Week 13: Chp 63: Incontinence Flashcards
Urinary Incontinence
involuntary or uncontrolled loss of urine in any amount
Micturition
voiding/ urination
Micturition cycle
involves a complex interplay between the sympathetic and parasympathetic nervous systems
- Parasympathetic nervous system provides motor stimulation to the bladder and mediates bladder contraction
- Sympathetic nerves mediate bladder storage by stimulating contractions in the bladder neck and proximal urethra, blocking urine flow
If perceived as an appropriate time to void, what is voluntarily relaxed, allowing urine to flow into the urethra?
external urethral sphincter
What results in an areflexic (flaccid) bladder, resulting in retention with overflow?
injuries or lesions at the level of S2 to S4 or below
Types of Incontinence
- stress incontinence
- urge incontinence
- Overflow
- Functional
- reflex
Stress Incontinence
urine leakage occurs when abdominal pressure increases; laughing, coughing, lifting, or exercising
-causes/risk factors: common in women, childbirth (which causes stretching and relaxing of pelvic floor muscles, ligaments, and urethra), postmenopausal women, smoking, obesity)
Urge Incontinence
strong urge to urinate followed by uncontrolled leakage
-Causes/risk factors: exposure to bladder irritants such as caffeine, artificial sweeteners, or nicotine
Overflow Incontinence
frequent urination
-causes/risk factors: flaccid/enlarged bladder due to obstruction (e.g enlarged prostate), spinal cord injury, stroke, diabetes, neurological diseases
Functional Incontinence
patient is continent but environmental factors lead to loss of urine in inappropriate areas
-causes/risk factors: inability to get to the toilet or communicate the need to do so
Reflex Incontinence
bladder muscle contracts on its own, urethral sphincters exhibit varying control
-causes/risks: disorders that affect the nervous impulse for voiding such as multiple sclerosis, brain tumors, or stroke
What is the first step in managing Urinary incontinence?
a realization on the part of the patient that incontinence is not a normal part of the aging process and that it is often treatable and always manageable
How to diagnose Incontinence
starts with a thorough history; should include medical, urological, voiding, neurological, and reproductive history
- be questioned as to management routines and patterns of incontinence and voiding characteristics
- a voiding diary is useful
- a physical should include a neurological assessment and examination of genitalia
Laboratory Testing for Incontinence
begins with urine culture and urinalysis, which may rule out infection and/or illness such as uncontrolled diabetes mellitus as factors
-blood test
Blood Tests for incontinence
associated with renal function
-BUN/Cr
>reveal the effects of bladder function on the upper urinary tracts
Imaging studies
- plain x-rays or films of the kidneys, ureters, and bladder (KUB)
- IV pyelogram
- voiding cystourethrogram (VCUG)
- Ultrasound
- Urodynamic testing (uroflowmetry)
- cystometrogram (CMG)
IV pyelogram
an x-ray of the renal system with IV contrast solution to facilitate imaging
Voiding cystourethrogram (VCUG)
uses contrast dye injected into the bladder to enable visualization of the voiding process
Ultrasound
provide useful information about the urinary tract without exposing the patient to radiation
Urodynamic Studies; uroflowmetry
measures the transport, storage, and elimination functions of the urinary tract
-uroflowmetry tests the urinary flow rate in millimeters per second
Cystometrogram (CMG)
assess the bladders filling and storage function
- graphically represents bladder pressure compared with volume while the bladder is filled with liquid
- often coupled with a sphincter electromyogram
Primary goal of treatment
to prevent or stop urinary leakage
-prevention or reduction of damage to the upper tracts or the kidneys, manifested by deteriorating renal function
What if it is not possible to stop or prevent urinary leakage?
containment with scrupulous skin care and odor control becomes the new objective
Management of Incontinence is based on what?
the type of incontinence and is done with medications, nonsurgical measures, or surgical measures if the medications or nonsurgical means have not worked
Nonpharmacological and nonsurgical measures include?
- measures to strengthen the pelvic floor such as Kegel exercise
- a Pessary
- Clean Intermittent Catheterization
Kegel exercises
helps strengthen the pelvic floor
- consists of contracting and relaxing the pubococcygeus muscles that form part of the pelvic floor in an effort to improve muscle tone
- used for strengthening the external urinary sphincter, which is under voluntary control
Pessary
device that fits into the vagina to support the bladder in an attempt to control incontinence and support bladder emptying
-treatment that alters the angle of the structures that affect bladder and urethral pressure
Clean Intermittent Catheterization (CIC)
technique used to manage incontinence
- involves the intermittent placement of a catheter through the urethra into the bladder
- this is done to completely empty the bladder in an effort to prevent UTIs or kidney damage due to urinary retention
- helps establish voiding patterns and may eliminate the frequent feelings of needing to void
Medications used to treat Incontinence
- Anticholinergics
- Topical Estrogen
- Tricyclic Antidepressants
- Alpha-adrenergic Blockers
- Beta 3 adrenergic agonists
Medications: Anticholinergics
-Oxybutynin (Ditropan)
-tolterodine (Detrol)
-darifenacin (Enablex)
-trospium (Sanctura)
-salifenacin (Vesicare)
-fesoterodine (Toviaz)
>used to calm an overactive bladder
>anticholinergics block nervous stimulation from the parasympathetic nervous system to help relax and control bladder muscle contractions
Medications: Topical Estrogen
used in stress incontinence in peri and postmenopausal women to help restore tone in the urethra and vaginal areas
Medications: Tricyclic Antidepressants
Imipramine (Tofranil)
-used to treat mixed-urge and stress incontinence; decreases bladder contractility and has a antispasmodic effect on the bladder
