Urinary Incontinence   21  

Annemarie Dowling-Castronovo and Christine Bradway

OVERVIEW

Despite evidence supporting UI management strategies (DuBeau, Kuchel, Johnson, Palmer, & Wagg, 2010; Fantl et al., 1996; Qaseem et al., 2014), nursing staff and laypersons often use containment strategies, such as adult briefs or other absorbent products, to manage UI. Individuals with UI believe that UI is a normal consequence of aging (Bush, Castellucci, & Phillips, 2001; Dowd, 1991; Kinchen et al., 2003; Milne, 2000; Mitteness, 1987a, 1987b), feel that UI is a difficult-to-discuss personal problem (Bush et al., 2001), and prefer self-help strategies, including containment, rather than seeking professional advice (Milne, 2000). Personal care strategies are often the result of information gained through lay media and personal contacts, not necessarily from health care professionals (Cochran, 2000; Miller, Brown, Smith, & Chiarelli, 2003; Milne, 2000). In comparison to nurses in other health care settings, nurses in hospitals view incontinent patients more negatively (Vinsnes, Harkless, Haltbakk, Bohm, & Hunskaar, 2001). Therefore, attitudes and beliefs regarding UI are important for the nurse to consider in an effort to best assess and manage UI.

BACKGROUND AND STATEMENT OF PROBLEM

UI affects more than 17 million adults in the United States and is most often defined as the involuntary loss of urine sufficient to be a problem (Fantl et al., 1996; National Association for Continence, 1998). Prevalence and incidence rates of UI are viewed cautiously because of inconsistencies with definitions and measurements of both these epidemiological statistics. In addition, variable or poorly articulated UI definitions (Abrams et al., 2003; Homma, 2008; Palmer, 1988) as well as underreporting and underassessment of UI (Schultz, Dickey, & Skoner, 1997) in the hospital setting can render data of questionable reliability. Prevalence of UI in community-dwelling adult populations ranges from 8% to 46% (Du Moulin, Hamers, Ambergen, Janssen, & Halfens, 2008; Kwong et al., 2010; Lee, Cigolle, & Blaum, 2009; Sims, Browning, Lundgren-Lindquist, & Kendig, 2011). For individuals with dementia, UI prevalence rates range from 11% to 90%; higher prevalence rates reflect institutionalized cognitively impaired older adults (Brandeis, Baumann, Hossain, Morris, & Resnick, 1997; Skelly & Flint, 1995). Although the highest prevalence rate occurs in institutionalized older adults, 15% to 53% of homebound older adults and 10% to 42% of older adults admitted to acute care also suffer from UI (Dowd & Campbell, 1995; Fantl et al., 1996; McDowell et al., 1999; Palmer, Bone, Fahey, Mamon, & Steinwachs, 1992; Schultz et al., 1997). Twelve percent to 36% of older hospitalized adults develop acute UI (e.g., new-onset UI, meaning that these individuals were continent on hospital admission) (Kresevic, 1997; Sier, Ouslander, & Orzeck, 1987; Zisberg, 2011); for patients undergoing hip surgery, the incidence of acute UI ranges from 19% to 32% (Palmer, Baumgarten, Langenberg, & Carson, 2002; Palmer, Myers, & Fedenko, 1997).

In addition to being a common geriatric syndrome, UI significantly affects health-related quality of life (HRQOL; DuBeau, Simon, & Morris, 2006; Dugger, 2010; Kwong et al., 2010; Shumaker, Wyman, Uebersax, McClish, & Fantl, 1994). The consequences of UI may be characterized physically, psychosocially, and economically. For example, an episode of urge UI occurring once weekly, or more frequently, has been associated with falls or fracture (Brown, Sawaya, Thom, & Grady, 2000; Chiarelli, Mackenzie, & Osmotherly, 2009; Hasegawa, Kuzuya, & Iguchi, 2010). Other physical consequences associated with UI include skin irritations or infections, urinary tract infections (UTIs), bloodstream infections, pressure ulcers, and limitation of functional status (Fantl et al., 1996). UI is associated with psychological distress (Bogner et al., 2002; de Vries, Northington, & Bogner, 2012), including depression, poor self-rated health, and social isolation or condition-specific functional loss (Bogner et al., 2002; Fantl et al., 1996; Sims et al., 2011), and poststroke UI is a risk factor for poor outcomes (Pettersen, Saxby, & Wyller, 2007). Therefore, it is essential that nurses assess and treat UI when addressing other health problems such as depression or falls.

