incontinence case study

Urinary Incontinence Case StudyCopyright 2006-2007, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Urinary Incontinence Case Study
*
*
Learner Outcomes
At the completion of this case study, the student should be able to:
Discuss the differences between transient and established persistent urinary incontinence (UI).
List essential elements of a focused history and physical pertaining to UI.
Develop an evidenced-based plan of care based on assessment findings for an older adult with UI.
List the appropriate indications for indwelling urinary catheter usage.
eSlide - P3562 - AACN Hartford-sponsored Faculty Development
*
*
Required Reading
ConsultGeriRN Topics on UI. Available at:
www.ConsultGeriRN.org
*
*
Opening Statement
Mrs. P. is a 69 year-old white widow who is status post an ORIF of her L hip subsequent to a fall down the stairs. She is admitted to sub- acute rehabilitation on post-op day two.
Mrs. P has a history of Alzheimer’s type dementia, hypertension, osteoporosis and psoriasis.
Mrs. P’s social history is questionable for alcohol abuse. Tobacco use includes one pack per day. She is widowed for a year and lives in two family home with her daughter’s family. Mrs. P’s daughter has hired a certified nursing assistant (CNA) to stay with her 24-hours per day.
*
*
Subjective Data
On the initial encounter with Mrs. P on the sub-acute unit, she offers no complaints and states: “I’m fine.”
Her daughter is present and appears very anxious, expressing the following:
“When will my mother’s urine tube come out? Don’t those tubes cause infections?”
“You cannot use that number pain scale, and she will never say that she has pain. In the hospital I told them to make sure she got pain relievers, otherwise she will not move.”
“My mom has not moved her bowels in three days, and she usually goes every morning.”
*
*
Subjective Data: Problem List
Review of Mrs. P’s medical records, discussion with the daughter and your initial impression resulted in the development of this problem list:
Recent fall with left hip fracture - s/p ORIF
Recent urinary catheterization
*
*
Question # 1
What other subjective information specific to problem #2 (indwelling catheter) do you need to know?
Answers:
Is there an appropriate indication for the indwelling urinary catheter?
Appropriate indication for a urinary catheter include:
acute management of a medical condition requiring strict intake and output measurements;
stage III-IV pressure ulcer on the trunk, or
urinary retention unmanaged by other means.
*
*
Question # 1 continued
Answers:
What was Mrs. P’s continence status prior to her hip fracture?
It is essential for nurses to assess ALL patient’s continence status and determine if the incontinence is transient (acute) or established (chronic). A careful history is the cornerstone to the appropriate diagnosis of UI type. Without an accurate assessment it is difficult to develop a successful plan of care.
*
*
Question # 1 continued
Answers:
What objective data from the nursing assessment is needed?
It is vital to perform direct visual assessment of the skin to note any pressure ulcer formation. The nurse should not rely on transfer documentation or verbal reports, but rather, direct observation. Other objective data include review of the medical record to determine if a physician order is present for strict intake and output and to determine if urinary retention was present prior to the insertion of the catheter. Another vital aspect is Mrs. P’s cognitive status, functional status and motivation. Input from this assessment will help to determine the plan of care.
*
*
Additional Subjective &
Objective Data
Mrs. P’s daughter informs you that prior to the fall her mom was independent with activities of daily living (ADL), but required assistance with instrumental activities of daily living (IADL’s).
You completed a Mini-Mental State Examination on Mrs. P and her score was 13/30. Errors were in recent memory, calculation and visual spatial [drawing a pentagon].
Assessment of the integument reveals silvery scaly plaques consistent with psoriasis, otherwise the skin is intact.
Based on these data, you conclude that there is no appropriate indication for the urine catheter.
*
*
Plan of Care
Because there is no appropriate indication for the indwelling catheter, you plan to pursue having it discontinued by:
Consulting with the primary care provider and obtaining an order.
Following discontinuation, you follow the nurse-led protocol which is institution specific, and continue to monitor Mrs. P.
*
*
Question # 2
What other subjective information specific to problem #3 (pain) do you need to know?
Answers:
Has a pain scale for the cognitively impaired been utilized by the nursing staff? Pain assessment is very important, but presents challenges when an older adult has impaired cognition and/or communication. Using a Checklist for Non-Verbal pain indicators (visit ConsultGeriRN.org and select: Try This Series: Assessing pain in persons with dementia) helped the nursing staff to observe and collect data consistent with pain. This data about Mrs. P. included moaning, grimacing and clutching the bed lines with movements, replying “ouch” frequently and withdrawing from activity.
*
*
Question # 2
Answers:
What were the components of pain management in the hospital? Mrs. P was medicated with Percocet 1-2 tablets by mouth every 6 hours. It appeared to control her pain, but periodically non-verbal behaviors were observed. This observation of continued pain, prompted further nursing assessment and revealed that Mrs. P was also experiencing abdominal pain. This is imperative to identify as narcotic analgesia lead to constipation, particularly in an older adult who is less active. The daughter's report of “no BM for 3 days” is very relevant, thus prompting a complete abdominal as well as rectal assessment.
*
*
Question # 2
Answers:
What is Mrs. P’s response to activity? Given the current problem list, it is vital to increase Mrs. P mobility and level of activity when she is pain-free. This requires attention to the timing of medication so that increased activity can take place. As activity improves, so too can a return to normal bowel habits. If lack of bowel movements persist, additional nursing intervention to prevent fecal impaction is warranted.
