common is pregnancy and childbirth. Prolapses can occur which means that a part of the anatomy of the body has slipped from its normal position. It can refer to the uterus, the bladder, anus or sometimes even the rectum. These are all caused through weakness to the supportive structures. This is why it is important to do pelvic floor exercise after birth to help prevent continence problems in later life. In younger women with severe continence problems these prolapses are repaired through surgery however surgery is rarely performed on older women. Menopause is another factor. This is due to the reduction in estrogen hormones that not only affect the vaginal wall it affects the urethra as well. Constipation continual straining affects the pelvic floor muscles and ligaments Chronic Coughing as mentioned before Urinary Tract Infections Birth defects Sometimes the urethra becomes narrow and what is called a stricture develops which means the outlet becomes narrow in one part of the urethra which prevent urine from flowing. Neurological injury or diseases like Multiple Sclerosis, Parkinson's disease, spinal cord injury, stroke, spinabifida, and hydrocephalus. These all affect the bladder in some form. Side effects of medications or complications of surgery 4

5 Diabetes Women with diabetes have a 70% increase of risk of continence problems contributed by increased thirst, increased bloods sugar levels irritate the bladder, nerve damage leading to loss of bladder sensation. Obesity the increased fat and the effect of gravity puts excess pressure on the pelvic floor. Dehydration can cause the onset of incontinence Or Physical problems associated with aging many of which have already been mentioned. Male Incontinence Slide 4 Male Anatomy While incontinence is not so prevalent in men, it does still occur and it does increase with age. If you look at the anatomy of the male, it is easy to see the urethra; the tube that passes the urine from the bladder is a lot longer than in women. You will also see the distance between the urethra and the anus is far greater in males than females. This renders them at a lesser risk of urinary tract infections. However the major problem for men comes from the prostate gland which you can see just below the neck of the bladder. Slide 5 What is the Prostate Gland So what is the Prostate Gland Is it an organ the size of a walnut in its shell. It is made up of glandular and muscular tissue and sits just below the neck of the bladder and partially surrounds the urethra. The role of the prostate gland is to assist with the transport of sperm on ejaculation. It produces between 13 and 33% of semen, a thin milky alkaline fluid that carries the sperm. However the majority of semen is made in seminal vesicles, another gland in the male reproductive system. Slide 6 (21) Prostate gland problems The most common problems for men over 50 is an enlarged prostate. This is caused benign prostatic hyperplasia where there is an increase in the number of cells in the prostate as the old cells do not die off. This accumulation of cells thickens the prostate, which can narrow the urethra, and puts pressure on bladder control resulting in urination problems. Sometimes this is called prostatic hypertrophy which is where there is an increase in the cell size but not necessarily the number of cells. This is not technically correct but you may hear both terms used. Some people think that an enlarged Prostate gland means they have Prostate Cancer. While in some cases men with an enlarged prostate will have cancer it is not the case in all incidences of an enlarged prostate. Prostatitis is also another problem that may arise. This is where the bladder becomes inflamed or irritated. Sometimes there is bacteria present but more often than not there is no bacteria. However whenever there is inflammation or irritation in the body, the body is either fighting germs or repairing itself. Slide 7 Male continence problems So what are the problems that men will experience? There may be problems with flow as mentioned before. Slow to get started even though they felt a rush to go to the toilet Weak stream of urine and when finished still feel there is urine in the bladder Few drops occur after emptying bladder, leaking or dribbling May have small amounts of blood in urine 5

6 Or they may have an overactive bladder that causes Frequency need to go to the toilet a lot Urgency or Urge incontinence Stress incontinence Blood in urine Anyone who gets up two or more times at night to go to the toilet has a condition called Nocturia. This can happen to both men and women. Slide 8 Conditions affecting males What are some of the condition or factors that affect males? Acute prostatitis - where the prostate becomes inflamed or irritated as mentioned earlier Enlarged prostate as we discussed and be caused more commonly by hyperplasia where there is an increase in cell number without the old cells dying off to make room for the new cells in the prostate or hypertrophy where the cell themselves increase in size thus causing the prostate to enlarge. Weakened pelvic muscles due to a life time of heavy lifting. This is common in men who have worked in heavy manual labor or sports like weightlifting without doing exercises to strengthen the pelvic floor muscles and ligaments. Neurological disease or injury such as Multiple