Although there is conflicting evidence regarding the role of UI as a predictor for nursing home placement, UI has been identified as a marker of frailty in community-dwelling older adults (Holroyd-Leduc, Mehta, & Covinsky, 2004) and a predictor of 1-year mortality among older adults hospitalized for an acute myocardial infarction (Krumholz, Chen, Chen, Wang, & Radford, 2001). The negative psychosocial impact of UI affects not only the individual but also family caregivers (CGs; Brittain & Shaw, 2007; Cassells & Watt, 2003; Gotoh et al., 2009; Jansen, McWilliam, Forbes, & Forchuk, 2013). Economically, the total direct cost for all incontinent individuals is estimated to be more than $16 billion annually in the United States (Landefeld et al., 2008; Wilson, Brown, Shin, Luc, & Subak, 2001).

Nurses are in a key position to identify and treat UI, a quality indicator (Donald et al., 2013; Wenger et al., 2011), in hospitalized older adults. This chapter reviews the etiologies and consequences of UI, with emphasis on the most common types of UI encountered in the acute care setting. Assessment parameters and care strategies for UI are highlighted and a nursing standard-of-practice protocol focused on comprehensive assessment and management of UI for hospitalized older adults is included.

ASSESSMENT OF THE PROBLEM

Adverse physiological consequences of UI commonly encountered in acute care settings include an increased potential for UTIs and indwelling urinary catheter use, dermatitis, skin infections, and pressure ulcers (Sier, Ouslander, & Orzeck, 1987). Moreover, UI that results in functional decline predisposes older individuals to complications associated with bed rest and immobility (Harper & Lyles, 1988).

Etiologies of UI

Continence is a complex, multidimensional phenomenon influenced by anatomical, physiological, psychological, and cultural factors (Gray, 2000). Thus, continence requires intact lower urinary tract function, as well as cognitive and functional ability to recognize voiding signals and use a toilet or commode, the motivation to maintain continence, and an environment that facilitates the process (Jirovec, Brink, & Wells, 1988). Physiologically, continence is a result of urethral pressure being equal to or greater than bladder pressure (Hodgkinson, 1965), of which angulation of the urethra, supported by pelvic muscles, plays a role (DeLancey, 1994, 2010). Continence also requires the ability to suppress autocontractility of the detrusor (Hodgkinson, 1965). Micturition (urination) involves voluntary as well as reflexive control of the bladder, urethra, detrusor muscle, and urethral sphincter. When the bladder volume reaches approximately 400 mL, stretch receptors in the bladder wall send a message to the brain and an impulse for voiding is sent back to the bladder. The detrusor muscle then contracts and the urethral sphincter relaxes to allow urination (Gray, Rayome, & Moore, 1995). Normally, the micturition reflex can be voluntarily inhibited (at least for a time) until an individual desires to void or finds an appropriate place for voiding. UI occurs as the result of a disruption at any point during this process. For a comprehensive review, Gray (2000) provided a detailed analysis of voiding physiology. Common age-associated changes, including a decrease in bladder capacity, benign prostatic hyperplasia (BPH) in men, and menopausal loss of estrogen in women, can affect lower urinary tract function and predispose older individuals to UI (Bradway & Yetman, 2002). Despite these aging changes, UI is not considered a normal consequence of aging.

The two major types of UI are transient (or acute/reversible) and established (or chronic/persistent; Ermer-Seltun, 2006; Newman & Wein, 2009). Transient UI is characterized by the sudden onset of potentially reversible symptoms that typically has a duration of less than 6 months (Specht, 2005). There may be cases of acute UI that do not resolve as in the case of acute UI caused by a spinal cord injury that then becomes an established UI. Causes of transient UI include delirium, infections (e.g., untreated UTI), atrophic vaginitis, urethritis, pharmaceuticals, depression, or other psychological disorders that affect motivation or function, excessive urine production, restricted mobility, and stool impaction or constipation (e.g., creates additional pressure on the bladder and can cause urinary urgency and frequency). Hospitalized older adults are at risk of developing transient UI. In the literature, these cases have been referred to as new-onset UI, hospital nosocomial, and hospital acquired (Ding & Jayaratnam, 1994; Kresevic, 1997; Paillard & Resnick, 1981; Palmer et al., 1997, 2002). Complicated by shorter hospital stays, older adults may also be at risk of being discharged without resolution of transient UI and, thus, urine leakage persists and may become established UI. However, transient UI is often preventable, or at least reversible (e.g., transient UI precipitated by a UTI that resolves with successful treatment, or acute UI related to diuretic therapy for heart failure exacerbation), if the underlying cause for the UI is identified and treated (Ding & Jayaratnam, 1994; Fantl et al., 1996; Palmer, 1996).

