Transcript Slide 1

Transitioning to Adult-Gerontology
APRN Education: Slide Library
Assessment and Management of Urinary
Incontinence in Older Adults
Authors: Christine Bradway, PhD, RN, GNP-BC,
University of Pennsylvania School of Nursing
Anne Marie Dowling-Castronovo, RN, MA-GNP, Wagner
College, NY
Adult-Gerontology APRN Slide Library
• The APRN Slide Library is a resource of
“Transitioning to Adult-Gerontology APRN
Education” a project of AACN and the Hartford
Institute for Geriatric Nursing 2010-2012
• The project is funded by the John A. Hartford
Foundation
Adult-Gerontology APRN Slide Library
"All materials are jointly copyrighted by the American
Association of Colleges of Nursing (AACN) and The Hartford
Institute for Geriatric Nursing, College of Nursing, New York
University or are used with permission from the original source.
Permission is hereby granted to reproduce, post, download,
and/or distribute, this material for not-for-profit educational
purposes only, provided that the American Association of
Colleges of Nursing (AACN) and The Hartford Institute for
Geriatric Nursing, College of Nursing, New York University are
cited as the source. They may not be used for ANY commercial
or other purpose."
Available at www.hartfordign.org
E-mail notification of usage to: [email protected]
Further information about the APRN program can be found at
www.aacn.nche.edu/APRN Gerontology.htm
Purpose of the APRN Slide Library -UI
• To provide APRNs an overview of urinary
incontinence (UI) in older adults*
• To introduce APRNs to print & web resources on
assessment, diagnosis & management of UI
• To provide APRN faculty with slides on UI to use in
lectures & to share with APRN students
* These slides have been modified from the those prepared for the Geriatric
Education Nursing Consortium (GNEC) program (www.aacn.nche.edu)
UI Resources
Resources to improve caregiver skill and knowledge
Wound Ostomy Continence Nurses
Society National Office
15000 Commerce Parkway, Suite C,
Mt. Laurel, NJ 08054
888-224-WOCN (9626)
http://www.wocn.org
An international society providing a
source of networking and research
for nurse’s specializing in
enterostomal and continence care
National Association for Continence
(NAFC) P.O. Box 1010 Charleston,
S.C. 29402-1019 (800) BLADDER
http://www.nafc.org/
A not-for-profit profit organization
dedicated to improving the lives of
individuals with incontinence
UI Resources
Resources to improve caregiver skill and knowledge
The Hartford Institute for Geriatric
Nursing http://www.hartfordign.org/
http://www.ConsultGeriRN.org/
Society of Urologic Nurse and Associated
(SUNA), National Headquarters, East
Holly Ave Box 56 Pitman, NY 080710056 ; (888) TAP-SUNA
http://www.suna.org/
These web sites will bring the reader to
the “Try This” series that includes a 2- An international organization dedicated to
page UI information sheet to share
nursing care of individuals with urologic
with nursing students and nursing staff disorders.
at affiliated clinical sites.
Source Books Specific to UI
Wein A, Newman D. (2009) Managing and
Treating Urinary Incontinence, 2nd Edition,
Health Professions Press
Newman D. Dzurnik MK (1999) The Urinary
Incontinence Source Book. Lowell Press
Source Books: Geriatrics
Auerhahn, C., Capezuti, E., Flaherty, E., & Resnick, B. (eds.) (2007). Geriatric Nursing
Review Syllabus: A Core Curriculum in Advanced Practice Geriatric Nursing, 2nd
Edition: New York: American Geriatrics Society. (3rd Edition, May, 2011)
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A concise & comprehensive text developed by the American Geriatrics Society (AGS) & the
NYU Hartford Institute for Geriatric Nursing , adapted for APRNs from the AGS Geriatrics
Review Syllabus: A Core Curriculum in Geriatric Medicine, 6th Edition
Authored by > 100 interdisciplinary experts in care of older adults
59 chapters on prevailing management strategies, extensive reference, appendix with
assessment instruments, 100 case-oriented, multiple choice questions and a self-assessment
tool. (www.americangeriatrics.org/.../the_geriatric_nursing_review_syllabus_2nd_edition/
Auerhahn, C. & Kennedy-Malone, L. (2010). Integrating Gerontological Content into
Advanced Practice Nursing Education. New York: Springer Publishing Co.
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Clear, user-friendly guidelines for integrating gerontological content into non-gerontological
APRN programs
Detailed lists of print resources and e-Learning materials
Utilizes a competency-based framework
“Success stories” written by APRN faculty who have integrated gerontological content into
non-gerontological courses
Assessing, Diagnosing, and Managing Older
Adults with UI: Guiding Principles for APRNs
Traditionally, health care practitioners view UI as a normal
consequence of aging and recommend containment
strategies
 UI is not a normal consequence of aging
 APRNs should work-up all complaints of UI as an abnormal
finding
 APRNs should be familiar with types of UI and appropriate
diagnostic & management strategies (e.g. pelvic floor muscle
exercises [PFME] or prompted voiding)
Incidence & Prevalence of UI
Dementia 11-90%
Community Dwelling
8-38%
Homebound
15-33%
Hospitalized
10.5%
Post-Hip Surgery
19-32%
Admission
36%
Additional: Hospitalized 13-42%
 Incidence and prevalence
rates of UI should be
viewed cautiously due to
inconsistencies with
definitions and
measurement limitations
as well as underreporting
and underassessment of
UI
Risk Factors for Developing UI
Modifiable Individual
risk factors
Risk Factors
Low fluid intake
that contributes to
bladder irritability
Dementia
Fecal impaction
Age
Medical conditions
and comorbidities
Depression
Obesity
Risk Factors for Developing UI
Risk Factors
Caffeine intake due to its
diuretic and irritable
effects on the bladder
muscle
Arthritis and back
problems
Hearing or Visual
impairment
Type 2
Diabetes
Mellitus (DM)
Parkinson’s
disease
Stroke
Delirium
Chronic
obstructive or
inflammatory
pulmonary
conditions
Heart failure
Risk Factors for Developing UI
Risk Factors
Medications that contribute to UI
Calcium channel blockers
Anticholinergic drugs
Angiotension converting
enzyme inhibitors
Sedatives
Examples exacerbating UI:
Diuretics
Alpha-adrenergic drugs
Narcotics
Psychoactive drugs
Additional Risk Factors
Smoking
Childhood
nocturnal
enuresis
Environmental barriers
Pregnancy
Episiotomy
Pelvic muscle
weakness
High-impact physical activities
Vaginal delivery
Hysterectomy
Estrogen depletion
Prostate surgery
Risk Factors for Women Developing UI
Race as Risk Factor
Females
European American women have higher rates of moderate and
severe UI when compared with African-American women
Similar rates of stress UI for Hispanic, white, and Asian women
Increased rates of detrusor (bladder) overactivity; urgency with or without UI;
stress UI for African-American women
Impact of UI on Older Adults Quality
of Life


