Lecture 6: Incontinence - Final Lecture Notes PDF

JESMAR S. ESPIRITU Associate. Professor LEARNING OUTCOMES PHYSICAL ASSESSMENT  UI is not reported because of... ❑ embarrassment ❑ lack of information ❑ a belief it is part of aging ❑ health care providers don’t ask ❑ a belief there is no effective treatment ❑ fear of...

JESMAR S. ESPIRITU Associate. Professor LEARNING OUTCOMES PHYSICAL ASSESSMENT  UI is not reported because of... ❑ embarrassment ❑ lack of information ❑ a belief it is part of aging ❑ health care providers don’t ask ❑ a belief there is no effective treatment ❑ fear of the therapies used to manage the problem Psycho-social Impact loss of self esteem embarrassment decrease in ability to maintain independence social isolation depression anxiety poor quality of life risk of institutionalization  Self-care behaviors used: locates or stays near a bathroom when out voids more frequently wears protective garment restricts fluid intake does not take certain meds if going out restricts social / physical activity  What is normal? daytime: –frequency of no more than once every 2 hours nighttime: –1-2 voidings are considered normal Age Related Changes decreased bladder capacity (normal is 500-600 ml., older adult capacity may be 250 ml.) increased residual urine increased involuntary bladder contractions decreased outlet resistance (females) decreased ability to inhibit contractions increased outlet resistance (males)  Forces that Affect the Pelvic Floor Neurological Anatomical In which ways do the Why would the female nerves affect the pelvic anatomy increase incidence floor? of urinary incontinence? Pelvic Floor Hormonal Mechanical How does estrogen affect the pelvic floor? What is the impact of pregnancy, constipation, and/ or prostate enlargement ? Psychological How would one’s psychological status impact incontinence?  Risk factors for UI immobility/chronic degenerative disease impaired cognition medications obesity diuretics fecal impaction, constipation Each of these factors can low fluid intake increase one’s environmental barriers risk for experiencing urinary diabetes incontinence. stroke Often older adults experience estrogen depletion more than one risk smoking factor at any given time.  Medications can cause... frequency nocturia urgency immobility retention sedation fecal impaction delirium polyuria Incontinence History Medical History? Frequency? Sensations? Medications? Amount?  Incontinence NOTE: Any one of these Screening conditions can cause “DRIP” acute onset urinary D - delirium, depression incontinence and must be evaluated R - retention, restricted mobility promptly ! and/or environment I - infection, inflammation, impaction P - pharmaceuticals, polyuria, pain  Kinds of Urinary Incontinence Stress Functional Environmental Urge Overflow Iatrogenic (caused by hospitalization, medications, etc.) Mixed  Stress Incontinence loss of urine that occurs during activities that increase intra-abdominal pressure: coughing sneezing laughing physical activity (lifting heavy objects) caused by pelvic muscular weakness as a result of pregnancy obesity surgery medications aging (lower estrogen levels) Pelvic Floor Muscle Exercises Intervention for stress incontinence Also known as Kegel exercises Requires 2-5 sets of pelvic muscle contractions done several times each day Feedback needed so client knows they are doing them correctly, such as... vaginal palpation biofeedback vaginal cones (Look this up; what are they and how are they used?) Like all exercises; success depends on doing them regularly.  Functional Incontinence physical or psychological impairment that results in incontinence when the urinary tract is healthy causes: Decreased mobility Pain Clothing Psychological factors Functional Assessment ability to put on /take off clothing sequence of tasks involved with toileting mobility: ability to ambulate, use a w/c and/ or transfer to and from the toilet access to toilet /device (such as urinals, bedside commodes, etc.)  