Kresevic (1997) reported that hospitalized older adults with new-onset UI were more likely to be on bed rest, restrained, depressed, dehydrated, malnourished, and dependent in ambulation when compared with their continent counterparts. Furthermore, the relative risk of developing new-onset UI was twofold for older adults with depression (odds ratio [OR] = 2.28), malnutrition (OR = 2.29), and dependent ambulation (OR = 2.55). Study participants identified that being able to walk, having use of a bedpan or commode, and nursing assistance fostered continence (Kresevic, 1997). Likewise, Palmer et al. (2002) determined that in addition to mobility dependency, other risk factors for new-onset UI, specific to a hip-fracture population, included institutionalization prior to hospitalization, the presence of confusion (identified by a retrospective chart review) preceding hip fracture, and being an African American woman. In addition to cognitive impairment, the use of indwelling urinary catheters and adult diapers statistically increased the odds of hospitalized older adults experiencing new-onset UI in a hospital in Israel (Zisberg, 2011).

Established UI has either a sudden or gradual onset and is often present prior to hospital admission; however, health care providers or family CGs may first identify UI during the course of an acute illness, hospitalization, or abrupt change in environment or daily routine (Palmer, 1996). Types of established UI include stress, urge, mixed, overflow, and functional UI.

Stress UI is defined as an involuntary loss of urine associated with activities that increase intra-abdominal pressure. Symptomatically, individuals with stress UI usually present with complaints of small amounts of daytime urine loss that occurs during physical effort or exertion (e.g., position change, coughing, sneezing) that result in increased intra-abdominal pressure. Stress UI is more common in women; however, stress UI may also occur in men postprostatectomy (Abrams et al., 2003; Fantl et al., 1996; Hunter, Moore, Cody, & Glazener, 2004; Jayasekara, 2009).

Urge UI is characterized by an involuntary urine loss associated with a strong desire to void (urgency). Individuals with urge UI often complain of being unable to hold the urge to urinate and leak on the way to the bathroom. This history is most helpful to the identification of urge UI (Holroyd-Leduc, Tannenbaum, Thorpe, & Straus, 2008). In addition to urinary urgency, signs and symptoms of urge UI most often include urinary frequency, nocturia and enuresis, and UI of moderate to large amounts. Bladder changes common in aging make older adults particularly prone to this type of UI (Abrams et al., 2003; Fantl et al., 1996; Jayasekara, 2009). Individuals with overactive bladder (OAB) may complain of urgency, with or without UI, as well as urinary frequency and nocturia. Assessment should focus on pathological or metabolic conditions that may explain these symptoms (Abrams et al., 2003).

Mixed UI is defined as involuntary urine loss as a result of both increased intra-abdominal pressure and detrusor instability (Fantl et al., 1996; Jayasekara, 2009). On history, individuals describe symptoms of stress UI in combination with symptoms of urge UI and OAB.

Overflow UI is an involuntary loss of urine associated with overdistention of the bladder, and may be caused by an underactive detrusor muscle or outlet obstruction leading to overdistention of the bladder and leakage of urine. Individuals with overflow UI often describe dribbling, urinary retention or hesitancy, urine loss without a recognizable urge, an uncomfortable sensation of fullness or pressure in the lower abdomen, and incomplete bladder emptying. Clinically, suprapubic palpation may reveal a distended or painful bladder as a result of urine retention, which may be acute or chronic. A common condition associated with this type of UI is BPH. Neurological conditions, such as multiple sclerosis and spinal cord injuries, or diabetes mellitus, which result in bladder muscle denervation, may also cause overflow UI (Abrams et al., 2003; Doughty, 2000; Fantl et al., 1996; Jayasekara, 2009).

Functional UI is caused by nongenitourinary factors, such as cognitive or physical impairments, that result in an inability for the individual to be independent in voiding. For example, acutely ill hospitalized individuals may be challenged by a combination of an acute illness and environmental changes. This, in turn, makes the voiding process even more complex, resulting in a functional type of UI (Fantl et al., 1996; Hodgkinson, Synnott, Josephs, Leira, & Hegney, 2008).

ASSESSMENT PARAMETERS

It is essential to ask patients about the presence of UI because they often will not offer this information or seek professional care (Qaseem et al., 2014). Nurse continence experts suggest that entry-level nurses demonstrate the ability to collect and organize data surrounding urine control and implement nursing interventions that promote continence (Jirovec, Wyman, & Wells, 1998). Nurses play a critical role in the basic assessment and management of UI in hospitalized older adults. Because UI is an interprofessional issue, collaboration with other members of the health care team is essential. It is not sufficient for nurses to only identify and document the presence of UI. Instead, the type of UI should be determined and documented based on a careful history and focused assessment; urodynamic tests are not required as part of the initial assessment of UI (DuBeau et al., 2010). Basic history and examination techniques are presented here to assist the nurse in identifying the type of UI along with a nursing standard of practice protocol (see Protocol 21.1 to guide UI assessment and management).

