Nighttime Management of Incontinence

Bladder and Bowel Master Series Independent Study Monograph IV Nighttime Management of Incontinence by Diane K. Newman, DNP, ANP-BC, FAAN This Mon...
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Bladder and Bowel Master Series

Independent Study Monograph IV

Nighttime Management of Incontinence

by Diane K. Newman, DNP, ANP-BC, FAAN

This Monograph was supported through an unrestricted educational grant made available by SCA Personal Care

Copyright © 2012 Diane K. Newman ALL RIGHTS RESERVED. This Document or parts thereof, may not be reproduced in any form without written permission from the author. This material was compiled from material copyrighted by Diane K. Newman. This manual contains proprietary materials, which are copyrighted by Diane K. Newman. You may not resell or distribute this material in whole or in part in any form whether by itself (altered or unaltered) or as part of another collection. The U.S. Copyright laws govern this material.

© 2012 Diane K. Newman

Monograph IV

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Bladder and Bowel Master Series PURPOSE Nighttime Management of Incontinence is Independent Study Monograph IV of a four part Bladder and Bowel Master Series combined to present a structured bladder and bowel rehabilitation program. The series is designed to help your residents’ progress from incontinence to continence and from constipation to regularity, through carefully guided nursing management. They are based on standard bladder and bowel training concepts combined with the newest theoretical and practical knowledge about rehabilitating the incontinent elderly. The Bladder and Bowel Master Series complies with current regulations included in the Resident Assessment Instrument: Minimum Data Set (MDS) Version 3.0, Care Area Assessments (formerly known as Resident Assessment Protocols or RAPs) and Care Area Triggers. The Master Series also incorporates requirements of the Quality Indicators and Quality Measures, and the Centers for Medicare and Medicaid’s (CMS) guidance Tag F315. These are all detailed in Monograph I. According to the Centers for Medicare and Medicaid Services (CMS), care for the resident with UI should be provided based on the type, severity, and underlying cause (s). The nursing intervention must be appropriate and consistent with the comprehensive assessment. The Master Series involves key components of bladder and bowel assessment, restorative bladder and bowel programs, skin care strategies, use of products and devices, and nighttime incontinence management. These Monographs are an essential resource for education of nursing home staff. These Monographs have been prepared for you, the nurse. Its goals are to: 1. 2. 3.

To increase your knowledge of the problem, causes of bladder bowel problems. To provide the essentials of resident evaluation, and the prospects for managing these conditions. To assist you in a step-by-step approach with the training of nurses and nursing assistants to implement a Bladder and Bowel restorative nursing care program in your facility.

Independent Study Monograph IV, Nighttime Management of Incontinence, is a practical guide for management of nighttime urinary and fecal incontinence, a difficult nursing problem in long term care residents. Monograph IV lists all products and devices used to contain urine leakage, with emphasis on nursing care to prevent any adverse complications from their use. I wish success for you, your staff, and your residents!

Diane K. Newman

© 2012 Diane K. Newman

Monograph IV

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Bladder and Bowel Master Series OBTAINING CONTINUING NURSING EDUCATION (CNE) This continuing nursing education activity was approved by the Society of Urologic Nurses and Associates (SUNA), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. SUNA Approval Number is 32-23. The expiration date of this activity is 05/24/2015. This continuing nursing education activity is made available at www.seekwellness.com and from SCA Personal Care. Requirements for completion of the program can be found at the website www.seekwellness.com. There is no cost to the participant for obtaining continuing nursing education credit. To receive a certificate for 1.0 contact hour credits, the participant must: (1)

Study the material in this monograph,

(2)

Take the Post-Test found in Appendix VI and attain a passing score (for this test, 8 out of 10 questions answered correctly); and

(3)