Environmental Incontinence psychological message that UI is expected chairs are plastic beds are protected pads are available and applied “just in case” architectural design long corridors poorly marked bathroom doors caregiver attitudes “Go ahead and go (urinate), I’ll clean you up later.” “S/he does that on purpose.” (Episodes of incontinence) delay in removing wet clothing Environmental Assessment location/ accessibility of toilets signs for bathroom call lights/ bells adaptive equipment cleanliness, safety Urge Incontinence: Treatment Behavioral therapy bladder training Electrical Stimulation biofeedback Medications Bladder Retraining treats urge incontinence voiding by the clock “Freeze & Squeeze” OR “Sigh and be Dry”. Not voiding with each urge can retrain the bladder, so that the need to void is increased to every two hours and/or when bladder is actually full.)  Overflow Incontinence loss of urine related to the overdistention of the bladder frequent or constant dribbling may include urge or stress UI causes loss of bladder muscle tone and/or outlet obstruction MS, DM, outflow obstruction (BPH), spinal or nerve damage  Overflow Incontinence least common, hard to diagnose treatment review medications drainage: intermittent, continuous  When to Refer? marked pelvic prolapse marked prostate enlargement difficulty passing a 14 Fr. catheter most cases of overflow hematuria treatment failures TREATMENT OPTIONS “Squeeze like you’r trying to hold back gas”  Treatment Options for UI behavioral techniques –biofeedback –scheduled toileting –exercise medication surgery continence promoting devices –Pessary TYPES OF PESSARY  Management of UI is a team effort Must involve: ☺ the client ☺ family ☺ caregiver(s) ☺ nursing ☺ primary care provider ☺ dietician ☺ PT/OT/RT/SLP ☺ management  Behavioral Interventions ❖are non-invasive ❖involve caregiver and individual ❖measure outcomes ❖are inexpensive ❖are effective ❖are low risk  Unlocking UI: Behavioral Methods ❖ assessments ❖ food and fluid changes ❖ pelvic floor muscle exercises ❖ bladder retraining ❖ education  Bladder (Voiding) Record time voiding occurs type/ amount of incontinence presence of urge sensation activity associated with loss of urine daily number of pad changes intake of dietary irritants fluid intake  Physical Exam Abdominal/Pelvic/Genitalia/Rectal exam Neurological Status Dexterity Mental Status Mobility  Maintain/Promote Mobility assessments by OT / PT use of assistive devices walkers, canes exercise programs proper shoes foot care uncluttered walkways  Absorbent Products trial and error evaluate products for... skin irritation noise comfort odor control ease of use/ability to change absorption confidence  Factors to consider with absorbent products ✓ skin integrity ✓ functional disability of ✓ comorbidity client ✓ optimal product for ✓ type and severity of UI client ✓ gender ✓ incidence of ✓ availability of vaginitis/ caregivers bacteriuria ✓ previous treatment programs ✓ client preference  Chronic Incontinence scheduled toileting improved access to toilets fluid and diet management absorbent garments/ devices change clothes when wet  Food & Fluids aim for 1500-2000 ml/day – include jello, soups, popsicles, water- packed fruits etc. (caution with diabetics) avoid bladder irritants – such as caffeine and chocolate avoid evening fluids treat dependent edema – elevation during the day – compression stockings – decrease sodium intake  Frequent UTI’s Cranberry juice, 10 oz daily –must have at least 25% cranberry juice Check fluid intake Check post-void residual Change catheter or remove  UI & Dementia can double the incidence of UI inability to dress and/or transfer can increase incidence 13 times one study: 55% of ambulatory dementia clients became dry or had a significant improvement in UI with an individualized scheduled toileting program (Shelly, J. & Flint, A. (1995). Urinary incontinence associated with dementia. Journal of the American Geriatric Society, 43(2), 286.)  UI and Dementia: utilize habit voiding dress in clothing that is easy to remove stay with the client and do not distract try again in 5 minutes if they say,”I just went.” use language that is understood simplify steps involved keep bathroom warm and comfortable  Habit Training voiding at predetermined times goal: to decrease/eliminate number of incontinent episodes (keep dry) fixed time intervals allows for schedule adjustments requires commitment ❑ soiling of underwear, clothing, or bedding several times a month or more, is a common and distressing health problem for older adults. ❑ affects 1 in 5 older people over age 65, with adults over age 80 reporting more frequent leakage and greater soiling than younger age groups. FECAL INCONTINENCE CAUSES CAUSES RISK FACTORS DIAGNOSIS DIET MEDICATIONS