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Continence: A Matter of Dignity

Care of Chronic and Complex UI

By

Marie Mangino, MSN, CRNP, BC

President, Vincent Healthcare, Inc.Consultant, Penn Nursing Consultation

Service

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AcknowledgementsAppearing in Video:

Name Appearing as

Bob Swensen……….Mr. BanksRuth Alpert…………Mrs. BanksSusaye Lawson…… SusayeNate Lazowick…….Mr. WilliamsKevin Brown……… Carl, DCSW Dinnie Childs………Piano PlayerClarese Herbert……Mr. William’s

friendMan at Piano………Arjun BhojwaniNancy Web…………Mrs. PowellEric Stewart……….Mike, grandsonRuth Livikoff………Ruth, DCSW

Name Appearing as

Dick Brown………………Mr. ClarkDeanna Penn…………….SupervisorSangeeta Bhojwani…….TraineeRoby Jacobs……………..Daughter Charlene Duff……………Shopper, Gift ShopSheila Mitchell-Ayers…Shopper, Gift Shop Marie Mangino………….Trainer, as herselfTanisha Jones……………TestimonialJulie Cohlmer…………….Testimonial

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© 2006 University of Pennsylvania Delaware Valley Geriatrics Education © 2006 University of Pennsylvania Delaware Valley Geriatrics Education CenterCenter© 2006 University of Pennsylvania Delaware Valley Geriatrics Education © 2006 University of Pennsylvania Delaware Valley Geriatrics Education CenterCenter

Special thanks to:

• Henrietta Roberts and Sandy Bailey, of Stapeley in Germantown for coordination of video shoot

• All the residents and staff of Stapeley in Germantown, for their participation and for permitting video production.

• Raybourn Rusk Productions

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© 2006 University of Pennsylvania Delaware Valley Geriatrics Education © 2006 University of Pennsylvania Delaware Valley Geriatrics Education CenterCenter© 2006 University of Pennsylvania Delaware Valley Geriatrics Education © 2006 University of Pennsylvania Delaware Valley Geriatrics Education CenterCenter

Review of “Causes, Signs and

Prevention”The first module covered the following objectives as learner outcomes:

List the common causes of Urinary incontinence (UI)

Describe the potentially serious effects of not treating UI

Recognize signs of a UTI Discuss effective ways to prevent

or reduce episodes of UI and enhance dignity

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Learning ObjectivesAt the end of “Care of Chronic and Complex Urinary Incontinence” you will be able to:

List the major types of chronic UI and the common signs and symptoms of each

Explain the importance of preventing constipation in older adults with UI

Discuss creative approaches to more complex cases of older adults with UI

Provide care to prevent or reduce episodes of UI and enhance dignity

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© 2006 University of Pennsylvania Delaware Valley Geriatrics Education © 2006 University of Pennsylvania Delaware Valley Geriatrics Education CenterCenter© 2006 University of Pennsylvania Delaware Valley Geriatrics Education © 2006 University of Pennsylvania Delaware Valley Geriatrics Education CenterCenter

Types of Chronic UI

Stress Urge /Overactive

bladder Overflow Functional Mixed

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Stress UI

Small amount of urine leakage Loss of urine with increased

pressure in the abdomen from: Coughing Sneezing Laughing Lifting Standing

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Stress UI : How You Can Help?

Set toileting schedule based on a log and stick to it

Expect small leaks; use a liner

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Stress UI : How You Can Help?

Change more frequently Use skin barrier

Mrs. Levy

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Urge UI (Overactive Bladder)

Involuntary loss of urine and a strong urge to urinate that occurs suddenlyMay be incontinent on the way

to the bathroom May be incontinent of a large

amount of urine

Mrs. Powell w/walker

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Urge UI (Overactive Bladder):

How You Can Help Encourage person to avoid

bladder irritants Stick to personalized

schedule Watch for signs of need to

toilet Keep urinal or commode

handy Expect heavier wetting with

longer period of dryness

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Mrs. Powell’s Success

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Case of Mrs. Powell

Remind the person to avoid bladder irritants (including sodas, caffeine, alcohol and artificial sweeteners)