Complete the program Evaluation Form found in Appendix V

The participant must then mail or fax the Post-Test and Evaluation Form to: Wellness Partners, LLC 237 Old Tilton Road Canterbury, NH 03224 (Fax) 603-783-3328 The participant can also take the Post-Test and complete the Evaluation Form online at www.seekwellness.com. A “Certificate of Contact Hour Credit” and corrected Post-Test will be mailed, faxed or emailed to participant within 6 weeks after submitting the post-test and evaluation. Disclosure Information: This educational activity was made possible through a grant from SCA Personal Care. Diane Newman and Lenore Howe are Consultants to SCA Personal Care. The discussion of any product, company, or corporation in this activity in no way signifies an endorsement of the product, company or corporation by ANCC Commission on Accreditation, SUNA, or Diane K Newman. No off-label use of any product is presented or discussed in this activity/Monograph.

© 2012 Diane K. Newman

Monograph IV

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Bladder and Bowel Master Series TABLE OF CONTENTS Learning Objectives……………………………..…..………….…………………...……..…..….4 Overview – Nighttime Voiding and Urinary Incontinence..…..…..………………...….….…......5 Causes of Increased Nighttime Voiding ……..…..…..………….…………..……………...…….7 Importance of Sleep Hygiene..…….…………………………........................................................8 Consequences of Nighttime Incontinence..…..…..………….…………….………...…..….….....9 Overview – Nighttime Fecal Incontinence..…..…..………….…………………….……….…...10 Use of Strategies and Alternative Measures……………………………………..........................11 Promoting Sleep Hygiene and Minimizing Nighttime Voiding………………….……...12 Use of Absorbent Incontinence Products……….…………..……………………...…….14 Use of Toileting Devices……………….………..……………………….….…………..17 External Catheter & Pouches……………….………..………………….………..……...19 Importance of a Skin Care Program..…………………………………………….………………23 Appendix I – References Appendix II – Glossary Appendix III – Care Plan 1. Nursing Diagnosis – Urinary elimination: nighttime incontinence Appendix IV – Post Test Appendix V – Independent Study Evaluation Form

© 2012 Diane K. Newman

Monograph IV

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Bladder and Bowel Master Series LEARNING OBJECTIVES At the end of this Independent Study Monograph, the participant will be able to: 1.

Describe the causes and consequences of nighttime voiding and incontinence (nocturia, nocturnal enuresis).

2.

Details strategies for reducing nocturia and nocturnal enuresis.

3.

Explain the indications and applications of absorbent products, toileting devices, and external catheters.

4.

Characterize the use of absorbent products for residents with nighttime incontinence.

5.

Define the reason for not using an “open to air” technique for managing nighttime incontinence.

NOTE: A Reference list, Glossary of commonly used terms and Care Plans are found in Appendix I, II and III.

© 2012 Diane K. Newman

Monograph IV

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Bladder and Bowel Master Series OVERVIEW – NIGHTTIME VOIDING AND URINARY INCONTINENCE Nighttime voiding is called “nocturia” and defined as more than two voids per night. Urinary incontinence (UI) or the loss of urine during sleep is called “nocturnal enuresis” or nighttime incontinence. Nighttime voiding and UI are major problems for many older adults and is a common problem in nursing home residents. Prevalence of nocturia has been reported in 58 to 90% of persons over 50 years of age and it increases rapidly in persons over age 65. Aging causes an increase in nocturia, defined as the number of voids recorded from the time the individual goes to bed with the intention of going to sleep, to the time the individual wakes with the intention of rising. Nocturia can also be diagnosed as nocturnal polyuria, a condition in which the largest amount of urine production occurs at rest while the person is supine (lying down flat). During the night, there is a lower level of physical activity and body fluid moves more quickly from one part of the body to another, causing an increase in the amount of urine in the bladder. The reason nocturnal enuresis occurs in adults is thought to be attributed to multiple factors. A large percentage of adults have significant symptoms associated with bedwetting and may have daytime UI as well. Nocturia and nocturnal enuresis have a large impact on a resident’s daily functioning. They can result in fatigue, sleepiness, falls, fractures, traumatic injuries, and can affect quality of life. They also have an impact on staff work levels and a facility’s costs. Types of nocturia which can occur alone or in combination include: Nocturnal polyuria (or nocturnal diuresis) is when 24 hour urine output is essentially normal, but there is an increased production of urine overnight with over 1/3 of urine produced at night. In those aged 65 and over, more than 33% of the 24 hour urine production occurs at night due to: o Changes in the circadian rhythm of water excretion o Changes in body fluid distribution. Lying flat promotes the movement of body fluid from extracellular spaces to blood vessels, causing an increase in the amount of urine in the bladder. This fluid shift might be caused by congestive cardiac failure, venous insufficiency/ peripheral edema and other medical conditions. o Reduced production of antidiuretic hormone (ADH). ADH tells the kidneys to decrease the amount of urine produced. Normally, the body produces more ADH at night, causing the kidneys to produce less urine. Decreased urine production at night allows people to sleep through the night without having to urinate. However, some people (e.g. elderly) do not produce the appropriate amount of this hormone at night, which leads to high production of urine. This is very similar to a symptom related with Type II Diabetes where an ineffective amount of ADH is produced. In other cases, the body produces ADH, but the kidneys do not respond and continue to produce the same amount of urine.

