Continence Management Flashcards
why is bladder and bowel dysfunction important
Social stigmata - leads to restricted activities and depression
Medical complications - skin breakdown, increased urinary tract infections
Institutionalization - UI is the second leading cause of nursing home placement
Still seen as “dirty” subject
People do not know how to verbalize the problem especially about the bowel
why is urinary incontinence often undiagnosed/untreated and why is this important
Only 32% of primary care physicians routinely ask about “incontinence”
50-75% of patients never describe symptoms to physicians
80% of urinary incontinence can be cured or greatly improved
what is epidemiology re. urinary incontinence
10-25%ofwomenage15-64reporturinary incontinence
15-40% of women over age 60 in the community report incontinence
More than 50% of women in nursing homes are incontinent
W.H.O. recognizes incontinence as an international health concern and a person centered initiative
what are common misconceptions about urinary incontinence
76% women believe leakage is just a normal part of ageing
2/5ths of women believe that leakage is caused by drinking too much water some attribute it to too much sex
Majority of 66% of people have never discussed it with their doctor
68% of all women have lived with UI over 3 years
why do women not seek help for UI
Not a socially or hygienic problem to them
Coping mechanisms, expected at a certain age
We promote incontinence and not bladder health
Studies demonstrate women wait 5 yrs before reporting to GP
Lack of information, poor health care professional attitude and knowledge and little done when reported to doctor/nurse
Pad expectation
why is communicating about bowel difficult
Lack vocabulary Never before articulated Cannot describe easily Too embarrassed Too ashamed Too guilty Not legitimate to seek health care
describe prevalence of constipation
Depends on definition (frequency, difficulty, consistency)
Rome ll criteria: frequency / hard stool /straining/ incomplete evacuation (2 or more, 25% of time)
Self-report: 26% women, 16% men over 65 years – increases with age
1-7% less than 3 stools per week
10% district nurses time
More take laxatives than say they are constipated
50-74% daily laxatives in Homes
what are current five areas of need in people with bladder problems
Assessment Treatment Access to service provision Professional education Information
30% of people in______ affected
40%-60% of people in __________ affected
Costly - UK cost ____ million
Treatable
Continence is associated within the domain of _____
30% of people in the community affected 40%-60% of in nursing homes affected Costly - UK cost £400 million Treatable Continence is associated within the domain of nursing
who should do continence assessments
Qualified nurses, pre registration student nurses and continence physiotherapists
Studies show that people with UI who receive care in acute settings have been shown to lack appropriate care- why?
because of the deficit of knowledge about assessment and management
evidence suggests that nurses are more inclined to contain incontinence, Rather than actively
promote continence.
Largely around attitudes, beliefs and nursing practices (Visnes 2000,Henderson 2000, Mason 2002)
Effects of continence education on practices (Williams 1997, Rigby 2003 Saxer 2009)
Lack of theory taught at undergraduate level (Morishita 1994 ,Lomas 2010)
Staff over estimate their knowledge base (Irwin 2001, Wagg 2008)
what is urge urinary incontinence
involuntary leakage accompanied by or immediately preceded by urgency
makes up 22% of UI (mixed w/ stress innocence = 29%)
what is stress urinary incontinence
involuntary leakage on effort or exertion or on sneezing or coughing
makes up 49% (mixed w/ stress innocence = 29%)
what is overactive bladder (OAB)
a syndrome of symptoms that suggest dysfunction of the lower urinary tract. Characterised by urgency with or without urge incontinence usually involving frequency and nocturia
Involuntary contractions of the detrusor muscle with sudden strong urge to void,often followed by involuntary loss of urine
• Contractions occur spontaneously or on provocation
• Time between desire to void and urine loss is very short
• Frequencyandnocturia
• Accentuated by caffeine, UTI, diuretics, constipation
• Othercauses–neurological increased sensory input to the bladder and idiopathic
what is abnormal bladder function
Urgency - Patient opinion determines !
