Transcript Centers for Medicare and Medicaid Services Urinary

Centers for Medicare and
Medicaid Services
Urinary Incontinence and
Catheters Satellite
Broadcast
October 27, 2004
Causes of Urinary
Incontinence
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Urinary tract conditions
Neurological disorders
Impaired functional status
Environmental barriers
Potentially Reversible Causes
of Urinary Incontinence
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Acute symptomatic urinary tract infection
Atrophic vaginitis
Severe constipation and fecal impaction
Conditions that cause a decrease in mobility
and toileting ability
Caffeine intake
Drug side effects
Urge Incontinence
“Overactive Bladder”
• Involuntary Bladder
Contractions
• Severe Bladder
Hypersensitvity
Signs:
• Urine loss
• Urgency
• Frequency > 8x/24 hrs
Stress Incontinence
Increase in intra-abdominal pressure
Symptoms: Small losses of urine when:
Coughing
Laughing
Exercising
Changing positions
Overflow Incontinence
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Urethral Obstruction
Enlarged prostate
Urethral Stricture
Fecal Impaction
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Neurologic Conditions
Diabetic Neuropathy
Low Spinal Cord Injury
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Medications
Anticholinergics
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Symptoms
Bladder Distention
Reduced Urine Flow
Dribbling
Frequency
Functional Incontinence
Conditions:
Symptoms:
Cognitive
Impairment
Inaccessible toilet
or lack of staff
assistance
Chronic Functional
Disability
Psychological
Impairment
Environmental
Barriers
Nocturnal
enuresis
Combined fecal
and urinary
incontinence
Objectives of the Assessment
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Identify causes and contributing
conditions
Co-morbid conditions and medications
Degree of bother to resident
Resident and family preferences for
treatment
Goals of Assessment
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Determine if the resident is incontinent,
nature of lower urinary tract symptoms, and
type of incontinence
Determine the type of assessment conducted of the
resident’s incontinence status before admission and
any interventions
Determine reversible factors
Determine conditions that may require further
evaluation
Implement a prompted voiding trial
Determine resident’s risk for complications and
preferences for treatment
Reversible Causes of UI
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Delirium
Impaired mobility
Infection
Fecal impaction
Frequent urination
Medications
Key Elements to Include in
Resident’s History
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Duration and characteristics of the
incontinence
Precipitants
Voiding patterns
Previous treatment and/or management
Factors that Increase Resident’s
Risk for UI
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Impaired cognitive function
Impaired mobility
Decreased manual dexterity
Poor upper and lower extremity strength
Visual problems
Neurological conditions
Medications
Factors that Increase
Resident’s Risk for UI
Medications:
 Diuretics
 Narcotics
 Anticholinergics
 Psychotropics (Sedatives, Hypnotics,
Antipsychotics)
 Calcium channel blockers
General Physical Assessment
Neurological conditions
 Mobility
 Cognition
 Manual dexterity
General Physical Assessment
Abdominal:
 Bowel sounds
 Surgical incisions
 Masses
 Suprapubic bladder fullness
General Physical Assessment
Female Perineum:
 Atrophic tissue changes
 Pelvic organ prolapse
 Perineal skin condition
 Color, odor, discharge
 Structural abnormalities
General Physical Assessment
Perineal assessment for men:
 Determine lesions of the shaft/skin
 Inspect scrotum for lesions and size
Additional Testing
Urinalysis - clean catch
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Nursing home residents should not be catheterized to collect
a urine specimen unless it is an urgent situation
Testing to exclude a UTI should only be done if the
incontinence is new or worsening, or other symptoms of UTI
Post-Void Residual (PVR)
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Risk factors: all men, diabetes, neurological disorders,
medications
How to Perform PVR
PVR:
 Conduct within a few minutes of voiding
 Record voided and PVR volume
 Done through sterile in-and-out
catheterization or bladder ultrasound
Behavioral Programs
Required skills for residents:
 Ability to comprehend and follow
education and instructions
 Identify urinary urge sensation
 Learn to inhibit or control urge to void
 Kegel exercises
Bladder Rehabilitation or
Retaining
Resident:
 Should be able to resist or inhibit the urge to
void
 Void according to a timetable
 Independent in activities of daily living
 Experience occasional incontinent episodes
 Aware of need to void
 Usually assessed as having urge incontinence
Lower Urinary Tract
Bladder Muscle Detrusor
Urethra
Pelvic Floor Muscle
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Habit Training/Scheduled Voiding
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Requires scheduled toileting, at regular
intervals, on a planned basis, and
match the resident’s voiding habits
Maintain record of resident’s voiding
patterns
Prompted voiding
Resident:
 Assessed with urge incontinence
 Cognitive impairment
 Dependent on facility staff for
assistance
 Able to say name or reliably pint to one
of two objects
 Requires training, motivation, effort
Risk of Complications for
Indwelling Urinary Catheter
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Bacteriuria
Febrile episodes
Bladder stones
Epididymitis
Chronic renal inflammation
Pyelonephritis
Assessment to Determine if
Indwelling Catheter is Medically
Justified
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Used for short-term decompression of
acute urinary retention
If used beyond 14 days, restrict to•
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Urinary retention not managed by other means
Presence of multiple pressure ulcers for which healing is
compromised by urinary incontinence
Pain or impairment is compromised
Assessment to Determine if
Indwelling Catheter is Medically
Justified
If indwelling urinary catheter is not
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Remove catheter
Complete a voiding trial
Determine best bladder management program
for resident
Risk Factors for Urinary Tract
Infections
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Fecal incontinence