Help by establishing a toileting schedule and sticking to it

Watch for signs of need to toilet

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Overflow UI Continuous or periodic leakage of small

amounts of urine Tension in bladder forces muscles to

leak small amounts, either continuously or off and on

Caused by either Blockage at the exit of the bladder (large

prostrate) Bladder, nerve or

muscle damage

Mr. Stanley

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Overflow UI: How You Can Help

Allow time to stand and wait Report complaints of

discomfort Report inability to urinate for

more than 8 hours or urination every hour

Watch for signs of mental status change

Maintain schedule for toileting

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Functional UI

Due to chronic functionalimpairment:

Confusion Physical disabilities Combination

Mr. Clark

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Functional UI: How You Can Help

Set toileting schedule based on the log and stick to it

Encourage clothing that is easy to remove

Assist as needed Praise successes and

effort

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Challenging Situations

Dementia Inappropriate

toileting Denial

Unsafe attempts to toilet

Chronic constipation

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The Challenges of Dementia and UI

Inappropriate toileting

Denial of incontinence

Mr. Clark

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Dementia and UI: How You Can Help

Never judge or disagree, accept the person’s explanation for wet clothing

Focus on Changing and cleaning Dignity and respect

Prompt (remind and encourage) to use the toilet, assist to get there, then prompt again

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Right Time, Right Place

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Case of Mr. Clark

Focus on: Dignity and respect Changing and cleaning

if needed Prompt (remind and

encourage) to use the toilet, assist to get there, then prompt again

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© 2006 University of Pennsylvania Delaware Valley Geriatrics Education © 2006 University of Pennsylvania Delaware Valley Geriatrics Education CenterCenter© 2006 University of Pennsylvania Delaware Valley Geriatrics Education © 2006 University of Pennsylvania Delaware Valley Geriatrics Education CenterCenter

UI and Unsafe Attempts to Toilet

Due to: Difficulty Walking Poor vision Poor safety

judgment

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Unsafe Attempts to Toilet: How You Can

Help Use individualized

toileting schedule; be there ahead of time

Do not rely on call bell Do not wait until the

person tries to get up

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Unsafe Attempts to Toilet: How You Can

Help Use safe footwear Use proper eyeglasses

when walking; assist person wearing bifocals

Provide a bedside commode or urinal to reduce the need to walk alone

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© 2006 University of Pennsylvania Delaware Valley Geriatrics Education © 2006 University of Pennsylvania Delaware Valley Geriatrics Education CenterCenter© 2006 University of Pennsylvania Delaware Valley Geriatrics Education © 2006 University of Pennsylvania Delaware Valley Geriatrics Education CenterCenter

Chronic Constipation and UI

Presence of stool in the pelvis Takes up room in the pelvis

so bladder cannot fill up Causes need to urinate

more often Increases incontinent

episodes

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© 2006 University of Pennsylvania Delaware Valley Geriatrics Education © 2006 University of Pennsylvania Delaware Valley Geriatrics Education CenterCenter© 2006 University of Pennsylvania Delaware Valley Geriatrics Education © 2006 University of Pennsylvania Delaware Valley Geriatrics Education CenterCenter

Chronic Constipation and UI: How You Can

Help Report it Encourage

Fluid intake Activity Foods rich in fiber

Avoid constipating food

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© 2006 University of Pennsylvania Delaware Valley Geriatrics Education © 2006 University of Pennsylvania Delaware Valley Geriatrics Education CenterCenter© 2006 University of Pennsylvania Delaware Valley Geriatrics Education © 2006 University of Pennsylvania Delaware Valley Geriatrics Education CenterCenter

Objectives Review

Can you now1.List the major types of chronic

UI and the common signs and symptoms of each?

2.Explain the importance of preventing constipation in older adults with UI?

3.Discuss creative approaches to more complex cases of UI in older adults?