sclerosis, Parkinson s disease, stroke or dementia. In fact all the conditions that cause urinary problems in women also have the same affect in men. Dehydration Side effect of medications. Medications like diuretics that are designed to take fluid from the cells increases urine output and makes urge incontinence a possibility. Alcohol to can alter memory, impair mobility, and cause increased urine output, resulting in incontinence Surgery especially surgery to the prostate can result in continence problems Birth defects that may cause a narrowing of the urethra, a stricture as mentioned in women In fact many of the conditions that cause incontinence in women will affect men as well. Slide 9 Treatment of incontinence The most important thing that you must do as a caregiver is regular toileting. This means you take a person to the toilet on a very regular basis like when the get up in the morning and after each meal or refreshment break and before they go to bed. Taking a person to the toilet up to 8 times a day helps to maintain the dignity of the person. The purpose of doing this is set up a pattern to train the bladder to empty itself before it gets full or over full. This will save you time in the long run as it is much quicker to take a person to the toilet than to have to change them if they are wet. By these actions you are showing a high degree of respect for the person. Remember, learning to pass urine in the toilet is something we learn at a very young age. It is something that everyone hates not being able to have any control over. Your job is to help people maintain some control over the body. This will also save you time as it is less time consuming to toilet a person than to have to change their clothes. Finally you must remember that you are there to serve your clients. If you don t take the time to take a person to the toilet it is verging on abuse so take care to spend the time in help a person to remain continent. Think about how it might feel to wet your pants or sit in a wet pad. To me it would be very demoralizing. Segment 3 Slide 1 Continence Aids There are three different types of aids Pads: These come in a variety of sizes and capacity. Some are small just to catch a dribbling incontinence and others are compete diaper to hold the complete emptying of the bladder. 6

7 Condom catheters for men Indwelling catheters that are inserted directly into the bladder Slide 2 Continent pads You will see on this slide that this is a plain pad. It sits between the legs and depending on the size of the pad or client choice, they are held in place with normal underwear or a fine net pant. Some times it will depend on the size of the pad on which method is used. These pads come in a variety of sizes from very small to quite large. The use of pads depends on the degree of continence and mobility. There is no one size fits all so check with your RN the right size required for the person in your care. Slide 3 Full Pad This is a called a full pad or diaper. It is attached at each side with adhesive tape just like diapers used for young children. These are resealable so you do not have to replace the pad each time you take a person to the toilet. If you look at the pad you will see a colored strip in the centre of the pad. This is there to tell you at what point you have to change the pad. When the line changes color at least ¾ of the way up the back then it is time to replace the pad. Do not change the pad until the line is well up the back and front of the pad. All disposable pads are expensive. They are designed to keep the person dry so they are not sitting in wet soggy pads. A person with full incontinence generally will only require around 3 pads a day. Each pad is manufactured to hold a certain capacity or amount of urine which is why they have a colored line to let you know how much urine has been passed so at what point you have to change the pad. Slide 4 Pull ups This is another type of pad. It is a pull-up variety. This is perfect for a person who is not fully incontinent but dribbles or doesn t get to the toilet on time or for someone who is independent going to the toilet. They can keep dry and all they need to do is pull them up and down like normal underwear. These are not generally used for night time incontinence as they are not designed to hold a large amount of urine. They are easy for staff as well. A point to note about all continence pads. They are expensive. Pull-ups are more expensive than diapers but they all cost quite a lot of money. This cost sometimes has to be paid by the person themselves and anyone with a disability is on a limited income. However the major cost has to be carried by the facility you work in or the organization. You must always be aware of this when using pads. Wasting pads adds cost to the operations of the facility and therefore takes money away from some other important area of care. You have a responsibility and an obligation to be aware of the costs and do your part to help management keep to budget. Slide 5 Summary of Pads Pads are designed to hold a certain amount of urine. Only change the pad when at least 2/3 of the line has changed color. Pads have a gel substance inside the pad that expands when urine is passed in the pad. The pad also has special cover that keeps the person dry so they do not need to be changed every time they pass a little bit of urine. Disposable Pads are very expensive so do not change them unnecessarily i.e. when they are only slight wet Reusable pads are available. These can be washed and dried for reuse however in New Zealand there is a preference to use disposable pads. The use of pads does not take the place of taking a person to the toilet. Slide 6 Condom Catheters These are used only by men. It is a rubber sheath designed to fit over the penis like a condom however this condom has an opening at the end. You will see this in the next slide. This allows the person to continually drain urine or pass urine intermittently. This means there is no need for them to use a urinal, bedpan or 7