© 2012 Diane K. Newman

Monograph IV

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Bladder and Bowel Master Series Reduced bladder capacity Smaller bladder size leads to nocturia when urine output is greater than the reduced bladder capacity/size. If capacity is less than nighttime urine volume, the resident will awaken with the desire to urinate or will experience incontinence. This may be a problem with residents who have overactive bladder as small volumes in the bladder will give more frequent signals of the need to urinate. Causes of small bladder capacity include: o Age related changes in the muscle fibers of the bladder. o Increased bladder sensation. o Bladder overactivity or overactive bladder (e.g. due to bladder outlet obstruction from prostate enlargement; neurological conditions such as stroke and Parkinson’s disease) Diurnal Polyuria An overall increased urine production is present and results in nocturia as urine output is greater than bladder capacity/size. For example, in 24 hours, more than 40ml/kg (body weight) of urine may be produced (e.g. for 80kg person >3200ml). Causes include: o High fluid intake by choice o Psychogenic polydipsia, has been associated with psychotropic medications o Diabetes mellitus o Nephrogenic diabetes insipidus (often secondary to lithium) o Central diabetes insipidus o Hypercalcemia

© 2012 Diane K. Newman

Monograph IV

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Bladder and Bowel Master Series CAUSES OF INCREASED NIGHTTIME VOIDING There are several causes of nighttime voiding and enuresis including chronic medical conditions such as congestive heart failure, venous stasis with peripheral edema, hypoglycemia and excess urine output, obstructive sleep apnea, and diuretics, as well as evening/nighttime fluid consumption which can lead to nocturnal polyuria. The following provides more details on these causes. Causes of Nocturia and Nocturnal Enuresis Sleep disorders or problems

Reason

Obstructive sleep apnea. Residents with heart failure have difficulty in lying flat to sleep, falling asleep, and maintaining sleep, as well as waking up too early. If the resident has multiple awakenings in one night, they may want to urinate.

Medications

Some medications have been documented to cause nocturnal enuresis as a side effect. including hypnotics or medications taken for insomnia and drugs taken for psychiatric purposes (e.g. thioridazine, clozapine, and risperidone).

Symptom of an underlying medical condition

Adult onset nocturnal enuresis is often a result of narrowing or blockage of the urethra. In men, this occurs with an enlarged prostate in men or narrowing of the neck of the bladder. In women, such problems can be associated with pelvic organ prolapse (dropped bladder, uterus).

Daytime sleeping

Residents spend a significant amount of the daytime asleep and factors that contribute to daytime sleepiness include decreased daytime activity, decreased light exposure during the day, increased light and noise during the night, poor sleep hygiene and fragmented sleep during the night due to sleep disorders, medications, and medical comorbidities.

