urinary incontinece 12 2011

Continence Management

Improving Resident Outcomes

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Understand the risk factors that contribute to Urinary

Incontinence.

Define the types of Urinary Incontinence and management criteria for each.

List the steps to a workable Continent Management program.

Learn how to use Quality Indicators to create appropriate continence management programs and support your care planning actions.

Review the CAA Elements of Urinary Incontinence and Indwelling Catheters.

Review care planning format ideas.


Identify the three primary purposes for evaluating Urinary Incontinence?

List 5 of 10 potential causes for urinary incontinence.

List 4 of 7 factors needed for continence.

List the three most common causes of reversible incontinence.


Part 1


Decreased bladder capacity Shorter time between awareness of the need to

void and symptomatic urgency Incomplete emptying and increased residual

volume Decreased flow rate Increased number of involuntary bladder

contractions (detrusor instability) Decreased strength of pelvic support muscles Atrophic changes in urethral lining and bladder

trigone in postmenopausal women


Bladder Continence refers to the ability to control bladder function.

Urinary Incontinence is the inability to control urination in a socially socially appropriateappropriate manner.


Bladder Retraining

The RESIDENT RESIDENT is the primary player.

Retraining demands the resident have the ABILITY to consciously delay urinating or resist the urgency to void.

Scheduled Toileting

The STAFF is the primary player.

The staff either takes the resident to the bathroom, hands them a urinal, or reminds them to go to the toilet. This includes habit training and/or prompted voiding.

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Key Definitions

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A bladder that can hold it! A urethra that can open and close properly Fluid balance, integrity of spinal cord,

integrity of peripheral nerves. Timely toilet access with or without assistance. Ability to adjust clothing. Cognitive and social awareness. Individual motivation


Urge Incontinence / Urge Incontinence / Uninhibited Uninhibited BladderBladder

Bladder contracts when it shouldn't, abruptly soaking the person.

Can occur with or without a conscious sensation of the need to void.

Leakage of urine, usually in large amount.

Associated with CNS disorders like

dementia, stroke, Parkinsonism

Spinal cord injury Cystitis, urethritis Tumors Stones, Diverticuli Overflow obstruction.


NeedPost Void

Residual test

OutcomeLess than 100cc urine in bladder.

Actions Candidate for timed

voiding Pelvic floor exercises. Meds used might

include anti-cholinergic, bladder relaxant, or tri-cyclic antidepressant.


Bladder fails to contract when it should. There is a leakage of urine, usually small

amounts or constant dribbling, bladder may complain about lower abdominal or pelvic pain.

Associated with: peripheral neuropathy secondary to diabetes mellitus, CNS lesions, fecal impaction & inadequate bowel elimination, BPH, obstruction of bladder neck.


NeedPost Void Residual Test

OutcomeLess than 400cc

of urine in bladder.

ActionAction Candidate for

timed voiding. Pelvic floor

exercises May require

urologic evaluation.


Rare in women Have increased

urine loss Negative stress

test Urethra blocked

Associated with Obstruction of prostate Stricture Cystocele Lack of contraction due

to diabetes mellitus, spinal cord injury

Neurogenic bladder related to MS, spinal cord lesions.


NeedPost Void Residual Test

Outcome Less than 100cc of

urine in bladder Negative stress test

ActionActionUrologic workup.


Rare in Men Urethra is unable

to close tight enough

Accompanies stress, such as coughing, sneezing, laughing, and exercising.

Associated with: Weakness Laxity of pelvic floor

muscles. Bladder outlet or

urethral sphincter weakness.


NeedPost Void Residual

Stress Test

Outcome Less than 100cc of

urine in bladder Positive stress test

ActionAction Candidate for

timed voiding Pelvic floor

exercises Perhaps medicine

that will increase urethral resistance.


Urine loss associated with inability to toilet because of

impaired cognitive or physical functioning, Psychological issues, unwillingness, or environmental

barriers.

Associated with Severe dementia,

and other neurologic disorders

psychological factors such as depression, regression, anger, & hostility


Need Complete Incontinence

RAP guidelines. Determine areas of

correctability/improvability & strengths.

Outcome Develop individualized

toileting program based fixability / improvability of identified problems.