The sensation of urgency is difficult to objectively define hence the need to rely on patient perceptions i.e. Voiding more due to an uncomfortable sudden desire to pass urine so consider urgency
But If voiding more because of stress incontinence and wants to keep her bladder empty has frequency without urgency
what are the 2 classifications of urgency
Sensory - a strong uncomfortable need to void without the fear of impending leakage the bladder has become hypersensitive delaying voiding is painful but rarely leads to incontinence/ = OAB dry
Motor – urinates frequently because they are afraid of experiencing complete or partial involuntary void as a result of an involuntary bladder contraction = OAB wet
describe bladder training
Neurotic Behavior is learned and is therefore open to unlearning (Clark 1997)
Problems must be current, repetitive and recordable
The principals of behavior management are clearly identified in bladder
training/drill
Treatment aimed at clearly defined goals
Bladder training
Prompted toileting
Progress is carefully monitored
Bladder training/drill can reduce frequency and voided volume nocturia
50-85% success rate
Also known as behavioural therapy
Based on the assumption that conscious efforts to suppress sensory stimuli re establishes cortical control over the bladder and thus a normal voiding pattern *
The aim is to reduce the frequency to 2-3 0r 3-4hrly
describe the 12 weeks of bladder training
Takes 3 months to achieve - a few weeks to break cycle
scheduled program either set and increased or self scheduling
Must have a motivated patient and staff
includes urge inhibition strategies such as mind games serial subtractions
involve other tasks as distractions
Positive affirmations using statements such as I can control my
bladder
deep breathing exercises with imagery
several rapid pelvic floor exercises to quiet bladder urgency fast twitch contractions
if voiding occurs more than hourly initial voiding interval should be 1hr
if voiding is less than hourly the initial voiding should be 30mins
15 mins used for severe urgency and review
Journaling adverse incidents is useful for the patient and nurse
explain the fluid advice nurses should give
Literature suggests that incontinent people restrict their intake (Norton)
This leads to urinary infection (Kennedy) urgency and frequency caused by irritation from concentrated urine (Norton ,Roe )
Pearson stated that health professionals are giving detrimental advice about restricting fluid intake
See Abrams/Kevler weight fluid matrix
Most fluid advice now comes with caffeine grams per cup
ecrease fluid intake by 25% more than 1L and less than 3L per day
No real benefit now from reducing caffeine according to authors
But risk factor to OAB is the relation to tea drinking
Alcohol and caffeine can be diuretics
Could be advised to stop drinking four hrs before bedtime if nocturia a problem
Water content of fruit and veg could be as much as 500 mls and to avoid in the evening
Intake of vit D protein and potassium seem to be protective of OAB and associated with decrease in onset
Recent studies show that Diet Coke and caffeine free diet Coke produce similar increases in urgency and frequency compared to carbonated water or classic coke suggesting the problem is associated with artificial sweeteners (Cartwright 2007)
what advice should nurses give about smoking and obesity
Obesity smoking carbonated drinks give a risk of OAB
Higher consumption of veg,bread and chicken are
associated with a reduced risk
5-10% weight loss seems to help SUI and urgency
This results in decrease weight in pads and Kings health questionnaire scores with 10% weight loss
In men obesity physical activity and smoking were not associated with OAB
what are some adjuncts to care
Lifestyle changes fluids/ weight loss/constipation
Review medication fluid loading/diuretics
Intermittent self catheterisation first line
Inplants sacral stimulators
intraurethral devices pessary
Products andcatheters last to attain socially dry
what medications can be given to help
Oxybutinin
Tolterodine
Trospium
Solifenacin
describe pelvic floor exercises
PFES poorly taught. Digital palpation of the lavater ani is essential to ensure that patients are able to contract correct muscle before teaching and devising training schedule
daily minmum of 30-45 pfes building to a duration of 10 secs
PFE training is only effective if muscles are overloaded
each client should have their own program Laycock 2000 need to be used for life if a cure is to be maintained(Stanton 1990) they are usually self purchased or given by the physiotherapist 70% cure rate
Biofeedback computer monitored via rectal or vaginal probe older patients can be treated but may find it too intimate
Electrostim aids pelvic floor to develop new fibres and increases the number of capillaries supplying blood to them usually 10-12 week treatments 38-49% cure rate over 8 wks
Pelvic Floor Exercises…. Never too early to start: Can stop a week before you die !!