8 toilet. These are commonly used for people with spinal cord injury, or a person who are confined to their bed. They are sometimes used for a person with dementia but there is a high degree of probability that they will pull it off if they do not understand what it is or why it is on. Slide 7 Condom catheter You can see how the rubber sheath fits over the penis and is attached to a leg bag. An adhesive tape is applied around the top of the penis to help keep the condom in place. Without this it would fall off. Once the sheath is applied you then attach the a drainage bag. These bags usually have an outlet tube at the bottom of the bag so you can empty the bag into the toilet or some other receptacle when it gets full. You don t need to put a new bag on each time it is full. Sometimes the condom catheter is attached to a drainage bag that is hooked up to the bed. These are a very useful aid for a person who has continence problems but as I said, they do need to know why it is there and what it is designed to do. Slide 8) Points to note when using a condom catheter Condom catheters usually come in small, medium and large. Make sure you use the right size for the person. Using a condom that is too small will cause extreme discomfort for the client and using one too large will just fall off and be of no use. Change the condom daily or at least every two day. Make sure the penis is washed and dried well before apply the condom You may need to trim back pubic hair so it doesn t get caught in the rubber catheter as this can be very painful Keep a close eye on the skin. If there is any redness or swelling, do not apply the condom catheter and report it to your registered nurse. It may be that they just need a break for a few days before a condom catheter can be used again. Condom catheters work very well for men but unfortunately there is nothing remotely like it for a woman. Slide 9 Catheters Catheters can be either indwelling meaning they are left inside the bladder to continually drain. These can be inserted through the urethra or Supra-publicly through the abdomen. Catheters can also be used intermittently or for some people they self catheterize themselves. Slide 10 What does a catheter look like? This is the usual catheter used when it is going to be left in the bladder to drain urine. They are usually made of silicon or latex rubber. The part that sits in the bladder has a balloon at the end so when the catheter is inserted into the bladder water is put into the balloon at the tip of the catheter to ensure it stays in place You will see at the end of the catheter there is a center tube where the urine flows out and a smaller tube as well. The fluid to blow up the balloon is put into the smaller tube. The picture show you clearly what a catheter looks like. Slide 11 What are the reasons for inserting and indwelling catheter? Catheters can be indwelling meaning that they are inserted into the bladder via the urethra, the external opening from the bladder where the urine passes out. These are likely to remain place in for a period of time. The main reasons for inserting an indwelling catheter is for Urinary retention which is when the bladder goes into spasm and does not allow the urine to escape. This can happen for a variety of reasons but if one of your clients has not passed urine for a while you need to be aware that this may be a problem. Generally it doesn t happen that often but if there is an absence of urine or a person is uncomfortable and showing they are in pain or discomfort, you need to report this to the Registered Nurse to make sure they don t have urinary retention. If there is an obstruction to the urine flowing then a catheter may be inserted. It could be enlarged prostate in a man or there could be a tumor blocking the flow. 8

9 Full incontinence but it is rare these days to insert a catheter for this reason. For some surgical procedures a catheter is inserted for a short period of time. For example if a person has a fractured hip, it is likely a catheter is inserted to make sure the new hip is not displaced by movement. It is usually on left in for 24 hours or so. Sometimes in these circumstances the bladder can go into spasm when it is removed and the person go into urinary retention through a neurogenic bladder. I remember when I was in hospital with a broken ankle, I had a 80 year old lady who had fractured her hip. She moaned for 72 hours before one of the nurses finally did something took some action. She had had a catheter put in when they pinned and plated her hip. After it was removed her bladder when into spasm i.e. became neurogenic, and the urethra would not open and allow the bladder to empty