Transcript Restorative Bowel and/or Bladder Retraining & Maintenance

Do we have an incontinence problem?
South Dakota Foundation for Medical Care
South Dakota’s Quality Improvement Organization (QIO)
A thought to ponder….
How does it make me feel?
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Embarrassed
 “I’m not going in there like this!”
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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
Anxiety
Diminished self-esteem
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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
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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?
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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
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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
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bladder can’t handle the increased compression during
exercise, coughing or sneezing
Urge Incontinence
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caused by sudden, involuntary bladder contraction
Mixed Incontinence
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combination of both stress and urge incontinence
Types of Incontinence
Overflow Incontinence
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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
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delirium
fecal impaction
depression
symptomatic urinary tract infection
edema
Possible Reversible Factors
Environmental Conditions
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impaired mobility
lack of access to a toilet
restraints
restrictive clothing
Possible Reversible Factors
Excessive Beverage Intake
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caffeine
Disease
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Parkinson’s
other neurological diseases effecting motor
skills
Possible Reversible Factors
Medications
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diuretics
drugs that stimulate or block sympathetic
nervous system
psychoactive medications
Contributing Factors
Resident Conditions
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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
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elevated blood glucose
elevated calcium
Assessment of Incontinent Residents
Identify potentially reversible and
contributing factors
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bladder record or voiding diary
targeted physical examination
 including rectal exam and pelvic in women
Assessment of Incontinent Residents
Optional tests as appropriate
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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
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3-5 day trial
prompted or timed voiding
Residents responding favorably should
continue with plan
Residents not responding favorably
should be referred for other treatment
options
Other Treatment Options
behavioral therapy
drug therapy
surgical treatment
electrical stimulation
intravaginal support devices
pads and external collection devices
intermittent catheterization
Drug Therapies
Urge Incontinence
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anticholinergics
bladder relaxants
Stress Incontinence
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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 record
resident satisfaction with treatment
side effects of treatment
Physical and Environmental Barriers
Toilet/commode accessibility
Grab bars are present if needed
Toilet seat is adequate height
Lighting is adequate
Commodes and urinals are used as
supplements as needed
Furniture allows easy rise for resident to be
able to get up to go to the bathroom
Call light is within reach / ability to use
Contractures
Ambulatory assistive devices needed
Physical Limitations
Ease of taking garments off and putting
on
Getting to the toilet
Ability to perform hygiene tasks
Current Approaches
Bladder retraining
Prompted voiding
Pads/briefs
Habit training
Prompted voiding with assistance
Catheter
Ureterostomy
Pelvic muscle rehabilitation
A Successful Restorative B&B Program Includes:
Adequate fluid intake
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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
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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
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Facility Assessment Checklists – Incontinence
Quality Measures Manual
RAI Manual
AMDA
Clinical Practice Guidelines
www.guideline.gov
Contact Us
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Bernadette Nelson, RN, Project Manager
 Phone (605)336-3505 Extension 263
 Email: [email protected]
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Rhonda Streff, RN, Assistant Project Manager
 Phone (605)336-3505 Extension 262
 Email: [email protected]
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Ryan Sailor, Analyst
 Phone (605)336-3505 Extension 220
 Email: [email protected]
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Jane Viereck, Coordinator
 Phone (605)336-3505 Extension 266
 Email: [email protected]