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© 2006 University of Pennsylvania Delaware Valley Geriatrics Education © 2006 University of Pennsylvania Delaware Valley Geriatrics Education CenterCenter© 2006 University of Pennsylvania Delaware Valley Geriatrics Education © 2006 University of Pennsylvania Delaware Valley Geriatrics Education CenterCenter

Closing

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© 2006 University of Pennsylvania Delaware Valley Geriatrics Education © 2006 University of Pennsylvania Delaware Valley Geriatrics Education CenterCenter© 2006 University of Pennsylvania Delaware Valley Geriatrics Education © 2006 University of Pennsylvania Delaware Valley Geriatrics Education CenterCenter

Special Thanks To:Christine W. Bradway, PhD, CRNP

Assistant Professor of Gerontologic Nursing

University of PennsylvaniaSchool of Nursing

Mary Ann Forciea, MDClinical Associate Professor of Medicine

Director, Primary Care ServicesUniversity of Pennsylvania Health Systems

Nicole ManginoIllustrator

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© 2006 University of Pennsylvania Delaware Valley Geriatrics Education © 2006 University of Pennsylvania Delaware Valley Geriatrics Education CenterCenter© 2006 University of Pennsylvania Delaware Valley Geriatrics Education © 2006 University of Pennsylvania Delaware Valley Geriatrics Education CenterCenter

References and ResourcesBurgio, K. L., Robinson, J. C. & Engel, B. T. (1986). The role of biofeedback in Kegal exercise training for stress urinary incontinence. American Journal of Obstetrics & Gynecology, 154: 58-64. •Choe, J. M. (1999). Freedom regained: Female urinary incontinence can be overcome. Columbus, Ohio: Anadem Publishing; 117-171. •Clinical practice guideline number 2: Urinary incontinence in adults. Rockcville Md: US Department of Health and Human Services Agency for Health Care Policy and Research; 1996. AHCPR publication 96-0682. •Gibbons, L. & Choe, J. M. (2005). Helping women quell urinary incontinence. The Clinical Advisor, 7 (5), 21-28.  

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References and ResourcesLanga, et al, (2002). Informal caregiving time and costs for UI in older individuals in the US. Journal of the American Geriatrics Society, 50,(4): 733-737.Lee SY, Phanumus D. & Fields S.D. (2000). Urinary incontinence: a primary care guide to managing acute and chronic symptoms in older adults. Geriatrics, 55(11): 65-72.  Morkved, S. Bo, K. & Fjortoft, T. (2002). Effect of adding biofeedback to pelvic floor muscle training to treat urodynamic stress incontinence. Obstetrics & Gynecology, 100; 730-739.  Multiple authors (2004). Special issue: Urologic care of the older adult. Urologic Nursing, 24, 247-333.  Teunissen, T.A.M., de Jonge, A., van Weel, C., & Lagro-Janssen, A.L.M. (2004). Treating UI in the elderly—conservative measures that work: A systematic review. Journal of Family Practice, 53 (1), 25.  .  

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References and Resources

Web sites:

Collaborative to Support Urinary Incontinence and Women’s Health www.stressUI.org

National Association for Continence: www.nafc.org

National Institute of Diabetes & Digestive & Kidney Diseases: www.niddk.nig.gov

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© 2006 University of Pennsylvania Delaware Valley Geriatrics Education © 2006 University of Pennsylvania Delaware Valley Geriatrics Education CenterCenter© 2006 University of Pennsylvania Delaware Valley Geriatrics Education © 2006 University of Pennsylvania Delaware Valley Geriatrics Education CenterCenter

Leadership and Staff:

Lois K. Evans, DNSc, RN, FAANSeries Associate Editor Viola MacInnes IndependenceProfessorSchool of Nursing University of Pennsylvania

Sangeeta BhojwaniAssociate Director, Series Assistant EditorDVGECUniversity of Pennsylvania

Laura RaybournSally Rusk, ConsultantsRaybourn Rusk Productions

Kathleen Egan, PhD Series EditorDVGEC Program Administrator Director, DVGEC University of Pennsylvania

Mary Ann Forciea, MDSeries Associate EditorClinical Associate Professor of MedicineDivision of Geriatric Medicine, University of Pennsylvania