Action Complete bladder

tracking & I & O to establish pattern habits.

Review relationship of medication to toileting habits and episodes of incontinence.

Check out environmental factors and needs..


Stress & Urge Stress (spurt of

urine induced with increased pressure) &

Urge incontinence (abrupt soaking)

Urge& Functional Urge (abrupt soaking)

& Functional

incontinence (impairment prevents timely toileting, bladder function okay)


1. Urinary Tract Infection

2. Fecal Impaction

3. Delirium

4. Lack of Toilet Access

5. Immobility

6. Depression

7. Congestive Heart Failure or Pedal Edema

8. Recent Stroke

9. Diabetes Mellitus

10. Medications


Part 2Regulations


A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary track infections and restore as much bladder function as possible.


To ensure that the facility develops, implements, and evaluates continence care programs that include systematic approaches to identify and routinely assess each resident who resides in the facility who are incontinent of urine to:o Improve or restore bladder function, where

possible.o Ensure treatment and services to assist the resident

to maintain their highest level of continence status.o Address and minimize the risk of potential negative

outcomes related to urinary incontinence.


PhysicalPhysical MentalMental

SocialSocial EmotionalEmotional


Comprehensive Assessment Comprehensive Care Plans Maintain or improve abilities Neglect Dignity


FAILURE TO ACCURATELY

ASSESS.

MAKING ASSUMPTIONS RATHER THAN EVALUATING.

Bladder tracking to establish/negate a pattern

Assess for reversibility, causes and contributing factors, and type(s) of incontinence.


FAILURE TO DEVELOP A CARE PLAN

OR FAILURE TO

APPROPRIATELY TREAT THE PROBLEM.

Plan does not address the specific problem or need and/or identify resident strengths.

Specific goals to manage and/or correct the incontinence, and prevent risk factors from materializing are not present.

Clear, appropriate interventions and approaches are not identified or fail to identify who is responsible for implementation.

Target dates are absent or inappropriate.


FAILURE TO IMPLEMENT THE

PLAN

Written and not used

Written and not known.

Written and not followed or not followed consistently.

Lacks individualization.

Inappropriate interventions.


FAILURE TO REVIEW PLAN

FOR EFFECTIVENESS

AND OUTCOMES.

When is the last time you discussed incontinence status or outcomes at care conference?


NEGATIVE OUTCOMES THAT SHOULD HAVE BEEN AVOIDABLE OR THAT

LACKED CLINICAL DOCUMENTATION OF

AVOIDABILITY OR SUBSTANTIATION OF

NEED.

accidents use of restraints use of psychoactive drugs urinary track infections dehydration behavior problems depression, mood or

behavior problems Isolation & withdraw pressure ulcers, skin

problems resident right violations


Resident was appropriately assessed. The care plan was developed and

reflective of status, risk, measurable, appropriate, do-able goals with reasonable time frames.

Care was implemented consistently in keeping with standards of practice

Resident outcomes were reviewed & care plan revised as needed.


Quality of LifeDeficiency

Physical, mental, social, emotional status declined, was not maintained or enhanced as it could have been based on a comprehensive review and assessment.


Evaluation of the incontinence requires appropriate classification by history, examination, and testing.

Residents who are likely to benefit from behavioral therapy for urinary incontinence can be easily identified.

Residents who show a response to a simple, non-invasive assessment consisting of 3-day trial of prompted voiding have potential to show long term benefit in control of their incontinence.

Comprehensive assessment should include an evaluation of the residents:

Prior history of urinary incontinence, including previous treatment or management.

Physical exam

Individual risk factors


Voiding Patterns Type of Incontinence Results of PVR or Ultra

sound for residents at risk of retention.

Presence or absence of UTI’s, persistent or recurrent, urine culture if symptomatic.

Environmental factors and assistive devices such as grab bars raised toilets, bed rails, restraints, etc.

Type and frequency of physical assistance needed to access toilet.

Cognitive status and behaviors that may affect continence status.

Functional impairments that can impede ability to maintain continence.

Significant alteration or impairment in patterns of fluid intake & hydration status including constipation & impaction.