Consequences of UI may affect individuals
 Physically
 Psychosocially
 Economically
UI associated with
 Depression
 Poor self-rated health
 Poor health related quality of life (HRQoL)
Impact of UI on Older Adults Quality
of Life


Urge UI is associated with:
 Falls and fractures
 Skin irritation and infections
 Urinary tract infections (UTIs)
 Pressure ulcers
 Limitations of functional status
Family caregivers may suffer as well
Definitions of UI (Expert Consensus
Opinion)
UI most often defined as the
involuntary loss of urine
sufficient to be a problem or a
bother
 Two Types of UI
 Transient (acute)
 Established (chronic) UI
Case Study
Hospitalized older
adults are at risk of
developing transient
UI, and with shorter
hospital stays, are also
at risk of being
discharged without
resolution of the UI
Transient UI
Characterized by the sudden onset of potentially
reversible symptoms

Usually has a duration of less than 6 months

Is most always preventable or reversible once underlying causes
of UI are identified and treated.
Common causes of Transient UI include:
 Delirium
 Infections (untreated UTI; urethritis)
 Medications
 Depression
 Excessive fluid intake in someone with restricted mobility
 stool impaction or constipation

Established UI


Established UI: sudden or
gradual onset
Healthcare providers or family
caregivers may discover
established UI during the course
of an acute illness,
hospitalization, or abrupt change
in environment or daily routine
Types of established UI





