Chapter 15: Urinary Incontinence

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Chapter 15Urinary Incontinence
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Learning Objectives

• Describe the prevalence of urinary incontinence
  among older adults in community, acute care, and
  long-term care settings.
• Identify the negative social, psychological,
  physical, and economic implications of urinary
  incontinence.
• Understand that urinary incontinence is not a
  normal part of aging.

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Learning Objectives (contd)

• Collect the appropriate data related to patients
  urine control and plan evidence-based nursing
  care accordingly.
• Initiate evidence-based behavioral interventions
  to treat urinary incontinence and promote
  continence for those at risk for urinary
  incontinence.

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Prevalence

• Estimates vary widely due to differences in
  definition, population studied, sampling
  approaches, and data collection methods
• Total population with UI 10
• Long-term care residents up to 70
• Older women 30 - 50
• Older men 9 - 28
• Not normal consequence of aging but some
  physiological changes of aging increase risk of
  UI and some conditions that predispose UI occur
  more in older persons

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Implications of Urinary Incontinence

• Physical
• Incontinence is associated with an increased risk
  of falls, fractures, skin breakdown, UTIs,
  disrupted sleep
• Psychological (Figure 15-1, p. 548)
• Depression and anxiety both cause and consequence
• Feelings of loss of control, dependency, shame
  and guilt, impaired self esteem
• Majority of UI people do not seek help because
  they consider it a normal part of aging

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Implications of Urinary Incontinence (contd)

• Social
• Social isolation, avoidance of activities
• Economic
• Costs not covered by insurance
• Direct costs of UI 16 billion/year
• Costs to nursing homes 5.2 billion/year
• Estimated 3 - 8 of nursing home costs and 1hr
  labor per day go to incontinence care
• Plus costs of medical effects like falls,
  fractures, pressure ulcers

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Assessment

• Transient Urinary Incontinence
• caused by onset of an acute problem and should
  resolve once problem is successfully treated
  (P.551, Table 15-2).
• Established Urinary Incontinence
• Stress UI
• Urge UI
• Overflow UI
• Functional UI
• Mixed UI

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• Stress incontinence involuntary loss of urine
  during activities that increase intra-abdominal
  pressure (Triggered by laughing, sneezing,
  coughing or straining of abdominal muscles)
• Absence of bladder contraction or
  over-distention.
• Related to pregnancy, obesity, surgery, exercise,
  medications
• Small amounts urine lost
• Occasional or continual episodes of incontinence
• Treatment biofeedback, Kegel exercise.

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• Urge incontinence a strong, abrupt desire to
  void and the inability to inhibit leakage in time
  to reach a toilet.
• Related to birth defects, spine or nerve damage,
  immobility, prostate problems or cancer
• Moderate to large amounts of urine lost
• Occasional or situational episodes of
  incontinence
• Increase risk of falls
• Treatment Kegels

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• Overflow incontinence overdistention of the
  bladder due to abnormal emptying.
• Related to birth defects, spine or nerve damage,
  MS, loss of bladder muscle tone, surgery,
  medications
• No warning prior to incontinent episode
• Small to moderate amount of urine lost
• Frequent or continual incontinence
• Treatment treat cause, intermittent cath,
  bladder scans for post-void residuals

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• Functional incontinence refers to problems from
  factors external to the lower urinary tract such
  as cognitive impairments, obesity, clutter,
  immobility, or environmental barriers.
• Related to inability to get to bathroom
  facilities due to functional reasons
• May be associated with urge incontinence (mixed
  incontinence)
• Treatment modify environment modify lifestyle

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• Mixed incontinence
• Clinically, patients may exhibit symptoms of more
  than one type of incontinence.
• Pure stress and pure urge incontinence were
  uncommon in a urodynamic evaluation of people age
  65 years or older.

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Assessment (contd)

• Data Gathering
• History and other pertinent data
• Bladder diary (Figure 15-2, P. 554)
• UI Interview Instruments (Table 15-4, p. 555)
• Cognitive status
• Physical Assessment

General Hydration Genitourinary Rectal Abdominal Bladder Volume Urinalysis Environment
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Interventions and Care Strategies

• Patient-Centered Urinary Incontinence Treatment
  Goals
• Understanding the patients expectations for
  treatment outcomes will provide direction for
  intervention
• Patient goals are multidimensional don't
  necessarily require total continence for patient
  satisfaction and improved health-related quality
  of life

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Interventions and Care Strategies

• Behavioral Management
• Prompted voiding (Table 15-7, p. 565) for the
  physically cognitively impaired people.
• Bladder training (Table 15-8, p. 566) for the
  physically cognitively independent, community
  dwelling people.
• Pelvic muscle rehabilitation draw in and lift
  up the rectal/anal sphincter muscles. Lift up
  the perivaginal muscles and avoid contracting the
  abdominal muscles. 10 repetitions 23 x /day (P.
  568)

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Interventions and Care Strategies (contd)

• Pharmacological Management (Table 15-9)
  Oxybutynin, Imipramine, Tamsulosin
• Can add to the effectiveness of behavioral
  strategies in frail older persons with urge UI
• Potential for adverse reactions
• Added cost
• Devices and products
• Continence garments
• Toileting equipment and collection devices

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Interventions and Care Strategies (contd)

• Skin care
• Preventing skin breakdown is very important
• Moisture barriers
• Moisture barriers no-rinse incontinence
  cleansers are recommended over soap and water
  alone in preventing skin breakdown.
• Incontinence-associated dermatitis (IAD)
• Increases risk of pressure ulcers

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Interventions and Care Strategies (contd)

• Environmental Intervention
• Modifying environment to allow rapid access to
  the toilet
• Indwelling urinary catheters
• No longer primary means of managing UI
• Centers for Medicare and Medicaid Services (CMS)
  developed regulations for guidance of long-term
  indwelling catheter use. (Table 15-10, p. 574)

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Summary

• Urinary incontinence
• is a serious, potentially disabling condition
  with negative social, physical, psychological,
  and economic impacts
• is a common condition in the older population,
  but is not a part of the normal aging process
• can be successfully treated for improved
  health-related quality of life