Medications that may affect continence, including those with anticholinergic properties


Resident was appropriately assessed. The care plan was developed and

reflective of status, risk, measurable appropriate, do-able goals with reasonable time frames.

Care was implemented consistently in keeping with standards of practice.

Resident outcomes were reviewed & care plan revised as needed.


Part 3


Quality Indicator Facility Profile

Provides facility status report in percentile

ranking format for each of the 24MDS based Quality Indicators as compared

to apeer group of the

facilities in the State or Nation.

Resident Level Summary Report

Provides the specific Quality Indicators triggered for EACH resident using the most current MDS .

Promotes a clinical thought map for determining cause and effect relationships of one indicator to another.



HOW TO READ PROFILE REPORT

Domain Indicator# in QI

TotalPoss.

NFAvg.

StateAvg.

Percentile Rank

Elimination/Incontinence

Prevalence of bowel or bladder

incontinence37 64 57.8 53.8% 60%

High Risk

Low Risk

17

20

17

47

100%

42.6%

91.6%

40.4%

100%

54%

Prevalence of occasional or

frequent incontinence

without a toileting plan

8 19 42.1% 48.1% 45%

39

Bladder or Bowel Incontinence: Frequently or always incontinent. Denominator excludes comatose or indwelling catheters

or ostomy

Risk Adjusted: High risk severe cognitive impairment or totally

dependent in mobility. Low Risk all others.


Resident Based Note if incontinence is

frequent or always. If high risk why? If low risk why? Identify

the type of incontinence.

Correlate relationships with other triggered indicators.

Determine cooperation. Identify best program. Create or review care

plan .

Facility Based Split residents into high or

low risk group. List residents as frequently

or always using RLSR. Identify if cooperative. Start program adjustments

using the low risk, frequent and cooperative resident.

Make educated assumption on type of incontinence and proceed accordingly.

Identify causal relationship with other indicators.


Occasional or Frequent Bladder or Bowel Incontinence without Toilet Plan:

Prevalence of Indwelling Catheters

Prevalence of Fecal Impaction


Resident Based Is reason acute &

reversible? If not why & make

educated assumption on type of incontinence and proceed accordingly.

Identify if occasional or frequent.

Remember to consider resident strengths.

Facility Based Split into occasional

and frequent using RLSR.

Identify residents who self manage.

Determine why no program is in place.

Look for negative relationships to other indicators.


A resident who enters a facility without an indwelling catheter is not catheterized unless the resident’s clinical record demonstrates catherization was necessary.


Physical Psychosocial

Cross check to UTI, dehydration, and pressure ulcer QI's for possible correlation.

Determine cause affect scenario.


Evaluate if coding error related to staff misunderstanding of what is and is not an impaction.

If it is true impaction evaluate for causative factors.

Is it food, fluid or mobility related or exacerbated? What actions has or could the facility take to improve this? If not, why not, and be sure the reasons are recorded in the medical record.

Is it med related or exacerbated? If so, can a different med be substituted? If not, why not, and record in chart, as well as care plan complication / risk and interventions.

Is it a result of disease process? If so, request physician address as such in progress notes periodically and / or summarize in your assessment notes. Care plan complication / risk and interventions.

Was the risk for impaction recognized? Was it care planned? If the goals were not met was residents reassessed and care plan revised?

Is impaction or constipation a cause or contributor to urinary incontinence?


Check medical record. Is their supporting documentation to indicate UTI did occur within 30 days of assessment reference date window?

For each resident determine if UTI’s are more than an isolated event. If so, have you evaluated the causes? Is it something you can reverse or minimizing? Was care planning in place? Was it followed? Is revision needed?

Review your infection control program for monitoring and investigating to be sure you are in compliance. I.e. tracking by site, source, organism, unit, care givers, etc.

Does the chart support presence of a true UTI? I.e. Positive cultures and symptoms were present. If not, evaluate if this was an isolated issue or a systemic problem related to facility policies or practices, including the need for staff training.


Part 4Types of Programs



Continence Management Treatment OptionsManagement Program Requirements: Schedule

Habit Training Resident is cooperative There is NO discernible voiding pattern. Able to be mobilized

Fixed.