History

When a patient is admitted to the hospital, nursing history should include questions to determine whether the individual has preexisting UI or risk factors (Table 21.1) for UI. The nurse should be alert for the following UI-associated risk factors specific to the hospital setting: depression, malnourishment, dependent ambulation, being a resident of a long-term care institution, confusion, and being an African American woman (Kresevic, 1997; Palmer et al., 2002). Therefore, the nurse should screen for depression, determine body mass index (BMI), monitor albumin and total protein levels if available, consult with a dietitian, and perform a validated assessment of both cognitive and functional status.

The nurse should include screening questions for all older adult patients, such as Have you ever leaked urine? If yes, how much does it bother you? Although not validated in the hospital setting, examples of screening instruments used in other settings include the Urinary Distress Inventory-6 (UDI-6) and the Male Urinary Distress Inventory (MUDI). The UDI-6 is a self-report symptom inventory for UI that is reliable and valid for identifying the degree of bother and type of established UI in community-dwelling females (Lemack & Zimmern, 1999; Uebersax, Wyman, Shumaker, McClish, & Fantl, 1995). The MUDI is a valid and reliable measure of urinary symptoms in the male population (Robinson & Shea, 2002). Determining the degree of “bother” and the effect on HRQOL is important and should include the perspective of both the patient and CG or significant other. Various instruments for quantifying bother and HRQOL exist (Abrams et al., 2003; Bradway, 2003; Robinson & Shea, 2002; Shumaker et al., 1994).

Historical questions should focus on the characteristics of UI: time of onset, frequency, and severity of the problem. Questions also should review past health history and address possible precipitants of UI such as coughing, uncontrollable urinary urgency, functional decline, and acute illness (e.g., UTI, hip fracture). Nurses should inquire about lower urinary tract symptoms, such as nocturia, hematuria, and urinary hesitancy, as well as current management strategies for UI. The presence and rationale for an indwelling urinary catheter should be documented (see Chapter 22, “Prevention of Catheter-Associated Urinary Tract Infection”).

A bladder diary or voiding record is recommended as a tool for obtaining objective information about the patient’s voiding pattern, incontinent episodes, and UI severity (Lau, 2009). There are numerous voiding records available; for example, visit consultgerirn.org/resources. Although the 7-day voiding record is the most evaluated and recommended tool used to quantify UI and identify activities associated with unwanted urine loss (Jeyaseelan, Roe, & Oldham, 2000), a 3-day voiding record has been recommended as more feasible in outpatient and long-term care settings (DuBeau et al., 2010; Fantl et al., 1996). A voiding record completed for even 1 day may help identify patients with bladder dysfunction or those requiring further referral. Advanced practice nurses or urologic/continence specialists can assist nursing staff with interpretation and offer suggestions regarding nursing interventions based on information from the voiding record.

TABLE 21.1

Risk Factors Associated With Urinary Incontinence

Comprehensive Assessment

A wide variety of medications can adversely affect continence. Diuretics are the most commonly known class of medications that contribute to UI caused by polyuria, frequency, and urgency. Medications with anticholinergic and antispasmodic properties may cause mental status changes, urinary retention with or without overflow incontinence, and stool impaction. Various psychotropic medications (e.g., tricyclic antidepressants, antipsychotics, sedative-hypnotics) have anticholinergic effects, contribute to immobility, and cause sedation and possibly delirium—each of which negatively affects bladder control. Alpha-adrenergic blockers may cause urethral relaxation, whereas alpha-adrenergic agonists may cause urinary retention. Calcium channel blockers also may cause urinary retention (Newman & Wein, 2009).

Nurses should document all over-the-counter, herbal, and prescription medications on admission. In addition, nurses must closely scrutinize new medications as possible causes if UI suddenly develops during the patient’s hospital stay. Medications that may contribute to iatrogenic (i.e., hospital caused) UI include diuretics and sedative-hypnotics. Essentially, when a hospitalized patient develops transient UI, the nurse must ask the question: Could a new medication be affecting this patient’s bladder control? If the answer is yes, then the nurse reviews this finding with the prescribing practitioner to learn whether the contributing medication may be discontinued or modified. Although studies demonstrate that older women respond to pharmacological treatment for urgency UI and/or OAB, when these medications, specifically trospium, are included as part of a drug regimen of greater than seven total medications, there is a higher likelihood of adverse effects (Qaseem et al., 2014).

Important components of a comprehensive examination include abdominal, genital, rectal, and skin examinations. In particular, the abdominal examination should assess for suprapubic distention indicative of urinary retention. Inspection of male and female genitalia can be completed during bathing or as part of the skin assessment. Postmenopausal women are especially prone to atrophic vaginitis. Significant findings for atrophic vaginitis include perineal inflammation; tenderness (and, on occasion, trauma as a result of touch); and thin, pale genital tissues. During the genital examination, female patients should be instructed to cough or perform the Valsalva maneuver (sometimes referred to as a bladder stress test) to determine whether there is urine leakage caused by increased intra-abdominal pressure, which may be attributed to stress UI (Burns, 2000; Holroyd-Leduc et al., 2008).

