Despite evidence supporting urinary incontinence (UI) management strategies (DuBeau et al., 2010; Fantl et al., 1996), nursing staff and laypersons often use containment strategies, such as adult briefs or other absorbent products, to manage UI. In addition, individuals with UI erroneously believe that containing UI is a normal consequence of aging, feel that UI is a difficult-to-discuss personal problem (Bush et al., 2001), and prefer self-help strategies rather than seeking professional advice (Milne, 2000). Personal care strategies are often the result of information gained through lay media and personal contats, not necessarilly from health care professionals. 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.
Nursing Standard of Practice Protocol: Urinary Incontinence (UI) in Older Adults Admitted to Acute Care
Annmarie Dowling-Castronovo, RN, MA-GNP, Christine Bradway, PhD, CRNP
Reprinted with permission from Springer Publishing Company. Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th Edition, © Springer Publishing Company, LLC. The text is available here.
The information in this "In Depth" section is organized according to the following major components of the NURSING PROCESS:
Parameters of Assessment
Nursing Care Strategies
Evaluation of Expected Outcomes
Follow-up Monitoring of Condition
Relevant Practice Guidelines
A. Nursing staff will utilize comprehensive assessments and implement evidence-based management strategies for patients identified with UI.
B. Nursing staff will collaborate with interdisciplinary team members to identify and document type of UI.
C. Patients with UI will not have UI-associated complications.
UI affects approximately 17 million Americans (Ref 1; 2; 3; Landfeld et al., 2008). 1, 2, 3 More than 35% of older adults admitted to the hospital develop UI. 4 In addition to medications, constipation/fecal impaction, low fluid intake, environmental barriers, diabetes mellitus, and stroke (Ref 1;5;6;7; Offermans, Du Moulin, Hamers, Dassen, & Halfens, 2009; Shamliyan, Wyman, Bliss, Kane, & Wilt, 2007), 1, 5, 6, 7 immobility, impaired cognition, malnutrition, and depression are additional factors specific to identifying older adults at risk for UI in the hospital setting.4 Complications of UI include falls, skin irritation leading to pressure ulcers, social isolation, and depression (Ref 1;8;9;10; Morris & Wagg, 2007). 1, 8, 9, 10 Nurses play a key role in the assessment and management of UI.
- UI is the involuntary loss of urine sufficient to be a problem. 1 UI may be transient (acute) or established (chronic). Types of established UI include:
- Stress UI: defined as an involuntary loss of urine associated with activities that increase intra-abdominal pressure. 1, 11, 12.
- Urge UI: characterized by an involuntary urine loss associated with a strong desire to void (urgency). 1, 11 An individual with an overactive bladder (OAB) may complain of urinary urgency, with or without UI. 11
- Mixed UI: usually defined as a combination of Stress UI and Urge UI (Jayasekara, 2009).
- Overflow UI: an involuntary loss of urine associated with over-distention of the bladder and may be caused by an under-active detrusor muscle or outlet obstruction leading to over-distention of the bladder and overflow of urine (Ref 1;11;13; Jayasekara, 2009). 1, 11, 13
- Functional UI: caused by nongenitourinary factors, such as cognitive or physical impairments that result in an inability for the individual to be independent in voiding (Ref1; Hodgkinson et al., 2008). 1
UI affects approximately 17 million Americans (Ref1;2;3; Landefeld et al., 2008). 1, 2, 3 UI studies specific to the hospital setting demonstrate that UI is present in 10% to 42% of older adults (Ref1;4;14;16;17),1, 14, 16, 17 therefore, assessment and implementation of an evidence-based protocol is essential.
Parameters of Assessment
Try This Issue 11.1 - Urinary Incontinence Assessment in Older Adults: Part I - Transient Urinary Incontinence
Try This Issue 11.2 - Urinary Incontinence Assessment in Older Adults: Part II - Persistent Urinary Incontinence
- Document the presence/absence of UI for all patients on admission (DuBeau et al., 2010).
- Document the presence/absence of an indwelling urinary catheter.