Stress
Urge
Mixed (defined as a
combination of
stress and urge UI)
Overflow
Functional UI
Stress 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 activity or with increased intra-abdominal
pressure (e.g., coughing, sneezing)
Women
more common
Men
May experience after
prostatectomy
Urge UI
 Urge UI is characterized by an involuntary urine loss
associated with a preceding strong desire to void
(urgency)
 Signs and symptoms of urge UI most often include
urinary frequency, nocturia and enuresis, and UI of
moderate to large amounts
Urge UI
 An individual with an overactive bladder (OAB) may
complain of urgency, with or without UI
 Individuals with an OAB also may complain of
frequency and nocturia
Overflow UI


Overflow UI is an involuntary loss of urine associated with over
distention of the bladder, and may be caused by an under active
detrusor muscle or bladder outlet obstruction leading to over
distention and urine overflow
Individuals with overflow UI often describe





urine dribbling
feel unable to empty the bladder
completely (urinary retention)
urinary hesitancy
urine loss without a recognizable urge
an uncomfortable sensation of fullness or pressure in the lower abdomen
Functional UI
 Functional UI is caused by non-genitourinary factors,
such as cognitive or physical impairments that result in
an inability for the individual to be independent in
voiding
 A cognitively impaired individual may fail to recognize
environmental cues or reminders to call for assistance
with toileting. This makes the voiding process overly
complex resulting in a functional type of UI.
Initial History of UI



Urine control is influenced by a myriad of anatomical,
physiological, psychological, and cultural factors
Complexity of UI requires cognitive, affective, functional,
physical, environmental, and motivational assessments
Despite advances in evaluation and management, UI continues
to be a “Don’t ask, don’t tell” health problem
Anatomy and Physiology of Micturition
 Continence occurs when urethral pressure is equal to or greater
than bladder pressure
 Angulation of the urethra and pelvic muscle support play a role
 Continence requires
 intact lower urinary tract function
 cognitive ability to recognize voiding signals
 functional ability to use a toilet or commode in a timely
manner
 motivation to maintain continence
Anatomy and Physiology of Micturition
 Micturition (urination) involves both
voluntary and involuntary control of
the bladder, urethra, detrusor
muscle, and urethral sphincter
 Voluntarily inhibited
 Urinary incontinence occurs as the
result of a disruption at any point
during this process
 UI is never a normal consequence
of aging
Micturition
When bladder volume reaches
about 400 milliliters, stretch
receptors of the bladder wall
relay a message to the brain,
which returns an impulse
message for voiding back to the
bladder.
In response, the detrusor
muscle contracts and the
urethral sphincter relaxes to
allow micturation.
Initial History for UI
 First step in assessment : ask if the problem
exists


Elicit data in the health history
Expect that many intake assessment forms used in the
acute or long-term care setting ask questions about
standard medical problems (e.g. heart failure or DM )
and fail to appropriately assess a history of UI
Initial History for UI

Ask screening questions such as


“Have you ever leaked urine? If yes, how much does it bother you?”
Further questioning addresses the duration and characteristics of
the urine leakage.
Female Patient
The Urinary Distress
Inventory-6 (UDI-6) is a selfreport symptom inventory
for UI that is reliable and
valid for identifying the type
of established UI in
community dwelling females
Male Patient
The Male Urinary Distress
Inventory (MUDI) is a valid
and reliable measure of
urinary symptoms in the
male population
Table 2. Urogenital Distress Inventory Short Form
(UDI-6)
Questions to ask on history taking and review of systems about UI
Do you experience, and, if so, how much are you bothered by:
This may indicate: Irritative/Overactive
Frequent urination
Bladder
Leakage related to feeling of urgency
This may indicate: UI/Irritative
Leakage related to activity, coughing,
or sneezing
This may indicate:UI/Stress
Small amount of leakage (drops)
This may indicate: UI/Stress
Difficulty emptying bladder
This may indicate
Obstructive/Discomfort: Obstructive
Micturation
Pain or discomfort in lower abdominal
or genital area
This may indicate:
Obstructive/Discomfort
Initial History: UI Risk factors





