When Laughing is No Longer Funny Managing Transient Urinary Incontinence in Hospitalized Elderly Women Grace Umejei, BSN, RN, CWOC. Texas Health Presbyterian Hospital Dallas NICHE Online Connect Webinars 2016 1
Objectives Identify Transient Urinary Incontinence (TUI) and discuss outcomes on the Healthcare System Discuss the effectiveness of behavioral modification therapy (BMT) in reducing TUI episodes Review the outcome of management of TUI in elderly female patients. Mechanism of Urination bladder, the muscular wall nerve the brain urethral closure muscle Classification and Types of Incontinence Categories of UI Transient Incontinence incontinence with reversible causes. Established Incontinence when transient cause have been addressed and incontinence persists NICHE Online Connect Webinars 2016 2
Urinary Incontinence (UI) Stress Occurs with increased abdominal pressure. Urge sudden overwhelming need to urinate without ability to control urine flow, when urinary sphincter fails as a result of pelvic floor weakness to support uterus, bladder, and other pelvic organs. Overflow involuntary leakage of urine small amounts, associated with incomplete bladder emptying mechanical forces on distended bladder Functional contributing factors outside urinary system not characterized by bladder dysfunction. Inability to get to the bathroom, cognition impairment. Facts About Urinary Incontinence People > 65 years are the reason for a growing hospital population. This segment of the population have the greatest need for health care. Acute hospital settings 20% to 42% of older adult patients are affected by UI 42.5% of UI patients have some type of skin injury. TUI Background Involuntary urine loss with reversible causes. Negatively impacts patient outcomes, e.g. independence, mood, falls, and skin integrity Affects 80% of hospitalized patients and 75% of females >60 years of age Cost of managing TUI is $26 billion annually NICHE Online Connect Webinars 2016 3
Gertrude s Story Literature Review Evidence based practice (EBP) TUI interventions include: BMT, i.e. bladder training and lifestyle modifications based on TUI assessments and causation Daily bladder diary (BD) to track continence/incontinence episodes/toileting behaviors Staff education on use of BD and BMT strategy Patient education and counseling PICOT Question Is BMT (including a BD) more effective than passive TUI care in reducing TUI episodes in elderly hospitalized female patients on a rehabilitation unit? NICHE Online Connect Webinars 2016 4
Change Strategy Inter-professional team formed Educated inter-professional team on treatment plan and management strategies Inter-professional team used the BD to establish toileting schedule/assess BMT effectiveness Incontinence episodes tracked with use of BD Patients queried prior to discharge on BMT satisfaction and use of incontinence protection (i.e. adult briefs) Inter-Professional Team Nurses Patient Care Technician Chaplain Occupational Therapist (OT), Physical Therapist (PT) Wound Ostomy and Continence Nurse Physicians Dietary Staff Behavioral Modification Therapy Foundation for behavioral intervention Bladder Training Skills to control symptoms of bladder dysfunction. Lifestyle Modification Healthy bladder habits that will alleviate bladder symptom, enhance function and promote bladder health NICHE Online Connect Webinars 2016 5
Behavioral Modification Therapy Detection Identify transient causes of UI and individual patient risk factors. Determine the actual or potential effect of incontinence on patient s quality of life and functional statues. Anticipate and address potential complications based on established causes. Develop a set of interventions that target the risk factors and causes for each patient through consistent approach to evaluation. May Utilize Urinary Incontinence Assessment for Older Adults (Hartford Institute for Geriatric Nursing, New York University, College of Nursing) Bladder Diary Key: D Diaper BSC-Bedside Commode P- Bed Pad BP-Bed pan PU- Pull Ups T- Toilet DIAPPERS Tools for Determining TUI D Delirium Acute confusion alters one s ability to anticipate and meet own needs. Delirium may occur from drugs, surgery, or acute illness. I Infection Urinary tract infection A Atrophy Thin dry, friable vaginal and urethral mucosa due to Hypo-estrogenization in older female is associated with irritating symptoms (burning on urination, urgency, frequency) P Pharmaceuticals Drugs including sedatives, hypnotics, alcohol, anticholinergic, antihistamine, narcotics, loop diuretics. P Psychological Depression impairs one s motivation and condition desire to manage self-care or be concerned about incontinence. Fear of odor, embarrassment, obvious leakage, and unpredictable urine leakages can lead to marked alternation in social activities, relationships with others, and loss of social support. Transient Causes of Urinary Incontinence and other contributing factors E Excess urine Excess urine output resulting large fluid output intake, caffeinated beverages endocrine problems CHF, Peripheral edema Poor mobility, arthritic pain, poor use of R Restricted mobility assistive device S Stool Impaction Narcotic use can lead to severe constipation and fecal impaction that obstruct the bladder neck, leading to urine retention and/or overflow incontinence NICHE Online Connect Webinars 2016 6