Digital rectal and skin examinations are essential in identifying transient causes of UI such as constipation, fecal impaction, and the presence of fungal rashes. The “anal wink” (contraction of the external anal sphincter) indicates intact sacral nerve innervation and is assessed by lightly stroking the circumanal skin. Absence of the anal wink may suggest sphincter denervation (Burns, 2000) and risk of stress UI. In men, the prostate gland should be palpated during the rectal examination because BPH may contribute to urge or overflow UI. A normal prostate gland is symmetrically heart shaped, about the size of a large chestnut, and often described as “rubbery” or similar to the tip of the nose. When enlarged, as with BPH, the examiner may palpate symmetrical enlargement. Pain on palpation or asymmetrical borders may be indicative of prostatitis or prostate cancer, respectively (Gray & Haas, 2000).

TABLE 21.2

Postvoid Residual

PVR, postvoid residual.

Sources: Diokno, Laijness, and Griebling (2014); Dorsher and McIntosh (2012); Shinopulos (2000).

In some cases, diagnostic testing may provide additional information. The most common diagnostic tests include urinalysis, urine culture and sensitivity, and postvoid residual (PVR) urine (Dubeau et al., 2010). Urinalysis and urine cultures are used to identify the presence of a UTI and bacterial agent responsible, which may contribute to acute UI. A measurement of PVR may reveal incomplete bladder emptying. Two methods for accurately evaluating PVR are bladder sonography and sterile catheter insertion after the patient has voided (Table 21.2). In addition, in some patients, it may be useful to determine optimal bladder volume, which in one study was defined as the sum of the voided volume plus the PVR (Iwatsubo, Suzuki, Igawa, & Homma, 2014).

An additional diagnostic test, such as a simple bedside urodynamic test, which provides information regarding detrusor activity, may be warranted in some cases (Burns, 2000; Lenherr & Clemens, 2013; Newman & Wein, 2009). A simple bedside urodynamic test is most likely to be performed by an advanced practice nurse or physician. It is done after a PVR has been performed and measured via the sterile catheterization method. After the bladder is emptied, the catheter is maintained in the bladder, and a 50-mL syringe (without plunger) is connected to the catheter, with the center of the syringe in alignment with the symphysis pubis. Sterile water is then instilled to fill the bladder. The fluid level is monitored for evidence of bladder contractions, which are reflected in movement of the fluid level.

Functional, environmental, psychosocial, and mental status assessments are essential components of the UI evaluation in older adults. The nurse should observe the patient voiding, assess mobility, note any use of assistive devices, and identify any obstacles that interfere with appropriate use of toilets or toilet substitutes such as a bedside commode.

INTERVENTIONS AND CARE STRATEGIES

Evidence demonstrates that hospital nurses lack the knowledge necessary for evidence-based incontinence care (Coffey, McCarthy, McCormack, Wright, & Slater, 2007; Connor & Kooker, 1996; Cassells & Watt, 2003); therefore, adapting this UI protocol for the acute care environment includes staff education. A brief, unit-based in-service followed by patient rounds may be instrumental in identifying patients at risk for UI and those actually experiencing UI. The North American Nursing Diagnosis Association (NANDA), Nursing Interventions Classification (NIC), and Nursing Outcomes Classification (NOC) provide structure for planning and evaluating UI assessment and management (Johnson, Bulechek, McCloskey-Dochterman, Maas, & Moorhead, 2001). However, there is no structured guidance for the assessment and management of transient UI. Nurses are likely to be the first to identify, and perhaps prevent, transient UI; more research is needed to understand the role nurses play in preventing UI (Sampselle, Palmer, Boyington, O’Dell, & Wooldridge, 2004).

Treating Transient and Functional Causes of UI

First, transient causes of UI should be investigated, identified, and treated. Individuals with a history of established UI should have usual voiding routines and continence strategies immediately incorporated into the acute care plan, whenever possible. Nurses play an essential role in the initiation of discharge planning and patient or CG teaching regarding all aspects of UI. Teaching and discharge planning should begin at admission as appropriate, reviewed continually, and revised as necessary.