© 2012 Diane K. Newman

Monograph IV

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Bladder and Bowel Master Series IMPORTANCE OF SLEEP HYGIENE A good sleep hygiene routine promotes healthy sleep and daytime alertness. Good sleep hygiene practices can prevent the development of sleep problems and disorders. Staff in LTC should be aware of sleep hygiene practices that are necessary to have normal, quality nighttime sleep and full daytime alertness. Poor sleep habits or hygiene is a common problem encountered in many older adults, especially in residents in nursing homes. Older adults tend to have frequent awakenings which can have a negative impact on daily alertness and activity. The most important sleep hygiene measure that can be adopted by residents is to maintain a regular sleep and wake pattern, seven days a week. It is also important that the resident spend an appropriate amount of time in bed, not too little, or too excessive. This may vary by individual; for example, if someone has a problem with daytime sleepiness, they should spend a minimum of eight hours in bed, if they have difficulty sleeping at night, they should limit themselves to 7 hours in bed in order to keep the sleep pattern consolidated. Additional sleep hygiene practices include reduction or elimination of caffeine, nicotine, and alcohol use; maintenance of regular bed and wake times; and avoidance of napping.

© 2012 Diane K. Newman

Monograph IV

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Bladder and Bowel Master Series CONSEQUENCES OF NIGHTTIME INCONTINENCE There is research showing that interrupted sleep can possibly impact many areas of a resident’s daily life and care. It can cause physical aggression and hostility, especially during daytime hours, it can increase the number of falls, and it can increase requests for pain medication and sedatives. Self-feeding skills and consumption of food also show improvements if someone gets a good sleep. The problem is that routine nighttime care in a nursing home involves frequent and routine awakenings for managing incontinence episodes, despite best efforts to provide residents with good care. Staff will continue to see residents who exhibit daytime sleeplessness and nighttime sleeplessness. Quality sleep gives the body the chance to refresh and repair itself, and is essential to overall well being for any nursing home resident. The following is a list of the consequences of nocturia and nocturnal enuresis: Sleep disturbance. Most significant consequence of nocturia that results in increased fatigue during the day and decreased energy and activity. The number of episodes of nocturia is significantly associated with the number of hours of sleep. Falls. Nocturia is an independent risk factor for falls with the risk increasing as the number of episodes of nocturia increases. Falls may happen on the way to the toilet, during the night (“direct falls”), or during normal waking hours due to tiredness (“indirect falls”). Depression. There has been a significant association seen in men and women between nocturia and major depression. Skin breakdown. Nocturnal enuresis can lead to perineal skin breakdown if the resident does not receive adequate nighttime incontinence care.

© 2012 Diane K. Newman

Monograph IV

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Bladder and Bowel Master Series OVERVIEW – NIGHTTIME FECAL INCONTINENCE Fecal incontinence (FI), the involuntary passage of fecal material through the anus, is a common medical problem in older people, especially in frail older nursing home residents. FI is often associated with UI. FI affects resident’ physical and psychological well-being, and is responsible for considerable morbidity and mortality in older patients. The spectrum of FI varies from mere soiling of the undergarments by liquid stools, to loss of control of even solid stools. Minor degree of FI, manifesting as soiling or smearing, especially when stools are loose, or poor control of flatus, is not uncommon in frail older patients. Diarrhea is common in the nursing home and is a particular problem in frail residents. Diarrhea is a significant cause of increased expenditures in the nursing home because of nursing time and laundry expenses. Most deaths from diarrhea occur in older persons, usually in association with dehydration.

It is important that nursing staff institute a routine for nighttime management of FI and/or diarrhea so as to prevent skin breakdown.

