do we have an incontinence problem? south dakota foundation for medical care south dakotas quality...
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Do we have an incontinence problem?
South Dakota Foundation for Medical CareSouth Dakota’s Quality Improvement Organization (QIO)
A thought to ponder….
How does it make me feel? Embarrassed
“I’m not going in there like this!” Isolated
No way, no how would I go in Sit by myself in the car
It really didn’t matter how I felt….it was what everyone else was going to think that helped me make the decision to stay in the car!!
Percentage of Residents Whose Need for Help with ADLs has Increased
National - 16%South Dakota - 16 %Our Nursing Home - _____
Percentage of Residents with Low-Risk for Developing a Pressure Sore
National - 3%South Dakota - 4%Our Nursing Home - _____
Percentage of Low-Risk Residents Who Lose Control of Their Bowels or Bladder
National - 46%South Dakota - 46%Our Nursing Home - ____
Emotional Stress R/T Incontinence
AnxietyDiminished self-esteem social isolation
depriving residents of opportunities for personal growth and enjoyment
Do we know….
How many of our residents are continent upon admission?How many of our residents become incontinent after admission?How many days it takes our continent residents to become incontinent?
Incontinence
Puts residents at risk for pressure ulcers urinary tract infections urosepsis perineal rashes falls fractures
Incontinence upon Admission
What are we doing about residents who come in to our facility suffering from incontinence? Do we accept it as a problem
associated with aging? AMDA RAI AHCPR Clinical Guidelines
Admission Process
Are we identifying not only incontinent residents but those at risk as well?Are we finding the cause behind the incontinence?Do we know how long the resident has experienced incontinence?
Become a Detective!
Low-Risk vs High-Risk High = residents with a high risk of
incontinence Low = residents with a low risk of
incontinence
Are we finding the cause behind the incontinence?
Types of Incontinence
Stress Incontinence bladder can’t handle the increased compression
during exercise, coughing or sneezing
Urge Incontinence caused by sudden, involuntary bladder
contraction
Mixed Incontinence combination of both stress and urge
incontinence
Types of Incontinence
Overflow Incontinence bladder becomes too full because it
can’t be fully emptied, is rarer and is the result of bladder obstruction or injury
Possible Reversible Factors
Resident Conditions delirium fecal impaction depression symptomatic urinary tract infection edema
Possible Reversible Factors
Environmental Conditions impaired mobility lack of access to a toilet restraints restrictive clothing
Possible Reversible Factors
Excessive Beverage Intake caffeine
Disease Parkinson’s other neurological diseases effecting
motor skills
Possible Reversible Factors
Medications diuretics drugs that stimulate or block
sympathetic nervous system psychoactive medications
Contributing Factors
Resident Conditions pain excessive or inadequate urine output atrophic vaginitis cancer of the bladder or prostate urethral obstruction disorders of the brain or spinal cord tabes dorsalis
Contributing Factors
Abnormal Lab Values elevated blood glucose elevated calcium
Assessment of Incontinent Residents
Identify potentially reversible and contributing factors bladder record or voiding diary targeted physical examination
including rectal exam and pelvic in women
Assessment of Incontinent Residents
Optional tests as appropriate urinalysis urine culture and sensitivity Glucose, calcium Vitamin B-12 Urine cytology Post-void residual determination Urodynamic tests
e.g., stress tests filling and voiding cystometry
Treatments
Trial toileting program 3-5 day trial prompted or timed voiding
Residents responding favorably should continue with planResidents not responding favorably should be referred for other treatment options
Other Treatment Options
behavioral therapydrug therapysurgical treatmentelectrical stimulationintravaginal support devicespads and external collection devicesintermittent catheterization
Drug Therapies
Urge Incontinence anticholinergics bladder relaxants
Stress Incontinence alpha-adrenergic antagonists estrogen
Should be initiated at the smallest recommended dose and slowly titrated upwards based on resident response and tolerance
Monitoring Responsiveness to Treatment
an objective measure of the severity of UI such as a bladder recordresident satisfaction with treatmentside effects of treatment
Physical and Environmental Barriers
Toilet/commode accessibilityGrab bars are present if neededToilet seat is adequate heightLighting is adequateCommodes and urinals are used as supplements as neededFurniture allows easy rise for resident to be able to get up to go to the bathroomCall light is within reach / ability to useContracturesAmbulatory assistive devices needed
Physical Limitations
Ease of taking garments off and putting onGetting to the toiletAbility to perform hygiene tasks
Current Approaches
Bladder retrainingPrompted voidingPads/briefsHabit trainingPrompted voiding with assistanceCatheterUreterostomyPelvic muscle rehabilitation
A Successful Restorative B&B Program Includes:
Adequate fluid intake 2000-2500 ml/day Honor preferences Assistance Encouragement Keep fluids readily accessible Offer fluids with each resident contact
Different Resident/Same Plan?
A scheduled two-hour voiding program will not work for all residents especially those who are receiving
diuretics and other medications it takes a good detective to determine
when the resident is most likely to use the toilet
?? Would it – Could it work ??
Having the same caregiver care for the resident during the evaluation phase……
Would it – could it assist us to determine the resident’s bowel and bladder elimination patterns?
Resources
www.medqic.org Facility Assessment Checklists –
Incontinence
Quality Measures ManualRAI ManualAMDA Clinical Practice Guidelines www.guideline.gov
Contact Us Bernadette Nelson, RN, Project Manager
Phone (605)336-3505 Extension 263 Email: [email protected]
Rhonda Streff, RN, Assistant Project Manager Phone (605)336-3505 Extension 262 Email: [email protected]
Ryan Sailor, Analyst Phone (605)336-3505 Extension 220 Email: [email protected]
Jane Viereck, Coordinator Phone (605)336-3505 Extension 266 Email: [email protected]