Scheduled Toileting

Prompted

Resident is cooperative There is a discernible voiding pattern. Voiding frequency greater than two hours.

• Resident is cooperative• Some awareness some of the time Mobilizes without help

Individualized, tailored to identified

voiding pattern.

49


Management Program Requirements: Schedule

Bladder Retraining

Resident has ability to be taught to: Consciously delay urinating or Resist the urgency to void.

Void on a predetermined

schedule.

Check &

Change

• Not cooperative• Not a restorative program

Based on assessment risk

50

Part 5Continence Management ProtocolComponents of Documentation


Any resident identified as incontinent of urine will be evaluated for causal factors and appropriate actions undertaken to obtain the most effective results.

Outcomes will be focused on attaining independent, dependent, social continence or a combination of these, dependent on the source and cause of the incontinence.

Management strategies might include toileting programs, use of prescribed medications, fluid and dietary management, exercise, external collection devices, environmental modifications, and use of absorbent products. The choice of interventions will be dependent on assessment findings.


1. Initiate bladder tracking and intake / output every for 2-3 days .

2. Complete the Incontinence CAA analyzing the data collected.

3. Develop the care plan.

4. Educate caregivers and resident.

5. Initiate the Care Plan.6. Monitor effectiveness

of the plan.7. Review and modify

the plan as needed.



Bladder Tracker

Taken /prompted/voided. Unaware of need.

4 Self control, voided.

Taken /prompted/did not void. Unaware of need.

5 Self control, Requires assistance.

Taken, dry, Then incontinent in this time period.

6 Self control, did not need to void in this time period.

1

2

3

Day 1Code

In-take

Out-put

Day 2

Code

In-take

Output

Day 3

Code

In-take

Out-put

7 AM to 9 AM

9 AM to 11 AM

11 AM to 1 PM

1 PM to 3 PM

54

Use the Incontinence CAA

to determine: Reversible causes Contributing factors Compounding

problems

Identify key issues impacting on the status.

Relationship of mobility, transfer, ADL abilities/needs to Incontinence as causes or contributors.

Identify cognitive status including ability to recognize urges, respond to urges, & cooperate with a toileting program

Identify remaining capabilities of resident.

Include resources available.


Functional Impairments

Cognitive function No awareness of

urges Some awareness Can respond to urges Can cooperate Able to find the toilet

Mobility Transferring, requires

assistance Locomotion, requires

assistance Distance problems

getting to toilet Access problems to

toilet Use of restraint/side

rails


Difficulty/inability

Communicating need Seeing/hearing Managing clothing With hygienic needs i.e.

wiping self, washing hands, etc.

Risk Factors Present Abnormal labs influencing

continence High calcium High blood glucose High BUN/Creatinine Positive urine culture

Signs of depression Edema Excessive fluid intake Excessive caffeine Wears pads/briefs Chemo/radiation therapy Other:


CONCURRENT MEDICAL PROBLEMS

Acute confusion Diabetes CHF CVA TIA Cancer

Brain Bladder Prostate Spine

Benign prostatic hypertrophy Recurrent UTI Parkinson’s disease Neurological disorder Developmental disability Mood or Behavior Disorder Other:

MEDICATIONS (can promote urge incontinence/urinary retention or overflow

incontinence)

Diuretic Urine Output greater than 1

liter/day Urine Output less than liter/day

Anticholenergics Antipsychotic Antianxiety/hypnotic Antidepressants Antihistamine Antispasmodics Parkinson’s med Disopyramide Narcotics Sympathomimetics Beta Blockers Calcium Channel Blockers


The following actions have been completed or are in progress

Urinary Tract Infection Ruled Out

Bowel Impaction Ruled Out

Pelvic exam (rule out atrophic vaginitis / prolapse/etc.)