describe sacral neuromodulation
For women with refractory OAB
Exact mechanism of action remains unknown
Stimulation of S3 sacral nerve root shown to modulate detrusor activity through afferent, efferent & autonomic pathways
2 stages - Test phase
permanent for those with at least 50%
reduction of symptoms
Efficacy
For Test phase Trials show high success rates – range 52 – 80% but recent analysis of medicare / insurance show lower 35 – 50&%
For successful tests – permanent implant 56 – 90% Effective for at lease 5 years. Replace after 54 months.
describe intraveseical botox
Injection of Botulinum Toxin Type A
Neurotoxic - Paralysis of detrusor muscle
More effective in pts who failed anti cholinergics due to S/E rather than in those it was ineffective
60% symptom improvement
Repeat injection 6 – 12 months
Rarely Ab’s form against BTX – confering resistence
ISC – 20%
what are different treatment options
Behavioural therapy (60%-80%)
- Dietary modification
- Fluid management
- Bladder drill/bladder training –individual programmes- Pelvic floor exercises, biofeedback etc
Pharmacotherapy
- Anticholinergic therapy (60% “dry”)
- Surgical management Intravesical botox Cystodistension
- Bladder augmentation Autoaugmentation
(>90% success)
- Clam cystoplasty
- TVT/TOT for SUI – mesh treatment now stopped in Scotland
- Urinary Diversion
describe obstruction/voiding dysfunction
Outflow obstruction – Prostate
Frequent voids small amounts
Hesitancy (difficulty in initiating the flow)
Poor flow rate and post micturition dribble
• Frequency, urgency, nocturia, dribbling, can occur if residual large
• Detrusor sphincter dysinnergia- neurological impairment causing failure to coordinate bladder contraction with urethral relaxation
what are symptoms of BOO
Irritative – frequency, urgency urge nocturia
Obstructive - hesitancy weak stream straining prolonged micturition post mictural dribble incomplete emptying
Other assoc.symptoms- dysuria haematuria and haemospermia
what is a UTI inflammatory response
UTI inflammatory response to urothelium to bacterial invasion
The inflammatory response causes a cluster of symptoms such as pain, bladder infection (cystitis) resulting in small frequent voids, urgency, suprapubic pain, urethral burning on voiding (dysuria)
what does acute kidney infection pyelonephritis cause
fever chills malaise loin pain and associated with LUTS
what is Bacteriuria
bacteria in urine can be asymptomatic or symptomatic if no pyuria indicates bacteriuria colonization of the urine rather than active infection
what is pyuria
presence of white blood cells in the urine
how do uncomplicated and complicated UTIs differ for patient
An uncomplicted UTI women respond quickly to a short course of antibiotics. E COLI GRAM NEG BACILLUS 85% OF COMMUNITY ACQUIRED AND 50 % HOSPITAL ACQUIRED INFECTION ALSO PROTEUS MIRABILIS, KLEBSIELLA
A complicated UTI results in the patient has DSD,or BOO or renal or bladder stones.E COLI, STREPTOCOCCUS FAECALIS OR STAP AUREUS
what are the 3 classes of UTI
isolated, recurrent, unresolved
isolated = an interval of six mths of last infection
Recurrent >2 in the month or 3 in 12 mths
Recurrent maybe reinfection by different bacteria or bacterial resistance calculi ( infected prostate prostatitis)
Unresolved implies inadequate therapy
what are risk factors for bacteriuria
Female sex Increasing age Menopause Diabetes Previous UTI Catheters And voiding dysfunction
what are the host defences against a UTI
Commensal flora
Mechanical integrity of mucous membranes
Urinary immunoglobulin inhibits bacterial adherence
Mechanical flushing of urine through urinary tract
Mucopolysacharide coating on bladder Low PH high osmolarity
how should recurrent UTIs be managed
Renal ultrasound
Flexible cystoscopy
If no functional abnormality found female patients need to be managed by -
Avoid spermicides used with diaphragm or condom
Oestrogen replacement for post menopausal loss of
vaginal lactobacilli increased colonisation of Ecoli
Low dose antibiotics prophylaxis given at bedtime 6- 12mths
Trimethroprim
Nitrofurantoin
Cefalexin 250mg nightly
Ciprofloxacin
Natural yogurt
Post coital antibiotic
Self start therapy
describe a cystoscopy
To exclude lesions in the urethra and bladder.