so the bladder kept filling up. However the bladder did let dribbles of urine escape so the nurses, all registered, thought she was passing urine. I repeatedly told them there was something wrong with this lady and they just told me she had dementia. I said no-one moans without reason. Finally someone listened to me. When they put a catheter in they drained out 1500mls. Imagine how much pain and discomfort this lady must have been in when you consider the bladder gets the urge to empty at around mls and the maximum amounts a bladder holds is 600mls 1500 mls was way in excess of what is normal. Some medical conditions Slide 12 Urethral catheter insitu - female You can see from this picture how an indwelling catheter is placed in a female. It goes in through the urethra and up into the bladder where the balloon in inflated to keep it in place. You need to be careful not to pull on the catheter or have any weight on it as this could damage the top of the urethra at the entrance to the bladder. We will talk more about this in a later slide on Catheter Management. Slide 13 Urethral indwelling catheter - male Here you can see how the catheter sits inside the bladder. Although this example is for a male, the principle is the same whether it is male or female. The catheter is inserted into the urethra and up into the bladder. However in males, special training is needed as it is important to get the tube into the bladder and up past the prostate. These catheters are usually inserted only by a medical practitioner or a registered nurse specifically trained in male catheterization technique. Slide 14 Supra-pubic catheters The initial insertion of these catheters is done under local or general anesthetic. It entails a small incision into the abdominal wall, directly over the bladder. This is below the umbilicus which is commonly called the tummy button. The principle is the same as having an indwelling catheter inserted via the urethra. Once the incision is made in the abdomen the same type of catheter is inserted into this incision directly into the bladder and the balloon is inflated so the catheter will stay in place. There are many reasons that a supra pubic catheter will be used instead of one via the urethra. The reason include The catheter may not be able to be inserted via the urethra because of a stricture a narrowing of the urethra that prevents urine being expelled. Comfort or ease for a disabled person especially a person in a wheelchair To promote sexual activity for the person. While it is possible for sexual intercourse to take place with and indwelling catheter via the urethra, it is a better option for self image of the person to have a supra-pubic catheter. If a catheter has been inserted via the urethra for a long time, damage can occur to the sphincter, the opening into the bladder so a supra pubic catheter inserted to prevent any further or future damage. The person may have disease or injury to the bladder that affects urination Long term incontinence however this is rarely used now as there are a better range of continence products available that promote comfort for clients 9

10 Sometimes after surgery to the urinary system Slide 15 Intermittent Catheterization For some people an indwelling catheter is not the best option so intermittent self-catheterization is used. This is done by the client and allows them to take complete control over their life. It also protects the kidneys as if the bladder cannot empty, once it reaches its full capacity around 600mls, the urine may flow back up to the kidneys causing damage to them. Other reasons this may be the best option are Reduce urinary tract infections as it is rare for a person to infect themselves but they do need to take normal infection control principles like washing hands and using clean equipment. Reduce the urgency to pass urine or number of visits to toilet at night Prevent leakage Enhance sex life Promote confidence when going out that is. They are not in danger of being incontinent. Slide 16 Intermittent catheter You will see in this picture the catheter used for intermittent catheterization is quite different. It is not made of latex but a cheaper plastic. It has no balloon on the end to blow up. This is not necessary as the catheter is immediately removed once the bladder is emptied and the catheter discarded. Slide 17 Managing a catheter Urine flows from the bladder by gravity so it is therefore important to make sure the bag is always lower than the body. Do not leave the drainage bag up on the bed as urine must be able to flow down hill. Always make sure the tubes are not kinked or blocked in any way that prevents urine from flowing out. Not only will this mean the bladder becomes over full and cause major discomfort, it may also cause urine to drain back into the kidneys and cause further damage to them. Older people often have kidneys that don t function that well so you do not want to cause them any further harm. Infection controls principles are important too. Always wash your hands before you handle the catheter or catheter bag and put on gloves when you go to empty the catheter Don t forget to wash your hands when you remove your gloves too. Refer to your own policies and procedure for Handling of Body Fluids. It is also important to make sure that you keep the urethral opening clean so make sure you wash the area at