© 2012 Diane K. Newman

Monograph IV

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Bladder and Bowel Master Series USE OF STRATEGIES AND ALTERNATIVE MEASURES Nursing care strategies to reduce nighttime urine volume and voiding, and alternative measures such as devices and products are used in residents who experience nighttime urinary and FI. The goal is to manage the urine and fecal leakage, while promoting an adequate sleep period. Strategies that promote good sleep hygiene will also minimize nighttime voiding. Urinary collection devices and products can promote sleep. They include: Absorbent Incontinence Products & Skin Care Toileting Devices External Collection Systems (urinary or bowel) These products can be beneficial for residents who: Have failed treatment and remain incontinent Who are too ill or disabled to participate in a behavioral programs Who cannot be helped by medications Who have overflow UI that cannot be alleviated by other interventions (e.g., drugs or surgery) The judicious use of products to contain urine loss and maintain skin integrity is a first-line defense for these residents. The issues surrounding in continence care during the night for longterm care residents are complex and will require coordination of the efforts of all nursing staff.

© 2012 Diane K. Newman

Monograph IV

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Bladder and Bowel Master Series Promoting Sleep Hygiene and Minimizing Nighttime Voiding Definition: Practices used by the staff and the resident to promote normal, quality nighttime sleep and full daytime alertness. Objective: To promote good sleep hygiene and maintain a regular sleep and wake pattern seven days a week. Strategy: The promotion of good sleep hygiene practices include: 1. Encourage regular sleep during nighttime hours. Discourage the resident from taking naps during the day; it can disturb the normal pattern of sleep and wakefulness. It is also important to spend an appropriate amount of time in bed, not too little, or too excessive. This may vary by resident; for example, if someone has a problem with daytime sleepiness, they should spend a minimum of eight hours in bed, if they have difficulty sleeping at night, they should limit themselves to 7 hours in bed in order to keep the sleep pattern consolidated. 2. Avoid Dehydration. Approaches that have been successful in increasing hydration in long-term care residents include: offering more between-meal snacks, supervision of residents at mealtimes to ensure adequate ingestion of liquids, designating a certified nurse assistant who is responsible for offering fluids every 2 hours from a “beverage cart,” and switching to a five-meal plan that provides a more even distribution of fluids over a longer period of time. 3. Monitor Fluid Intake. Limiting intake of fluids in the late afternoon and evening before bedtime causes a decreased amount of urine produced at night. This could be a helpful first step to reduce wet nights. However, this does not mean that overall fluid intake should be reduced. The largest amount of urine production occurs at rest, usually between the hours of midnight and 8:00 AM. To decrease nocturia precipitated by drinking fluids primarily in the evening or with dinner, the person should be instructed to reduce fluid intake after 6 PM and shift intake toward the morning and afternoon. 4. Dietary Modification. Elimination of caffeine-containing beverages and foods in the evening hours, especially with dinner, will decrease the frequency of nighttime voiding. Beverages containing caffeine and alcohol will be more irritating, so eliminate all caffeine and alcohol containing beverages in the afternoon, and especially in the evening. These beverages should not be ingested after 6 PM. Remember that even decaffeinated drinks (tea, coffee, soda) have some caffeine and should be avoided. Chocolate pudding © 2012 Diane K. Newman