Urological testing and/or consultation

BLADDER TRACKING

Not done: In progress Voiding pattern present No voiding pattern

established


SUSPECTED TYPE OF INCONTINENCE

Stress (spurts of urine when coughing/laughing caused by increased intra-abdominal pressure)

Urge (abrupt loss caused by involuntary bladder contraction)

Mixed (loss caused by a combination of stress and urge incontinence)

Overflow/Obstruction (loss when bladder holding capacity exceeded /dribbles urine)

Neurogenic bladder (uncontrolled or continuous leakage)

Functional (restricted mobility/dexterity, vision, hearing, speech loss, inability to communicate)

Resident/Family/Sig. Other Input

Questions and concerns:

Preferences /Suggestions

Interviewer Comments





Do Not Proceed Self manages continence needs Other

Proceed Functional compromise and concurrent medical

problems require intervention Continence status may be improved with toileting plan Continence may be restored with re-training program Teaching plan is indicated Other:


Criteria for use

Terminal illness Stage III or IV pressure ulcer Need for exact urine

measurement Poor fluid intake and output History of inability to void

after catheter removal Neurogenic/atonic bladder Untreatable urinary blockage

(inoperable related to diagnosis/medical condition)

Obesity prevents adequate toilet/skin care

Debilitating illness

PROBLEM FACTORS to CONSIDER

Treated for UTI in absence of symptom

Treated for UTI with active symptoms

Hx of Hospitalization for septicemia, bacteria/pylonephritis

Fluid intake less than 500cc per day

Irrigation of bladder for other than blockage

Catheter tube placement problems:

Tube anchoring system is used Other:


Other Considerations

Assessment for continuing need done within past 3-6 months by urologist

Trial without catheter tried In progress Yes, results No, reason

Resident/Family/Sig. Other Input








ProceedCatheter is short time until condition

stabilizes.Catheter use is long term based on

irreversible factors, risk plan is indicated.

Teaching is indicated.Other:


Indwelling Catheters CAA

Consider MDS 3.0 Triggering Items

Identify Key Issues / Problems

Resident Strengths

Risk Factors / Potential Complications

Refer to Related / Linked CAA’s……

Care Panning Decision: Proceed Do Not Proceed

• Potential for Improvement• Improve Current Status

• Maintain • Slow Decline• Minimize/Prevent

Complication

Referrals toNursing Social Service Dietary Activities Therapy Physician Other


Independent ContinenceIndependent Continence Able to maintain continence without assistance.

Dependent ContinenceDependent Continence Kept dry through the efforts of others; for physically or mentally impaired.

Social ContinenceSocial Continence

Dependent on absorbent products & other measures to contain urine leakage. Social continence means clean, dry, and odor free.


Gain resident agreement if resident is cognitively able.

Discuss with responsible party Instruct caregivers. Monitor compliance.


Problem/need Related to Risks/challenges

❏Occ. incontinence ❏Frequent incontinence ❏Always incontinent

Bladder incompetence: ❏Abrupt loss of urine ❏Urine loss with stress ❏Uncontrolled leakage

Physical limitation: ❏Compromised mobility ❏Inability to manage clothing ❏Inability :wipe self, wash hands

Medical condition: ❏Diabetes ❏Multiple sclerosis ❏CVA ❏Quadriplegia ❏ Depression ❏ Seizure disorder ❏ Constipation ❏ Impaction ❏ Catheter use

Medication: ❏Diuretic ❏Narcotic use

❏Falls ❏Skin irritation ❏Urinary tract infections ❏Social isolation ❏Socially inappro.behavior ❏Behavior outburst ❏Embarrassment ❏Curtailment of fluids ❏Curtailment of activities

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Problem/need Related to Risks/challenges

Urinary incontinence resulting in the need for: —— Indwelling catheter —— Suprapubic catheter

Urinary retention unresolved by other interventions

Terminal illness

Uncomfortable or disruptive bed and clothing changes

Stage 3 or 4 pressure ulcers on the resident’s trunk

❏The resident’s preference when failing to respond to more specific treatments

❏ The resident’s preference after being informed of the attendant risks

❏Monitoring the adequacy of fluid intake and output

❏Chronic bacteria

❏Symptomatic infection

❏Septicemia, pylonephritis

❏Abscesses

❏Leakage around the catheter

❏Urethral and bladder neck trauma

❏Urinary calculi

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urinary incontinece 12 2011

Health & Medicine

bladder relaxant

bladder trigone

bladder outlet

bladder continencerefers

bladder function

obstruction of bladder

cc urine

cc of urine