least daily if not twice daily. Because a catheter is a foreign body, the body will naturally want to get rid of it. In doing this it is likely to produce a considerable amount of mucous a thick white matter you will frequently see in the drainage bag. Therefore it is really important that a person who has a catheter in drinks a lot of water to flush out the bladder. If the urine becomes concentrated it will mean they are more at risk of infections. This is really basic nursing but I will talk more on the importance of fluid intake in the topic on Hydration. Slide 18 Problems associated with Catheters It is a foreign body and the body will try to get rid of it as I mentioned earlier. This will also mean the person will almost certainly have a continuous urinary infection however this is not usually treated unless a person is showing signs of infection. That is a temperature, change in behaviors, and increased sediment in the urine or excessive odor so you must always be on the look out for any of theses symptoms. Blockages will occur so always make sure the catheter is draining. Check the bag level when you come on duty and frequently throughout the shift. Report to the Registered Nurse when you if you see the catheter has not drained on your shift or any other changes you observe. 10

11 When a catheter is left in place for a long time, the bladder will lose the urge to empty so it will mean it will have to stay in permanently or if it is removed the person will be totally incontinent and pad will need to be used. In a younger person who has had a catheter in a long period the bladder will need to be retrained again to pass urine as the urge function will be gone. While this is unlikely to be an option in a long term residential care setting you may have people who have suffered severe trauma who come into your facility for rehabilitation so you may have to consider this possibility. Slide 19 Risks of using and indwelling catheter A person with a catheter in will always have a urinary tract infection as I mentioned before so you need to be aware of the symptoms of infections and report immediately to the Registered Nurse if a client is showing any of them. If this is not treated then it is possible for a person to die from a blood infection bacteremia Bleeding from damage caused by the catheter so you need to report if there is any blood in the drainage bag. When the catheter is inserted a false passage or a sinus may occur if the catheter being inserted incorrectly or pushed through the thin membranous wall of the urethral canal There will always be some form of discomfort for a person if they have a catheter in place. They are not the most comfortable thing to have inside you. While a person would get used to it, it is still a foreign body and you must be mindful of the comfort of the person at all times. There is also a danger of chronic renal inflammation. This is where the kidneys become inflamed which can lead to high blood pressure and kidney failure If a bacterial Infection in Kidney occur which is known as chronic pyelonephritis and where the kidneys themselves become infected could lead to kidney failure or even death from septicemia Slide 20 Review of what to report So lets review of what to look for when someone has a catheter insitu Fever thought a lot of older people don t spike a fever it is good to take note if there is any change in body temperature Lack of drainage if the bag level hasn t changed on you shift or you suspect it is not draining Resident off food or drink if a person appears unwell and is not wanting to eat or drink. This is a sign of something not right Excessive sediment if there appears to be more sediment than normal in the bag or tube Excessive smell urine in catheters will spell but if there is a change in the smell, some different smell then the person may be brewing an infection Change in behavior if they are more sleepy, more confused than normal or anything that is different to how they usually are. Blood in urine or bag if any blood appears report it including the color and if it is a lot or just a trace. All of these things are telling you something is not quite right. Use you intuition, you gut feeling to back up what you see. Most of you will know your clients very well and will know when there is something out of the ordinary. Slide 21 Summary of facts Catheters are used as a lost resort only. Remember it is a foreign body. We are not meant to have a tube inserted into our bladder unless it is absolutely necessary. You must always observe record and report any changes in the person, their urine color, smell or if there is any blood. 11