Depression
Dementia
Malnourishment
Dependent ambulation
Medications
Initial History for UI
 Differentiate between transient and established UI
because transient UI may convert to persistent UI
 The seven-day bladder diary or record is the most
evaluated and recommended tool to quantify UI and
identify activities associated with unwanted urine loss
 A three-day bladder diary may be more feasible in the
clinical setting
The Bladder Diary
 Resource:
kidney.niddk.nih.gov/kudiseases/pubs/diary/
 The bladder diary can help identify potential
bladder irritants (e.g., acidic foods or fluids, aka
acid-ash) that contribute to UI
The Bladder Diary

Bladder Diary: Essential for assessing UI and developing an
individualized scheduled toileting program, which mimics the
patient’s normal voiding patterns
 Continual assessment and evaluation improves success
Example
If the initial scheduled toileting time is set for 7 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 A.M.
Prompted voiding requires the caregiver to ask if the patient needs to void,
offer assistance, and then offer praise for successful voiding
Physical Exam for UI
 Observe the patient during urination to
determine ability to remove undergarments, sit
on toilet etc
 Abdominal exam:
 Determine the presence of bladder distention
 Determine presence of stool impaction in left
quadrant
Physical Exam for UI
 Inspect male and female
genitalia
 Note perineal irritation or longstanding pigmentation change,
often indicative urinary
leakage
Physical Exam for UI
Female Patient
Valsalva maneuver (if not medically contraindicated) to detect pelvic
prolapse (e.g., cystocele, rectocele, uterine prolapse) or urine leakage
(suggestive of stress UI), as a result of increased intra-abdominal pressure
with bearing down
Ask the patient to cough while observing for urinary leakage, especially
important when performing a “Valsalva” maneuver is contraindicated
During the genitalia examination, instruct the patient to cough while
assessing for urine leakage that may be attributed to Stress UI
Physical Exam for UI
 Look for signs of atrophic vaginitis post-menopausal
women
 Perineal inflammation
 Tenderness and, on occasion, trauma as a result of
touch)
 Thin, pale genitalia tissues that are often friable and
prone to bleeding
 Perform digital rectal exam to identify constipation or
fecal impaction
Women
Physical Exam for UI
 Assess for “anal wink,” (contraction of the external
anal sphincter) by lightly stroking the circumanal skin
 Indicative of intact sacral nerve routes
 Absence of the “anal wink” may suggest sphincter
denervation
Physical Exam for UI
 In men, palpate the prostate gland
 Typically an enlarged prostate is readily detected
and correlates with symptoms of urinary
urgency, incomplete bladder emptying,
decreased urinary stream or nocturia
Men
Lab Tests For UI
 Urinalysis and/ urine culture and sensitivity
 Post void residual urine or simple bedside
urodynamics
– The International Continence Society (ICS)
does not recommend urodynamic testing in
the initial assessment and management of UI
Treatment vs Referral
Initiate referral if any of the following apply:
Need for additional testing
Abnormal U/A or culture
Palpable abdominal or pelvic mass
Elevated PVR
Abnormal prostate exam
Vaginal bleeding; obstruction; new underlying
disorder; surgical candidate
Management of UI: Pelvic Floor Muscle
Exercizes (PFMEs) for Stress UI


Stress UI management includes PFMEs, more commonly known
as Kegel exercises
PFMEs facilitate continence by increasing strength, endurance,
and contractibility of the pelvic muscles, which support the
bladder neck, contribute to optimal anatomical positioning of
the urethra, and facilitate neuromuscular control necessary for
continence
Women
Teach PFMEs during the pelvic
examination
Instruct the patient to squeeze
(contract) her vaginal muscles
around the examiner’s gloved hand
Men
During the rectal
examination, male patients
are instructed to squeeze
the rectal muscles
PFMEs
 Patient should be instructed to
avoid contracting abdominal,
buttocks, or thigh muscles so as
to not increase intra-abdominal
pressure.
 While there are variations on the
number of PFME per day required,
it is usual practice to recommend
15 PFMEs three times per day
Ideally, each PFME should
consist of a contraction
lasting for 10 seconds,
followed by a relaxation
period of 10 seconds
PFMEs
 Accurate performance of PFMEs requires some degree
of performance appraisal, which may be performed with
digital examination, biofeedback, or vaginal
cones/weights, to verify that the incontinent individual
is correctly isolating and contracting the pelvic floor
muscles
 Urine stream interruption test (UST) is a simple
measure of pelvic floor muscle strength and provides a
numerical value to supplement data collection
PFMEs
 Patients may need several weeks to note improvement
in bladder control
 Once patients are confident with performing PFMEs
they may benefit from “The Knack”
Women
UST should be under two
seconds in women reporting
significantly fewer UI
episodes
Men
UST is currently being tested
in a male sample
PFMEs
 In addition to building muscle strength, PFMEs
may cause neuromuscular changes that
promote a decrease in the autocontractility of
the bladder, thereby inhibiting the urge to
urinate
 There is evidence that PFMEs decrease
incontinent episodes related to urge UI
Other Management of Stress UI