Medications: Alpha-adrenergic blockers
-Tamsulosin (Flomax)
-alfuzosin (Uroxatral)
>used in issues of urge or overflow in men- useful in enlarged prostate issues
>promote urethral relaxation, relaxes bladder neck and muscle fibers in the prostate
Mediations: Beta-3 adrenergic agonist
Mirabegron (Myrbetrig)
>used to treat frequent and/or urgent uncontrolled urination; relaxes bladder muscles
Surgical Management includes
procedures that tighten the pelvic floor and provide support to the urethra
- suburethral sling
- augmentation cystoplasty
- artificial urinary sphincter
Suburethral sling
used for stress incontinence
-several types of slings
-a bladder neck or pubovaginal sling with support at the bladder neck and proximal urethra
-midurethral sling with support at midurethral level
>prevent urethral descent and urine leakage during physical activity or stress when abdominal pressure increases
Augmentation cystoplasty
procedure to increase bladder capacity
Artificial urinary sphincter
severe stress incontinence after prostate cancer treatment in men can be treated with an artificial urinary sphincter
- surgically implanted device; a cuff, balloon and pump, which supports the function of the urinary sphincter by restricting flow from the bladder via the saline filled cuff around the urethra
- when appropriate to void, the man squeezes the pump located in the scrotum, allowing the saline to flow from the cuff into the balloon, releasing the pressure to allow urination
Surgical and Nonsurgical measures for Stress Incontinence
- Nonsurgical: pelvic floor exercises (Kegel), Pessary (or pessaries)
- Surgical: Suburethral sling, artificial urinary sphincter, collagen injection (periurethral) to strengthen the muscles around the urethra
Surgical and Nonsurgical measures for Urge incontinence
-Nonsurgical:
>eliminate bladder irritants such as nicotine or coffee
>prompted voiding-voiding at predetermined intervals
>fluid control; adequate intake without large volumes at one time, stop intake 2 hours before sleep
>clean intermittent catheterization (CIC) when antispasmodics are used in doses high enough to paralyze the detrusor muscle
>biofeedback
-Surgical:
>augmentation cystoplasty to increase bladder capacity
Surgical and Nonsurgical measures for Overflow Incontinence
(overflow is frequent urination) -Nonsurgical: >CIC >indwelling catheter >double voiding- void and then wait 3-5 minutes and void again >fluid control- adequate intake-spread out during waking hours- stopping 2 hours before bed -Surgical: >correction of underlying obstruction
Surgical and Nonsurgical measures for Functional Incontinence
- Nonsurgical: nursing measures to alleviate functional aspects of leakage, such as timed toileting or mobility devices
- Surgical: as indicated by concomitant causes of incontinence
The patient with stress incontinence is prescribed Kegel exercises. The nurse tells the patient that Kegel exercises will help:
A. Strengthen the detrusor muscle
B. Strengthen the posterior urethral valves
C. Strengthen the internal sphincter
D. Strengthen the external sphincter
D. strengthen the external sphincter
Complications of Urinary Incontinence
- skin changes associated with exposure to a moist environment
- poorly managed incontinence may also lead to renal disease secondary to retention and/ or incomplete emptying, which results in backflow of infected urine
Assessment and analysis: Clinical manifestations vary depending on what?
depending on the causative factors
- some may have stress incontinence associated with physical activity due to sphincter incompetence
- some have incontinence associated with urinary retention issues secondary to obstruction such as benign prostatic hypertrophy
Nursing Diagnoses
- alteration in urinary elimination r/t lack of control
- knowledge deficit r/t incontinence skin care and management
- alteration in body image perception r/t incontinence or “wetting episodes”
Nursing Assessments
- vital signs
- assessment of what precipitates urinary incontinence
- urinalysis
- urine culture
- voiding diary
Assessment: Vital Signs
increased temperature, rapid pulse, and decreased blood pressure may indicate infection with urinary retention as a possible etiological factor
Assessment: Assessment of what precipitates urinary incontinence
determining the cause, such as stress or urge incontinence, impacts treatment
Assessment: Urinalysis
WBC, nitrates, proteinuria, and hematuria may indiate infection
Assessment: Urine culture
a urine culture identifying specific bacteria identifies the presence of an infection and dictates anti-biotic treatment
Assessment: Voiding diary
determining incontinence patterns is essential to outlining management options
Nursing Actions:
-administer medications as ordered on the basis of incontinence assessment results >anticholinergic/ antispasmodics >tricyclic antidepressants >alpha- adrenergic blocking agents >Beta-3 adrenergic agonists
Actions: administer anticholinergics/ antispasmodics
blocks impulses from the parasympathetic nervous system to relax and control the bladder
Actions: administer tricyclic antidepressants
decreases bladder contractility and has an anti-spasmodic effect on the bladder
Actions: Administer alpha-adrenergic blocking agents
promote urethral relaxation; aid in issues of urinary retention
Actions: Administer Topical Estrogen
restore tone in urethra and vaginal area
Actions: Administer Beta-3 Agonist
relaxes bladder muscles
Nurse Teachings
- medications
- technique for CIC
- voiding diary
Teachings: Techniques for CIC
clean intermittent catheterization is fairly easy but awkward procedure; adequate teaching with a return demonstration helps ensure effective technique at home
A well-managed patient
has been assessed for type of incontinence, and appropriate interventions have been implemented
- incontinence has been resolved or managed through containment and skin barrier products, and the patient is able to carry out normal activities of daily living
- patient is clean, odor-free with intact skin, and has a management plan in place that considers mobility, skin integrity, and maintenance of urological health