The environment is vital in managing UI, particularly functional UI. Incontinent older adults are often dependent on adaptive devices (e.g., walker), family CGs, and hospital staff for assistance with voiding, making them “dependently continent.” Call bells should be identified and within easy reach. If limited mobility is anticipated, nursing staff should consider using an elevated toilet or commode seat, male or female urinal, or bedpan. Nurses should obtain referrals to physical and occupational therapy for ambulation aids, gait training, further assessment of activities of daily living associated with continence, and improved muscle strength. Physical and chemical restraints should be avoided, including side rails (see Case Study). Patients should be encouraged and assisted to void before leaving the unit for tests or therapy (Fantl et al., 1996; Jirovec, 2000; Jirovec et al., 1988; Palmer, 1996). Incorporation of an exercise program with support from physical therapists in nursing homes improved UI (Ouslander et al., 2005). In the hospital setting, patients describe worrying about having an “accident” in the therapy gym and request “diapers” for fear of being sent back to the nursing unit if they “wet themselves” or asking the therapists for assistance to use the bathroom during a therapy session (Dowling-Castronovo, 2014). A better understanding of the role of therapists, both occupational and physical, in an acute care continence promotion program is needed.

Toileting programs (e.g., individualized, scheduled toileting programs, including timed voiding; prompted voiding) have varied success rates (Colling, Ouslander, Hadley, Eisch, & Campbell, 1992; Eustice, Roe, & Paterson, 2000; Ostaszkiewicz, Johnston, & Roe, 2004; Rathnayake, 2009c). In contrast to hospitalized older adults, hospital nurses in one study reported preferring toileting programs over containment strategies, but this has not been explored further (Pfisterer, Johnson, Jenetzky, Hauer, & Oster, 2007). Timed voiding has been promoted as a strategy for managing UI in individuals who are not cognitively or physically able to participate in independent toileting (Rathnayake, 2009c). A voiding record is essential for developing an individualized, scheduled toileting or timed voiding program, which mimics the patient’s normal voiding patterns and requires continual assessment and reevaluation for successful outcomes. For example, if the initial scheduled toileting time is set for 8:00 a.m., yet, at 6:30 a.m., the patient consistently attempts to independently void or is noted to be incontinent, then the toileting time should be adjusted to 6:00 a.m. Evidence is lacking regarding the effectiveness of timed voiding as a primary management strategy for UI; however, it may be used based on the nurse’s judgment of the clinical situation (Rathnayake, 2009c).

Prompted voiding requires someone (nurse or the family CG) to ask whether the patient needs to void, offer assistance, and then offer praise for successful voiding (Eustice et al., 2000; Jirovec, 2000; Ostaszkiewicz et al., 2004). In nursing home residents with UI, prompted voiding may achieve short-term improvement in daytime UI and may be effective in reducing UI in cognitively intact older adults (Hodgkinson et al., 2008; Rathnayake, 2009b). Among hospitalized older adults in Japan, a prompted voiding program resulted in patients expressing a need to void, improvement in their ability to successfully void, and a decrease in the use of absorbent products (Iwatsubo et al., 2014).

The role of the family CG, such as spouses and children, needs to be explored in the acute care setting (Dowling-Castronovo, 2014). In the home care setting, evidence suggests that these CGs may provide better consistency with the implementation of healthy bladder behavior skills (HBBS) than paid CGs (Egnatios, Dupree, & Williams, 2010). Moreover, a mutual learning process regarding management of UI (as well as other health problems) occurs when older adults with UI, their family CGs, nurses, and nursing aides interact (Jansen et al., 2013). In both home care and hospital settings, older adults attempt to build connections with nursing staff to meet their bladder needs (Dowling-Castronovo, 2014; Jansen et al., 2013). Therefore, from a practical and patient/family-centered approach, it is reasonable to suggest that both hospital nurses and therapists “coach” (Frampton et al., 2008) patients and their family CGs in the skills needed to manage UI.

Healthy Bladder Behavior Skills

Traditionally, nursing interventions for UI focus on containment strategies by means of receptacles (e.g., bedpan, urinal, commode, urinary catheters) or by various absorbent products (e.g., sanitary napkin, adult brief, incontinent pad; Harmer & Henderson, 1955; Henderson & Nite, 1978; Palese et al., 2007). Various treatments beyond containment strategies include dietary and fluid management (Vaughan et al., 2011), pelvic floor muscle exercises (PFMEs; Kegel, 1956; Qaseem et al., 2014; Vaughan et al., 2011), urge inhibition and bladder training (retraining) strategies, toileting programs (e.g., individualized, scheduled toileting programs/timed voiding; prompted voiding), pharmacological therapy, constipation management (Vaughan et al., 2011), and surgical options (Fantl et al., 1996; B. Hodgkinson et al., 2008; Qaseem et al., 2014). These treatments (excluding pharmacological and surgical options) are viewed as HBBS. Although the recommendation is to offer HBBS to all older adults with UI (Fantl et al., 1996; Teunissen, de Jonge, van Weel, & Lagro-Janseen, 2004), it is unclear how to best incorporate HBBS in the care of hospitalized older adults. Despite the fact that contemporary nursing practice textbooks list and describe HBBS as nursing interventions (Kozier, Erb, Berman, & Snyder, 2004; Newman & Wein, 2009; Taylor, Lillis, & LeMone, 2005), many of these interventions have not been adequately examined in the acute care setting, and nurses do not routinely implement these interventions in the acute care setting (Bayliss, Salter, & Locke, 2003; Schnelle et al., 2003; Watson, Brink, Zimmer, & Mayer, 2003). Underreporting and underassessment are barriers to optimally addressing UI in the hospital setting as reflected in the study by Schultz et al. (1997), which reported that only 0.1% of medical records captured the problem of UI present at the time of hospital admission. Accurate assessment and identification of type of UI are needed before care strategies are initiated.