12 Preserve the dignity of the person. Be respectful and try to understand what it might be like to have a catheter in situ. How comfortable would it be? How embarrassing might it be for you? How would you feel if it smelled? How would you like someone to be cleaning around your very private and intimate areas? Don t take any of this for granted. Take care to be respectful, gentle, kind and considerate. Segment 4 Slide 1 Faecal Incontinence Slide 2 What is feces or stools? Feces or stools the waste product from the food we eat that the body has no use for. So we need to have a basic understanding of how we digest food. You can follow the picture on the screen from where the food enters the mouth through till it comes out the anus. Firstly the food it taken into the mouth, we chew it and then it goes down into the stomach where it is mixed with stomach acids and enzymes that break the food down, removes the nutrients the body needs and distributes around the body. Then the contents of the stomach passes into the duodenum and into the small bowel where more nutrients are taken from the food. The second process. The small bowel or you may hear it referred to the intestine, is very long. It is approximately 7 meters longs so takes a while for the remaining food to travel through this section. The small intestine is approximately 10 times longer than the length of the body. As the food carries on down the bowel the body is taking out more nutrients it needs. Once it has travelled down the 7 meters of small bowel it then moves through to the large bowel. This is a much short section of the bowel and much wider. It is approximately 1.5 meters in length. When the food gets to this section it is much bulkier as all the nutrients and much of the fluid has been removed for use by the body. No decomposition of the food takes place here but the bacteria in the bowel breaks down the foods that have not been completely digested so the large intestine is really only used to store feces or waste. This waste is made up of 10-50% bacteria, undigested fiber or plant waste, minerals and water. So once the undigested food has travelled down the small bowel it then starts the next part of the journey and travels up the right hand side of the large bowel which is called the ascending colon, across the top section which is called the transverse colon and down the descending colon to the rectum to finally passing out the waste out though the anus. This waste is called faeces or stools Slide 3 Organs involved in fecal incontinence So the organs involved in bowel incontinence is the rectum and the anus as you will see on the diagram on the screen. Slide 4 What is fecal incontinence? So what is fecal incontinence? It is the Inability to control bowels or Inability to hold on to stool (feces) to get to the toilet or Unexpected fecal (or stool) leakage from the rectum. (this may sometimes happen while passing wind 12

13 Slide 5 Causes fecal incontinence. There are a number of factors. Constipation is a major cause of fecal incontinence. When the feces are stuck in the rectum, fluid will leak out of the rectum leaving the stools to be very hard which become lodged or stuck. Over time, this will weaken the muscles in the rectum and anal area. The job of the sphincters or muscles in the rectum and around the anus that are designed to keep the stools in the bowel till a person reaches the toilet to expel it. If these muscles are damaged then the bowel is unable to hold the feces in they have no control over their bowel and this leads to bowel leakage. Women are more prone to fecal incontinence than men. This is due to child birth. Things like forceps deliveries and episiotomies (where the perineum is cut to allow the baby out) contribute to muscle and nerve damage around the anal sphincter and rectum which means the muscles are not strong enough to hold in the feces. So overall pelvic floor dysfunction is a problem but doesn t usually show up till a women is in her 40 s some years after childbirth. Men too can become incontinent through disease and injury to the pelvic floor area. Loss of storage capacity in the rectum is another reason that people may become incontinent. This can be caused by things like rectal surgery, radiation treatment, and inflammatory bowel disease which can cause scarring that makes the walls of the rectum stiff and less elastic. This means the rectum is unable to stretch as much to hold stool and fecal incontinence results. Inflammatory bowel disease also can irritate rectal walls, making it difficult for the bowel to contain the stools. Diarrhea bowel leakage from diarrhea can happen to anyone even people who are not incontinent. It is just difficult to control the stool as the rectum fills up really quickly and the stools leak out. There are a number of diseases that can also contribute to incontinence like cancer, polyps, diverticula, ulcerative colitis and infections Slide 6 Intervention to help fecal incontinence How to manage fecal incontinence. If a person is able to take care of themselves a food diary is helpful to see what foods contribute more to being incontinent. Once a pattern is discovered the person is able to take some control over their continence. Everyone is affected by the food eaten. Just think about yourself for a minute. What foods do you eat that are more likely to make your bowels move than others? Knowing how your body reacts to foods is the key to taking control of fecal incontinence. Food intake is important too. Some people may find that they can control their bowels better by eating smaller meals more often. Drinking with meals may make it worse so don t drink while eating. Because fluids helps to pass food through the alimentary tract, drinking fluid at a different time to eating can make a difference. If you have any clients with this problem try giving them a drink 30 minutes before a meal rather than with their meal and see if this makes a difference. Having more fiber in the diet. On average a person needs between 20 to 30 grams of fiber a day. Fibers come is the form of