Urinary retention
Diabetes
Structural abnormalities of the lower
urinary tract
Atrophic vaginitis in women
Asymptomatic Bacteriuria
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Common in geriatric population
Should not be treated
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Unnecessary risks of antibiotic therapy
Excess costs
Potential to develop multi-drug resistant
bacteria
Symptomatic Urinary Tract
Infections (UTIs)
Residents without an indwelling urinary
catheter include at least three of the following:
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Fever of at least 2.4 degrees Fahrenheit above the
resident’s baseline temperature
New or increased incontinence, burning or pain on
urination, frequency or urgency
New flank pain or tenderness
Change in character of urine such as blood, new
pyuria or hematuria
Worsening of mental or functional status
Symptomatic Urinary Tract
Infections (UTIs)
Residents with an indwelling urinary
Catheter include at least two of the
following :
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Fever of at least 2.4 degrees Fahrenheit
above the resident’s baseline temperature
New flank pain or tenderness
Change in character of urine such as blood,
new pyuria or hematuria
Worsening of mental or functional status
Assessment for Absorbent
Products
Assess resident’s;
 Functional ability to ambulate, toilet, disrobe,
use of assistive devices
 Ease in self-toileting
Assess product for:
 Contain urinary leakage
 Comfort
 Ease of application/removal
Bladder Rehabilitation/Retraining
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Goal is to achieve a normal voiding
pattern, or
Achieve the longest possible interval
Resident should be able to hold urine
until reaching the toilet
Prompted Voiding
Three components:
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regular monitoring with encouragement
prompting the resident to toilet on a scheduled
basis
praise and positive feedback when the resident
is continent and attempts to toilet.
Prompted Voiding (PV)
Predictors of responsiveness to PV
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Resident’s response to a therapeutic trial of
PV
Normal bladder capacity (>200 and <700cc)
Recognizes need to void
Baseline incontinence < 4 times/12hours
Maximum voided volume > 150 cc
Post void residual < 100 cc
Able to void successfully when given
toileting assistance
Evidence from properly designed and implemented controlled
trials by University of Iowa Gerontology Nursing Intervention
Research Center
Habit Training/Scheduled Voiding
Goal is to prevent incontinence from
Occurring:
Provide access to the toilet based on the
resident’s voiding pattern
Key Considerations for Medication Therapy
for Urge Incontinence and Overactive
Bladder
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Identify residents with symptoms
known to be responsive to medication
therapy
Ongoing incontinence despite treatment
of reversible causes
Risk for anticholinergic side effects
Costs
Anticholinergic Medications
Side Effects:
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Dry mouth
Constipation
Development or exacerbation of
gastroesophageal reflux
Urinary retention
Impaired cognitive function
Delirium
Determination of Urinary Tract
Infection
Review several test results in combination with
clinical findings:
 Microscopic urinalysis showing the presence
of pyuria; or
 Positive urine dipstick test for leukocyte
esterase (indicating significant pyuria) or
 Nitrites (indicating the presence of
Enterobacteriaceae)
Determination of Urinary Tract
Infection
Nonspecific symptoms, look for:
 Hematuria,
 Fever or
 Evidence of pyuria
Urinary Tract Infection Prevention
Strategies
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Infection control policies and
procedures
Identification of high risk residents
Perineal hygiene, especially for women
with fecal incontinence
Hydration
Treatment of atrophic vaginitis
Complications of Indwelling
Catheters
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Urinary Tract Infections
Encrustations
Leakage around catheter
Inadvertent removal of catheter
Catheter Related Urinary Tract
Infections
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Risk
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Most common complication seen with longterm use of indwelling catheters
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method and duration of catheterization
quality of catheter care
host susceptibility
MRSA
E-coli most common organism
Urosepsis –results from frequent and
repeated UTIs
Encrustations
Risk factors:
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alkaline urine
poor mobility
decreased fluid intake
Leakage Around Catheter
Contributing factors:
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Detrusor (bladder) overactivity
Infection
Urethral/catheter obstruction
Catheter or balloon size too large
Constipation or fecal impaction
Other Care Practices to Reduce
Complications
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Educating the resident or responsible party
on the risks and benefits of catheter use;
Recognizing and assessing for symptoms of
complications;
Attempts to remove the catheter;
Monitoring for post void residual; and
Keeping the catheter anchored to prevent
urethral tensions
Skin Problems Related to Urinary
Incontinence
Early:
 Irritant dermatitis
 Inflammation
 Caused by prolonged
contact with moisture
Advanced:
 Blistering
 Erosion
 Exudate
Decline or Lack of Improvement
in Continence
Practices that prevent or minimize a
decline or lack of improvement:
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Assessment and documentation of the resident’s
baseline continence status
Interventions to improve functional abilities
Environmental modifications
Treatment of the underlying cause
Adjustment of medications
Fluid management program
Websites
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Qualidigm Medicare Information
http://www.ctmedicare.org/qip_med_nursing_res.shtml
AHRQ National Guideline Clearinghouse
http://www.guideline.gov/
National Institute of Diabetes and Digestive and
Kidney Diseases (NIDDK)
http://kidney.niddk.nih.gov/kudiseases/topics/incontinence.asp
Society of Urologic Nurses and Associates
http://www.suna.org/
National Association for Continence
http://www.nafc.org/
The Simon Foundation for Continence
http://www.simonfoundation.org/html/