Prior to instituting HBBS, the nurse needs to assess the motivation of the patient, family CG, and nursing staff because behavior modification is a premise of HBBS (Palmer, 2004). Examples of dietary management strategies include avoiding certain foods and beverages known to be bladder irritants such as caffeine, acidic foods or fluids, and aspartame (e.g., NutraSweet; Gray & Haas, 2000). Some individuals with a BMI greater than 27 may benefit from a weight-loss program. For example, in one study, a weight loss of 5% to 10% significantly decreased UI episodes for some obese women (Subak et al., 2005).

If not contraindicated, the nurse recommends adequate fluid intake, specifically water, and an increased intake of dietary fiber to maintain bowel regularity. It is important to work closely with older adults who fear that unwanted urine loss is a result of increased fluid intake. Education should focus on the adverse consequence of inadequate fluid intake, such as volume depletion or potential for dehydration, and that too little fluid intake may result in concentrated urine, which, in turn, may cause increased bladder contractions and increased feelings of urinary urgency. Finally, to manage and limit nocturia, patients may be advised to limit fluid intake a few hours before bedtime (Doughty, 2000; Fantl et al., 1996); however, this is questionable for older adults who do not have easy access to fluids or have diminished thirst sensation (DuBeau et al., 2010). In the hospital setting, the nurse must note the schedule of diuretics. For example, institutions may automatically schedule every-12-hour diuretic dose times at 10 a.m. and 10 p.m. For some patients, it will be extremely important that nurses navigate organizational processes to reschedule diuretic doses to an alternate time such as 6 a.m. and 6 p.m or even 4 p.m. This simple strategy may decrease nocturia, which, in turn, will likely decrease the risk of falls. Research that examines which UI interventions best modify fall risk is needed (Wolf, Riolo, & Ouslander, 2000).

For community-dwelling, cognitively intact older adults, PFMEs are at least as effective as pharmacological therapies in treating stress and urge UI (Hodgkinson et al., 2008). PFME holds promise for the primary prevention of UI, but requires additional research (Hay-Smith, Herbison, & Mørkved, 2002), particularly in the acute care setting. PFMEs were developed to augment the strength, endurance, and coordination of the pelvic muscles, which play a role in maintaining continence.

Integrating PFMEs into the plan of care requires an assessment of the patient’s baseline understanding of PFMEs to identify knowledge deficits. Ideally, PFMEs are taught during a vaginal or rectal examination when the clinician manually assists the patient to identify the pelvic muscles by instructing the patient to squeeze around the gloved examination finger. This method allows for performance appraisal (Hay-Smith et al., 2002); and together with weekly phone consults and monthly performance appraisal, this method is known to improve UI outcomes for community-dwelling individuals (Tsai & Liu, 2009). Alternately, PFMEs may be verbally taught by instructing the patient to gently squeeze or contract the rectal or vaginal muscles. Either teaching method includes instructions to not squeeze the stomach, buttocks, or thigh muscles (because this only increases intra-abdominal pressure), but to isolate the contraction of the pelvic muscles.

Preferably, each exercise should consist of contracting for 10 seconds and relaxing for 10 seconds. Some patients may need to start with 3 or 5 seconds, and then increase as their muscle becomes stronger. There is no set “exercise dose” (Du Moulin, Hamers, Paulus, Berendsen, & Halfens, 2005); however, it is usual practice to recommend 15 PFMEs three times per day. For community-dwelling women with stress, urge, or mixed UI, PFMEs (at least 24 per day for at least 6 weeks) should be included in first-line conservative management programs (Choi, Palmer, & Park, 2007; Syah, 2010). Patients may notice improvement in 2 to 4 weeks, but not immediately. Nurses should reinforce compliance and other HBBS and initiate a referral for discharge follow-up with a continence specialist for PFME reinforcement via biofeedback, if available (Bradway & Hernly, 1998). In a study of community-dwelling adults, PFME instruction and reinforcement using biofeedback improved both UI outcomes and concurrent depressive symptoms (Tadic et al., 2007); therefore, hospitalized patients may benefit from a referral to a continence nurse or other provider specializing in care of individuals with UI (e.g., urologist, gynecologist, urogynecologist) for follow-up after discharge.