Other management strategies for stress UI beyond the
scope of this module include:
 Pelvic support devices
 Surgical procedures
Management of UI: Urge Inhibition


Urge inhibition is based on behavioral theory and
is another recommended HBBS for treatment of
urge UI although the mechanism of how urge
inhibition works is not well understood
Urge inhibition includes
 distraction techniques
 relaxation techniques
 pelvic muscle contractions
Management of UI: Bladder Retraining



Bladder training (re-training) is another behavioral technique
used to treat urge UI and OAB. It requires a baseline bladder
diary 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, and if the patient is not in
a position to empty the bladder in a socially appropriate
manner, instruct the patient to quickly squeeze and relax
pelvic floor muscles several times to suppress the urge to
void
Management for UI: Medications


Anticholinergic
(antimuscarinic),
antispasmodic medications are
commonly prescribed for urge
UI and OAB because they
reduce detrusor overactivity
and spasm, and in turn,
decrease urinary urgency,
frequency, and urge UI
If prescribed, the nurse should
assess the patient for common
side effects
Available Medications
oxybutynin (Ditropan®), tolterodine
(Detrol®), darifenacin (Enablex®),
trospium chloride (Sanctura ®),
solifenacin succinate (Vesicare ®)
Long-acting formulations, transdermal
patch preparations, and lower dose
preparations are available
APRN Rx of Medications & Other
Treatments
Anticholinergic, antispasmodic for urge UI
 Be aware of side effects
 Follow principles of prescribing for older
adults, “start low and go slow”
 Alpha-agonist for Stress UI
 not FDA approved
 Referral for surgery: stress UI, pelvic organ
prolapse, BPH
Devices (e.g., pessary)
Environmental Management of UI
 Environment plays a vital role in managing functional UI
 Incontinent individuals are often dependent on adaptive
devices (e.g., walker) or caregivers for assistance with
voiding
 Many may also suffer from cognitive impairment, a
significant comorbidity which causes forgetfulness to recall
voiding times or loss of awareness of the need to void
Management: Overflow UI


Strategies specific to manage overflow UI include PFMEs if it is
determined that bladder outlet obstruction is due to persistent
contraction of the pelvic floor muscles
Interventions to manage overflow UI:
 Crede’s maneuver
 Timed voiding
 Double voiding
 Intermittent urinary catheterization
Management: Overflow UI
 Crede’s maneuver: Cautiously used and requires
manual compression over the suprapubic area during
bladder emptying

Avoid: If vesicoureteral reflux or overactive sphincter
mechanisms are suspected as the Crede’s maneuver would
dangerously elevate pressure within the bladder
 Double Void: Repositioning to void again directly after
the initial void

For a patient with overflow UI the APRN should evaluate if
medications may be causing urinary retention
Management of UI: Containment Products
 UI management presented here avoided a detailed
discussion of containment products
 This was intentional as this module focuses on evidencebased management strategies beyond traditional
containment
 Note: If absorbent products are used, studies emphasize
individualization in choosing absorbent products
Priority Setting: Avoiding UI
Complications
 Goal of incontinence management may not be to have
the patient be totally dry but to decrease the number of
UI episodes
 Realistic goal for UI evaluation and management
includes interdisciplinary collaboration and the
inclusion of the patient, and in many instances, the
caregiver or significant other
 In the acute care setting, new onset of UI needs to be
closely assessed and appropriately managed
Priority Setting: Avoiding UI
Complications in the Hospital