The bladder neck is examined.
It should close in response to straining.
However, it opens in case of stress urinary incontinence.
describe urodynamics
Medical science concerned with the study of urine transport from kidney to bladder as well as its storage and evacuation
Classification:
1.Cystometrogram( most important test), Filling
Cystometry and Voiding Cystometry
2.Urethral pressure profile
3.Uroflow
4.Electromyography
describe uroflowmetry
It records the rate of urine flow through the urethra when the patient is asked to void spontaneously while sitting on uroflow chair.
It is used to evaluate patients with stress incontinence before surgery to exclude difficulty in voiding which may be increased by bladder neck surgery.
Also for men with BOO
what lab tests are helpful in evaluating incontinence
Postvoid residual is an easy initial test to obtain. After the patient voids, there should be less than
50 ml of urine in the bladder.
Postvoid residual is measured by ultrasound or in /out catheter
A patient with an elevated Postvoid residual (repeat measurements greater than 150 ml) may have an underlying neurologic disorder suggesting voiding dysfunction
what should you ask about when taking a history for UI
Duration, severity, symptoms, previous treatment, medications, GU surgery
3 P’s: Position of leakage (supine, sitting, standing), Protection (pads per day, wetness of pads), Problem (quality of life)
Bladder record or diary
what are diagnostic tests for UI
Stress test (diagnostic for stress incontinence; specificity >90%)
Post-void residual
Blood Tests (calcium, glucose, BUN, Cr) Urine Culture
Simple Cystometrics
what would the following values mean for interpretation if post void residue
1) <50ml
2? >150ml
3) >200ml
4) >400ml
1) adequate bladder emptying
2) avoid ladder relaxing drugs
3) refer to urology
4) overflow UI likely
what is haematuria
Painless haematuria needs investigated urgently – suggests tumour OR TB
Dipstix confirm by microscopic MSU
PAIN SUGGESTS INFLAMMATION OR INFECTION
BLEEDING AT START OF STREAM URETHRA OR PROSTATE
TOTAL HAEMATURIA START TO END STREAM = UPPER URINARY TRACT BLADDER
AT END OF STREAM = PROSTATE /BLADDER CAN BE REFERRED TO UROLOGY HAEMATURIC CLINIC
describe care panning/goal setting for UI
Eliminate the symptoms of frequency urgency and urge incontinence
Start with the least invasive treatment
Should there be a combination of behavioural and pharmalogical intervention at the outset?
Establish realistic treatment goals
Patients should be offered only evidence based treatments
Behavioural interventions form the key part of any nurse led clinic
The nurse makes the clinical decision when to use them
Programmes and structures need to be in place to support them
Nurses need to demonstrate competencies in each behavioural domain
Treatment that will focus on patient characteristics - beliefs about treatment
respond to patient goals and preferences
Targeted, tailored and individualised
move beyond the practitioner centered thinking - treatment is whatever it means to the patient
research has shown that there is special patient meaning and response to what a practitioner wears as well as manner, style and language the practitioner uses to interact
Concordance/compliance
Do I assess their knowledge and attitudes?
Do I chose my other attitudes and words?
Do I deliver a programme using my skills to stay on their agenda ?
Do I deliberately reduce their anxiety? Do I summarise plans, next steps and
reassure the patient?
Do I reflect post clinic visit?
what alternative therapies are there for UI
Hypnotherapy reported to have had 86% subjective and 50% objective cure rate (Freeman and Baxby 1982) High relapse rate
Acupuncture 76% Phillip et al 1988 lack of controlled trials due to difficulty in creating a placebo effect.
Only one RCT published that stated women receiving 4 weekly bladder specific acupuncture treatments had significant improvement in bladder capacity, urgency, frequency and qol compared with placebo (2005)
TENS sites include thigh and abdomen no RCT but subjective improvement (1998)
Post tibial nerve stimulation near medial malleus 10-12 weeks duration 30 mins session reported 67-81%
Recent study on refractory OAB treated for 10 weeks reported complete resolution of symptoms 54% with significant improvement in urgency and quality of life measures effect maintained up till 1yr in 23%
But more studies required poor evidence for above