- For patients with presence of UI: The nurse collaborates with interdisciplinary team members to:
- Determine whether the UI is transient, established (Stress/Urge/Mixed/Overflow/Functional), or both and document (Ref1;21; DuBeau et al., 2010; Jayasekara, 2009). 1, 21
- Identify and document the possible etiologies of the UI (DuBeau et al., 2010; Ref1). 1
Nursing Care Strategies
- General principles that apply to prevention and management of all forms of UI:
- Identify and treat causes of transient UI (DuBeau et al., 2010).
- Identify and continue successful prehospital management strategies for established UI.
- Develop an individualized plan of care using data obtained from the history and physical examination, and in collaboration with other team members. Implement toileting programs as needed (Ref 43; Rathnayake, 2009c).
- Avoid medications that may contribute to UI (Newman & Wein, 2009).
- Avoid indwelling urinary catheters whenever possible to avoid risk for UTI (Ref 14; 23; 25; Gould et al., 2009). 23, 25
- Monitor fluid intake and maintain an appropriate hydration schedule.
- Limit dietary bladder irritants. 27
- Consider adding weight loss as a long-term goal in discharge planning for those with a body mass index (BMI) greater than 27 28
- Modify the environment to facilitate continence. 1, 29, 30
- Provide patients with usual undergarments in expectation of continence, if possible.
- Prevent skin breakdown by providing immediate cleansing after an incontinent episode and utilizing barrier ointments. 20
- Pilot test absorbent products to best meet patient, staff, and institutional preferences (Ref 44), bearing in mind that diapers have been associated with UTIs. 25
- Strategies for specific problems:
- Teach pelvic floor muscle exercises (PFMEs) (DuBeau et al, 2010; Hodgkinson et al., 2008).
- Provide toileting assistance and bladder training PRN (whenever necessary) (DuBois et al., 2010).
- Consider referral to other team members if pharmacological or surgical therapies are warranted.
Urge UI and OAB:
Implement bladder training (retraining) (Ref 33; DuBeau et al., 2010). 33
- If patient is cognitively intact and is motivated, provide information on urge inhibition. 34, 35
- Teach PFMEs to be used in conjunction with bladder training, and instruct in urge inhibition strategies (Ref 36; Rathnayake, 2009a; Ref 33) . 36
- Collaborate with prescribing team members if pharmacologic therapy is warranted.
- Initiate referrals for those patients who do not respond to the previous steps.
- Allow sufficient time for voiding.
- Discuss with interdisciplinary team the need for determining a post-void residual (PVR) (Ref 37; Newman & Wein, 2009). 37 See Table 18.2 in protocol book.
- Instruct patients in double voiding and Crede’s maneuver (Ref 13).
- If catheterization is necessary, sterile intermittent is preferred over indwelling catheterization PRN. 39, 40, 41
- Initiate referrals to other team members for those patients requiring pharmacological or surgical intervention.
- Provide individualized, scheduled toileting, timed voiding, or prompted voiding (Ref 29; 42; 43; Lee et al., 2009). 29, 42, 43
- Provide adequate fluid intake.
- Refer for physical and occupational therapy PRN.
- Modify environment to maximize independence with continence (Ref 1; 29; 30; Jirovec et al., 1988). 1, 29, 30
Evaluation of Expected Outcomes
- Will have fewer or no episodes of UI or complications associated with UI.
- Will document assessment of continence status at admission and throughout hospital stay. If UI is identified, document and determine type of UI.
- Will use interdisciplinary expertise and interventions to assess and manage UI during hospitalization.
- Will include UI in discharge planning needs and refer PRN.
- Incidence and prevalence of transient UI will decrease.
- Hospital policies will require assessment and documentation of continence status ("Assessing Care," 2007; Fung et al., 2007).
- Will provide access to evidence-based guidelines for evaluation and management of UI.
- Staff will receive administrative support and ongoing education regarding assessment and management of UI.
Follow-up Monitoring of Condition
- Provide patient/caregiver discharge teaching regarding outpatient referral and management.
- Incorporate continuous quality improvement (CQI) criteria into existing program ("Assessing Care," 2007; Fung et al., 2007).
- Identify areas for improvement and enlist multidisciplinary assistance in devising strategies for improvement
Relevant Practice Guideline
National Guideline Clearinghouse Guideline Synthesis. http://www.guideline.gov/syntheses/index.aspx
For Definition of Levels of Quantitative Evidence Click Here
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Last updated - July 2012