Appropriate assessment and management of UI is often
overlooked in the hospital setting due to patients’ acuity level or
short length of stay
 UI is often managed with the use of temporary indwelling
urinary catheterization
 Justification for this intervention revolves around the
patient’s inability to access toilet facilities independently,
including use of a bedpan or urinal due to voicelessness
from intubation or other mechanical, life-sustaining devices
Priority Setting: Avoiding UI
Complications in LTC

Admission to a skilled nursing
setting (e.g., an assisted living
or a nursing home) should
trigger an accurate assessment
of UI including:
 Review of medical records
 Speaking to the hospital
discharge primary nurse
or physician
Prochoda
Detailed presentation of how long-term
care processes - Resident Assessment
Instruments, the Minimum Data Set, and
resident care plans – are utilized in the
provision of quality incontinence
assessment and management, which are
now a focus of state surveyors in response
to Tags F315 and F316.
AHRQ UI Clinical Practice Guideline

1988: National Institute for Health (NIH) led a multidisciplinary
Consensus Panel to examine the state of knowledge regarding
adult UI
 Examined available research in a directed effort to answer
specific trigger questions
 Agenda for future research and practice
1988 NIH

AHRQ’s UI clinical practice guidelines
2008: NIH State of Science: Prevention of fecal and urinary
incontinence
AHRQ UI Clinical Practice Guidelines
 Few outcome studies have evaluated the AHRQ UI
guidelines
 Most studies have examined UI evaluation and
management in the LTC setting
 Most studies show that AHRQ guideline use in LTC
have not produced positive outcomes in bladder health
AHRQ UI Clinical Practice Guidelines
Studies show that containment products are the primary
strategy employed in LTC settings to manage UI

LTC
LTC setting incontinent residents not adequately assessed for UI
 only 2% of women having a pelvic examinations
 less than 15% receiving a rectal examination
 less than 1% being assessed for characteristics of
established UI - stress, urge, mixed, overflow, functional
LTC

Research on UI
 Research in UI in the acute care setting has
predominantly focused on incidence, prevalence, and
risk factors of UI
 Most research in UI has been conducted in long-term
and community care settings
UI Outcome Indicators

Research regarding UI outcome indicators has used the “If…then…”
approach
Example
IF an individual has involuntary urine loss THEN a focused history is performed and
documented
Nurses will find that North American Nursing Diagnosis Association (NANDA), Nursing
Interventions Classifications (NIC), and Nursing Outcomes Classification (NOC) provide
structure for planning and evaluating UI assessment and management
UI Outcome Indicators in the Community Setting

In the community setting, performance quality indicators for
continence management include:
 evidence of screening all older adults for UI at initial health
encounters and then yearly
 evidence of performing a focused health history, including
characteristics of voiding, ability to toilet self, any previous
treatment for UI, degree of bother, and mental status
assessment
UI Outcome Indicators in the Community Setting

In the community setting, performance quality
indicators for continence management include
(continued):
 evidence of a urinalysis and post-void residual
 evidence that HBBS, as well as pharmacological and
surgical options were appropriately reviewed with the
incontinent individual
 Bladder diaries continue to be the predominant clinical
outcome indicator measure to determine if continence
management interventions are effective.
UI Outcome Indicators in LTC

In the LTC setting, state surveyors audit for evidence of:
 an assessment for UI
 the presence and implementation of a continence
management plan
 the appropriate use of indwelling urinary catheters in
response to the F315 Tag.
Patient Education: AHRQ UI Clinical Practice Guidelines
 Majority of patients delay seeking health care for UI because of
inadequate knowledge, embarrassment, feelings that symptoms were
“normal” or advice-seeking from non-health care providers
40.0
28.0
Learned UI
from
8.0
general
practitioners
hospital
services
nurse
United Kingdom
Continence policies and research
add an important contribution in
understanding what is known
about translating continence
guidelines into practice
UI Health Promotion and Risk Reduction
 Continence experts recommend
prevention of UI in adults using
population-based strategies
Case Study
little evidence
pertaining to the
benefits of primary
prevention of UI for
older women, and for
preventing childbirth
related UI
Patient Education: Healthy Bladder Behavior
Skills (HBBS)
 Regardless of the type of established UI, be aware
of and teach HBBS to patients, family & staff
 Prior to instituting HBBS, assess the motivation of
the patient, informal caregiver, and/or nursing staff,
since behavior management is a premise of HBBS
Patient Education: Fluid Intake
 Work closely with older adults who fear that unwanted
urine loss results from increased fluid intake
 Focus education on the adverse consequence of
inadequate fluid intake such as volume depletion, or
potential for dehydration.
 Emphasize that too little fluid intake causes urine to
become concentrated which in turn, leads to increased
bladder contractions and feelings of urinary urgency
 To manage and limit nocturia, advise to limit fluid
intake a few hours before bedtime
Patient Education: Medications
 Examine and discuss medications contributing
to UI with the prescribing health care provider
 Determine the necessity of the medication or
ideal scheduling to promote continence
Staff Education: Appropriate Use of Indwelling Urinary Catheters
 Indwelling urinary catheters, typically used for
diagnostic reasons or, often inappropriately, for
containment of UI, are not recommended for
treatment of UI
European study
Dowd and Campbell (’95)
141 hospitals demonstrated that
catheter-associated UTI was
present in over 60 percent of
nosiocomial UTI cases
UTI incidence of 10 percent
associated with indwelling
catheter use resulting in an
increased length of hospital stay
and decreased opportunities for
nursing staff to identify
continence as a problem