Urge inhibition is based on behavioral theory and is another recommended HBBS for treatment of urge UI (Teunissen et al., 2004), although the mechanism of how urge inhibition works is not well understood (Gray, 2005; Smith, 2000). Urge inhibition includes distraction techniques (e.g., reciting a favorite poem or song), relaxation techniques, and rapid pelvic floor muscle contractions with the goal being to suppress the urge to void until desirable (Smith, 2000).

Bladder training (retraining) is another behavioral technique used to treat urge UI (DuBeau et al., 2010; Teunissen et al., 2004) and OAB, is often used in conjunction with urge-inhibition techniques and functional incontinence training (FIT; DuBeau et al., 2010; Schnelle et al., 2003), and may be more effective if used in combination with PFMEs or anticholinergic drugs (Rathnayake, 2009a). Bladder training requires a baseline voiding record to determine the timing of voids and UI episodes. If urinary frequency is present, the patient is instructed to lengthen the time between voids in an effort to retrain the bladder. When a strong urge to void occurs, the patient is instructed to use urge-inhibition techniques to suppress urinary urgency. For example, if the patient is not in a position to empty the bladder in a socially appropriate manner, the nurse instructs the patient to quickly squeeze and relax pelvic floor muscles several times to suppress the urge to void. This technique is sometimes referred to as “quick flicks” (Gray, 2005). Relaxation and distraction and urge inhibition techniques are also beneficial during bladder training.

In some instances (e.g., for patients experiencing incomplete bladder emptying or overflow UI), patients and staff can use Crede’s maneuvers (i.e., deep suprapubic palpation) to facilitate bladder emptying. The Crede’s maneuver is used with caution and requires manual compression over the suprapubic area during bladder emptying. The Crede’s maneuver should be avoided if vesicoureteral reflux (i.e., abnormal flow of urine from the bladder back up the ureters) or overactive sphincter mechanisms are suspected because it may dangerously elevate pressure within the bladder (Doughty, 2000). Therefore, if the nurse suspects that UI is related to neurologic impairments, a urologic specialist should be consulted before implementing this specific HBBS. In some cases, instructing patients to double void (i.e., after an initial void, instruct patients to stand or reposition for a second void) also facilitates bladder emptying.

Additional Nursing Interventions

Maintaining skin integrity is a goal of nursing care. Decomposition of urinary urea by microorganisms releases ammonia and forms ammonium hydroxide, an alkali. This alkali makes the protective “acid mantle” of the skin vulnerable and jeopardizes skin integrity. If UI episodes persist despite management strategies, perineal skin care interventions should focus on maintaining the integrity of the protective acid mantle of the skin (Ersser, Getliffe, Voegeli, & Regan, 2005; see Chapter 24, “Preventing Pressure Ulcers and Skin Tears”).

Although absorbent products are commonly used for UI containment, there is little evidence available to guide product selection and no evidence of how absorbent products may interact with the acid mantle (Fader, Cottenden, & Getliffe, 2008). Community-dwelling women with light UI reported important characteristics of absorbent pads, including the ability to hold and hide UI and ease of use (Getliffe, Fader, Cottenden, Jamieson, & Green, 2007). In hospitals, nursing staff reported problems with quality and availability of absorbent products (Clayman, Thompson, & Forth, 2005). Pertaining to reusable versus disposable absorbent products, there is no demonstrable risk of cross-infection with reusable absorbent products when appropriate laundering protocols are followed, and there are no clear cost savings with using one over the other. Reusable products have limited acceptability among users (Fader et al., 2008), and use of adult briefs is significantly associated with an increased risk of infection (Zimakoff, Stickler, Pontoppidan, & Larsen, 1996). Although bed pads absorb urine, consumer satisfaction is questionable, and there are no studies on the use of chair pads. In the hospital, patients fear “wetting the bed.” Some gain a sense of control when able to contain and conceal UI with adult diapers; however, in one study, patients described a preference for brand name over the generic absorbent products provided by the hospital (Dowling-Castronovo, 2014). Although limited evidence suggesting that disposable insert pads may be more effective for women with UI than other absorbent products exists (Rathnayake, 2009d), there is no clear evidence to suggest one absorbent product is superior to another, particularly in the acute care setting. Evidence does support pilot testing of absorbent products according to individual circumstances, including patient, family, and institutional preferences, and offering a choice of products to women with UI (Dunn, Kowanko, Paterson, & Pretty, 2002; Fader et al., 2008; Rathnayake, 2009d).

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