fruit, vegetables and grain. So how much is 30 grams fiber? ½ cup all bran is 10gr while a cup of brown rice cooked is 2.5 gr. 1 apple or pear is 4gr and a banana is 1.5 gr and 1 medium potato is 3 gr and ½ cup broccoli is 2.5 gr. If you want to find out how to get your required amount of fiber check for some tables on the internet that will give more information. Sometimes the doctor will chart a bulking agent for a person but make sure the person has plenty of water with this fiber or they will become constipated. Eat foods that can help bulk up stools. Some foods are better at this than others. Generally speaking we are talking about the same food that contains fiber that is fruit, vegetables and whole grain cereals work well. Water it is important too. I know the elderly generally don t like drinking too much water but the body needs water. As a general rule it is considered 8 glasses per day is what the body requires. Coffee, tea, carbonated drinks and mild can trigger diarrhea in some people so it is better to drink 13

14 water than these. However I know you are going to have a very difficult time convincing the elderly that they should drink more water than tea or coffee but do your best.. At the end of the day the important thing is to find out what works well with a person and what doesn t. The more you get to know you clients the less the problem of incontinence will be. Remember it is very degrading to not be in control of your bowels. Always bear this in mind when working with clients who are incontinent. Slide 7 Bowel Retraining It is possible to train the bowel to move at regular times. The best thing you can do for your clients is to take them to the toilet at the same times each day. Just like with urinary continence, by assisting or reminding a person to go to the toilet after each meal can develop a routine where the body gets very used to this pattern. This then preserves the dignity of the person and saves you valuable nursing hours to do more with your clients. Slide 8 Skin complication of fecal incontinence Remember the feces or stools are made up of waste product from the food we eat. The anal area is a very sensitive area. Some times if feces is left on the skin or a person has diarrhea the skin can break down and it is very painful so make sure there is never any feces left on the skin. Slide 9 Treatment of Anal Area Care of the skin Clean with warm water. Be careful using soap as it can sometimes dry the skin out and make it more uncomfortable for the person. When drying the skin use a soft towel. Toilet paper can be very harsh to the sensitive area and sometimes it does not remove the feces. Alcohol free wipes are very good for cleaning the skin so use them if they are available. Some creams and ointments are also very healing and soothing. I find that ung vita is usually a very good healing balm however the doctor may chart something else or the registered nurse in your facility may prefer some other ointment or cream. Remember to always report any of these problems to your Registered Nurse and check to see what she advises to put on the area. Underwear is also important. Soft, cotton underwear is always best. Avoid synthetic underwear as it can make the whole problem a lot worse. Slide 10 To summarize Fecal incontinence The things you can do to prevent fecal incontinence are Avoid allowing a person to be constipated. You need to observe the persons normal bowel habits and not allow them to go more than 3 days without a bowel movement. It is your responsibility to advise the Registered Nurse as soon as possible so intervention can be taken to prevent any discomfort to the person. Too often I have found that caregivers did not advise me of a potential problem. This means a more aggressive tack has to be taken to remedy the situation. Registered Nurses rely on you to give them the information immediately. There are usually fewer Registered Nurses than there are caregivers so we rely on your observational skills to inform us. As soon as you see something a miss with the person, tell the Registered Nurse. Observe you clients and see if there are any foods that contribute to their incontinence. This way you can reduce or eliminate the foods that are causing the problem. Make sure your client has a diet high in fiber. To find out more information on this ask your registered nurse, dietitian or do your own search on the internet. 14

15 Fluid intake is essential for the body including keeping the bowel healthy and functioning. Make sure you give your clients extra water and try giving drink of water before a cup of tea or coffee to help increase their fluid intake. Bowels can be trained to defecate at a specific time so take your client to the toilet at the same time every day. Make sure you keep the anal area clean and free of feces to prevent skin breakdown and excoriation which is very painful. Slide 11 Final note Nothing replaces being able to pass urine or feces naturally, in the toilet Learning to pass urine & feces appropriately is a primal instinct learnt as a child A person s dignity is seriously harmed when this factor is not taken into account Failure to toilet a person so they become incontinent is abuse Leaving a person in soiled clothing is neglect Always have the utmost respect for a person for it is not so long ago they were active and living a life just like you. 15