Staff Education: Appropriate Use of Indwelling Urinary
Catheters
Appropriate indications for indwelling urinary catheter use
include:
 Severe acute illness
 Urinary retention uncontrollable by other interventions
(including medication management and sterile intermittent
catheterization)
 UI management for patients with Stage III-IV pressure
ulcers of the trunk
Sterile intermittent catheterization may result in a lower
incidence of infection and may be a viable alternative to
placement of an indwelling urinary catheter
Staff Education: Appropriate Use of Indwelling
Urinary Catheters


When an indwelling urinary catheter is indicated it is
recommended that the smallest lumen size catheter is
used
 Sterile water is used to inflate the catheter balloon with
balloon volume assessment every two weeks or as
clinically indicated
 Catheter be secured to the patient’s thigh
There is no evidence supporting routine collection of urine
for collection nor for routine timing of catheter changes
Examples of Teaching Pedagogies for Urinary
Incontinence in Older Adults
Teaching Pedagogies for Urinary Incontinence in Older Adults
Content Area: Topic
Recommended Teaching
Pedagogy
List & discuss 5 clinical problems that
can lead to UI in an older adult
Recognition/Screening for UI
Review the medical record of an
older adult with multiple comorbidities and identify potential
medications that can have adverse
side effects of urinary incontinence.
Examples of Teaching Pedagogies for Urinary
Incontinence in Older Adults
Teaching Pedagogies for Urinary Incontinence in Older Adults
Content Area: Topic
Assessment of Older Adults with UI
Recommended Teaching Pedagogy
Describe the components of assessment
of an older adult with new onset of UI.
Critically analyze “why” the older adult
has a new onset of UI. What are
important historical questions and
physical examination techniques to be
performed with a new onset of UI?
Describe the components of assessment
of an older adult with chronic UI.
Examples of Teaching Pedagogies for Urinary
Incontinence in Older Adults
Teaching Pedagogies for Urinary Incontinence in Older Adults
Content Area: Topic
Recommended Teaching Pedagogy
Assessment of Older Adults with UI
Review and respond to a case study
on UI
Management of Older Adults with UI
Review a clinical case whereby a
indwelling urinary catheter is used for
the chronic management of UI. Ask the
student to select a patient from their
caseload and to respond/determine on
a case-by-case basis why a indwelling
urinary catheter is used?
Examples of Teaching Pedagogies for Urinary
Incontinence in Older Adults
Teaching Pedagogies for Urinary Incontinence in Older Adults
Content Area: Topic
Recommended Teaching Pedagogy
How long has it been used?
What were the presenting symptoms
leading to use of the indwelling urinary
catheter if any.
Management of Older Adults with UI
What are the major risks associated with
the use of a indwelling urinary catheter
and what are realistic alternatives to
management other than a indwelling
urinary catheter?
Examples of Teaching Pedagogies for Urinary
Incontinence in Older Adults
Teaching Pedagogies for Urinary Incontinence in Older Adults
Recommended Teaching
Content Area: Topic
Pedagogy
Outline the basic components of a
toileting program. What are some
issues that impact the success of a
Management of Older Adults with
toileting program?
UI