*
*
Post-Op Day 4
Mrs. P daughter comes to you demanding to know why her mother is in a diaper.
*
*
Question #3
How do you respond to Mrs. P and what is your rationale?
Answer:
You need to respond to Mrs. P’s daughter and the situation in a calm and respectful manner. Stating that you will look into it right away. This provides the daughter with immediate reassurance as well as it confirms that you don’t know, but will check into it.
*
*
Question #3
How do you respond to the fact that Mrs. P. is wearing a diaper and what is your rationale?
Rationale:
Often care is focused on containment and not management. Traditionally, nurses assistance and nurses are taught about incontinence care-frequent toileting and/or skin care with diaper changes and barrier creams. While studies do reveal poor staffing is a perceived barrier to maintaining toileting schedules- this cannot be applied in this case, because there is a private CNA. Therefore, it should be questioned what attitudes and beliefs the private CNA’s and floor nurse have relative to the elimination needs of the older adult.
*
*
Additional Data
After removing the indwelling urinary catheter, Mrs. P became incontinent. Rather than notify the RN, the CNA used a diaper for management.
*
*
Question #3
What other data do you need to collect at this point?
Is this “new” UI or “old” UI?
Since you have already collected further subjective data that Mrs. P was independent in ADL’s at home, you determine that this is new-onset UI.
What are the causes for new, transient, UI?
Using the mnemonic, TOILETED (visit www.ConsultGeriRN.org and select Try This Series: UI Assessment) to review potential reversible causes of UI. In this case, restricted mobility due to hip fracture and repair, use of narcotic analgesia causing constipation are all important factors.
*
*
Question #3
Could this be iatrogenic UI?
Iatrogenic UI refers to a medically induced problem. In this case, the catheterization could have led to the new onset of a bacterial infection.
What additional objective data is needed?
Review the output and note how many voiding episodes versus leaking episodes have taken place. Is Mrs. P moving her bowels? A reassessment of the abdomen is needed to assess for any supra-pubic tenderness and left lower quadrant fullness or pain. These are signs of urinary or stool retention. Assessment reveals a slight firmness in both the supra-pubic region and the left lower quadrant.
*
*
Assessment and Plan of Care
After consulting with the NP, another abdominal assessment, including a rectal exam is performed. Results show that soft stool is present, the post-void residual (PVR) is 100 cc, the urinalysis shows: + WBC, trace blood, +nitrates, culture pending. The following is ordered:
MOM 30cc po X once at bedtime
Colace 100 mg po TID
*
*
Question #4
What should the nurse add to the plan of care?
Answer:
The nurse needs to learn from the CNA staff if Mrs. P has any non-verbal or verbal cues that may help to determine the need to toilet. A bladder record for a few days will assist in determining Mrs. P’s individual elimination patterns so that an individualized toileting schedule may be implemented. Emphasize to the CNA staff the need to toilet according to Mrs. P’s patterns. Clearly communicate that Mrs. P. did not have incontinence issues prior to her hip fracture, and that part of her rehabilitation is to maximize her continence in an effort to return to baseline. Consider a bedside commode as an environmental modification to promote continence.
The nurse should anticipate an antibiotic order for a urinary tract infection (UTI). A PVR of 100cc needs to be carefully assessed, in this case the treatment of the UTI improves Mrs. P’s continence status.
*
*
Additional Information
During the remainder of her short term rehabilitation stay, Mrs. P. and her daughter struggled to maintain continence. This was challenged by a bout of diarrhea caused by a bacterial infection in her bowel (e.g., clostridium difficile). She was discharge after one-month to her home – wearing her own underwear and maintaining a state of continence.
Discharge planning included regular toileting and use of a bedside commode at night.
*
*
One Year Post-discharge
Mrs. P has done well. She continues to live at home with her daughter’s family and the help of home attendants. She has had two UTI’s – her first sign/symptom was UI. She now is dependent with her ADL’s, with the exception of feeding and at times toileting. About 80% of the time she is continent, but at night does not recognized the urge to void – the daughter and attendant use diapers at night and prompt to void during the night at least once. This is all in an effort to balance continence with sleep needs. In this case, not diapering means that the pad and her Pajamas get wet and she is uncomfortable. However, for now she is still diaper free during the day and attends a social adult day program three times a week.
*
*
Take Home Points
Urinary incontinence is a problem for both those experiencing it (the older adult patient) and their caregivers. For the older adult it can lead to embarrassment and frustration, and for caregivers it can lead to anxiety when attempts to manage it fail. Fecal incontinence is under addressed in clinical practice. In this case, the staff was not prompted to determine the cause of the diarrhea and, in fact, continued administering the stool softener. Note that antidiarrheals are contraindicated with concurrent C. difficile infection of the bowel.
UTI’s can develop and complicate the care of an older adult who also has functional limitations.
*
*
Take Home Points
Reduced mobility can lead to urinary retention and sluggish bowel function, both of which contribute to urinary track infections and to urinary incontinence
Older adults with dementia and impaired communication have limitations in their ability to express pain. Non-verbal clues are important to recognize so that appropriate management can take place.
Urinary incontinence is often reversible, but its cause first needs to be determined which only occurs when a proper assessment takes place.
*

incontinence case study

Documents