Incontinence Training-Nursing Assessment Focused Assessment Determine Cause Intervention Develop individualized plan of care using data obtained from the history and physical examination, and in collaboration with other team members Evaluation of Outcome Bladder Diary Follow up assessment Patient assessment. Nursing Education Perform Comprehensive Assessment Focused Urinary Incontinence assessment Determine Neurological Status Identify Mobility and Activity Level Incontinence Training-Patient Counseling Intervention BMT Evaluation Follow up patient questionnaire NICHE Online Connect Webinars 2016 7
Bladder Re -Training Progressive voiding schedule, using relaxation and distraction techniques together with multicomponent behavioral training which patient has to learn. Positively affects mobility, behavior, skin integrity, urinary tract infection and bowel function. Goal Increase amount of time between emptying your urinary bladder and amount of urine your bladder can hold. Diminish leakage and sense of urgency associated with incontinence Determine fixed voiding schedule that corresponds to patients assessment Bladder Re-Training Prompted Voiding Neurologically Intact Responsibility of RN/PCT/Patient and interdisciplinary team Description Prompt patient on a schedule of every three hours during the day and every four hours at night as time allows. Report continence status and to assist to the toilet Provide positive feedback for maintenance of continence. Goal To keep the patient dry and to increase the patient s awareness of incontinence status and participation in bladder program Bladder Re- Training Cont. Scheduled Voiding Patients with Cognitive Impairment unable to accurately determine wetness or dryness unable to take responsibility for self-toileting but able to follow instructions with assistance. Responsibility - RN/PCT/Patient and interdisciplinary team Description Every two hours while awake every four hours at night the patient is taken to the toilet (or bedside commode) on schedule and cued to void Goal Prevent over-distention of bladder and keep the patient dry by toileting frequently enough to prevent incontinence. NICHE Online Connect Webinars 2016 8
Bladder Re Training cont., URGE Suppression Techniques Freeze, Squeeze, Breathe or Distraction. If urge cannot be suppressed and you must go slowly DOUBLE Voiding Lifestyle Modification Habits that may be modified to alleviate bladder symptoms or promote bladder health Dietary Ensure adequate fluids Avoid caffeinated beverages Promote high-fiber diet for bowel regularity Promote a regular voiding schedule, about every 3 hours Pharmacology Monitor poly-pharmacy, drug interactions Life style Modification Cont. Mobility OT, PT. to assist with gait or transfer training, assistive devices, develop toilet skills to promote independence. Utilize clothing that is easy to undo to promote independence in toileting. Monitor for transient causes of urinary incontinence and treat quickly. Social Environment Promote a positive approach to continence. Promote socialization. Assist with toileting if needed Recognize urinary incontinence as medical syndrome that is abnormal, promote the desire to maintain urinary continence. NICHE Online Connect Webinars 2016 9
Lifestyle Modification cont. Environmental Modifications Physical Environment Ensure good lighting in room, bathroom, call light within reach Obtain bedside commode, promote independence. Non-skid sock, non-glare floor also cord free floors Smoking cessation Optimal treatment outcome changes Adhering to these changes will require significant behavioral changes from the patient. Results Reduction of Incontinence Episodes Pre & Post Behavioral Modification Therapy (BMT) (n = 10 patients) Pre-BMT 3.3 Mean Range 1-5 Post- BMT 0.2 Mean Range 0-1 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 Mean # Incontinence Episodes in 24 Hours Results (cont.) Mean age 81.2 years (range 68-90) Days on BMT, mean 8.1 days (range 9-11) All patients (n=10) reported they were able to wear fewer adult briefs (cost reduction = $10 per day/per patient) 100% reported satisfaction with BMT NICHE Online Connect Webinars 2016 10
Conclusion BDs are effective TUI management tools; maintaining documentation is challenging. BMT is a cost-effective EBP intervention Summary Increase of elderly patients with UI. Behavioral modification interventions can significantly improve symptoms of TUI when education, counselling, support and encouragement are applied. Need to implement BMT in acute care setting in order to reverse the current practice of focusing TUI management on UI consequences rather than treating underlying causes of UI. Thank you! NICHE Online Connect Webinars 2016 11
References DuBeau, C. E., Kuchel, G. A., Johnson II, T., Palmer, M. H., & Wagg, A. (2010). Incontinence in the frail elderly: Report from the 4 th international consultation on incontinence. Neurology and Urodynamic, 29, 165-178. Melville, J.L., Katon, W., Delaney, K., Newton, K. (2005). Urinary incontinence in US women: A population-based study. Archive Internal Medicine, 165(5) 537-542. Shamliyan, T., Wyman, J., Kane, R.L. (2012) Nonsurgical treatments for urinary incontinence in adult women: Diagnosis and comparative effectiveness. Agency for Healthcare Research and Quality, 36. Wyman, J.F., Burgio, K.I., Newman, D.K. (2009). Practical aspects of lifestyle modifications and behavioral interventions in the treatment of overactive bladder and urgency urinary incontinence. International Journal of Clinical Practice, 63(8), 1177-1191. Questions NICHE Online Connect Webinars 2016 12