Monograph IV

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Bladder and Bowel Master Series or protein drinks contain caffeine, so if the resident is given chocolate ice cream, pudding or cake with dinner or as a nighttime snack, this may worsen nocturia problem. 5. Avoid Eating Before Sleep. Food can be disruptive right before sleep so avoid serving the residents large meals close to bedtime. Also dietary changes can cause sleep problems, if someone is struggling with a sleep problem, it's not a good time to start experimenting with spicy dishes. And, remember, chocolate has caffeine. 6. Bladder Training. This technique is an effort to increase bladder capacity in those who have a small bladder capacity so as larger voided volumes occur during daytime hours. The training involves drinking large amounts of fluid during the daytime and refraining from voiding as long as possible, up to 2 to 3 hours. Through training, the bladder capacity is increased, making voids more infrequent. This method may be especially helpful to those diagnosed with an overactive bladder, a condition in which the muscles of the bladder contract frequently and involuntarily. This is discussed in more detail in Monograph 3. 7. Reduce Peripheral Edema. Residents with peripheral edema (e.g. swelling in their legs) should elevate the lower extremities for several hours during the afternoon. This will help to stimulate a natural diuresis and limit the amount of edema present at bedtime. These residents may also want to consider wearing support stockings. 8. Alter Diuretic Administration. The use of diuretics has been associated with nighttime urine volumes. Altering the timing of the administration of diuretics (e.g., giving diuretics at 2:00 PM rather than 6:00 or 7:00AM) may decrease nocturia. Residents who are taking diuretics should maintain adequate fluid intake by drinking the bulk of their liquids before dinner and restricting fluids in the evening. 9. Ensure a Sleep Conducive Environment. An intervention that combines individualized nighttime incontinence care with a noise and light abatement program can significantly reduced awakenings. Nighttime waking episodes lasting four minutes or longer are associated with noise, light, or incontinence care activities. A noise and light abatement program that centers on common sense procedures, such as closing doors to residents' rooms, fixing squeaky equipment, turning off unattended TVs and radios, and using table lamps instead of overhead lights, should be followed when providing incontinence care. 10. Assess for Risk of Skin Breakdown. Staff should assess residents to determine their risk of developing skin problems. Then nursing staff should conduct hourly incontinence rounds and provide incontinence care only if the resident is found awake during the round. Residents at low risk for skin problems should be allowed to sleep for as many as four consecutive hourly checks. Residents at high risk for skin problems should be allowed to sleep for only two consecutive hourly checks and awakened on the third if asleep.

© 2012 Diane K. Newman

Monograph IV

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Bladder and Bowel Master Series Use of Absorbent Incontinence Products Definition: Absorbent incontinence products (referred to as “bodyworns”) absorb or contain urine leakage and are either disposable or reusable. Products, such as absorbent incontinence products, contain or collect the urine and are a part of the management of nighttime bladder dysfunction. The following are available: Perineal pads or panty liners for slight or light incontinence Guards and drip collection pouches for men Undergarments and protective underwear for moderate to heavy leakage Adult briefs (diaper-style products) for moderate or heavy incontinence Washable pant/disposable pad systems Reusable/washable products Objective: To contain urine leakage in those residents who are not capable of maintaining continence independently, through regular toileting, or other measures. NOTE: Residents with cognitive impairment and who need the assistance of two staff members or mechanical lifts, may be more appropriately managed with absorbent products and preventive skin care practices. Choosing the Most Appropriate Product An incontinence absorbent product should be chosen based on its absorbing properties, quantity of urine leakage and ability to minimize or prevent exposure to urine and feces. Changing technology in absorbent product composition involves the use of super-absorbent polymers (SAP). This technology may have a significant impact on IAD and subsequent development of pressure ulcers. Most of these products are “skin-friendly,” which means they provide a surface area against the resident’s perineum, which collects and transmits the urine to the SAP inner core that holds more urine than fluff pulp (e.g., the TENA® brand). These products have two layers, an upper layer that distributes the urine more efficiently, and maintains a drier layer next to the skin, and the outer layer that provides the absorption capacity. These products have “breathable” backings to reduce skin occlusion. This inner core promotes urine distribution throughout the entire pad, facilitating absorption capacity, while preventing urine leakage and odor. Most incontinence experts recommend the use of products containing SAP. Complications: Incontinence-associated dermatitis, skin irritation, breakdown, and infection (bacterial and fungal), and UTIs © 2012 Diane K. Newman

Monograph IV

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Bladder and Bowel Master Series

NOTE:

The use of disposable blue bed pads (e.g. blue Chux) should not be used to manage UI or FI. These products trap the moisture against the skin, as they are plastic-backed or non-polymer. These can also interfere with moisture control with support surfaces (e.g. low air-loss mattresses).

Considerations: Incontinence pads come in different shapes, sizes and absorbency. Select the best product after careful assessment. Consider resident comfort, ease of application/removal, containment of urine and control of odor. Consider ease of product use in those residents who are independent and self-toileting, but need some protection for occasional urine leakage. Select a more absorbent product in those residents who are not capable of maintaining continence independently, through regular toileting or other measures. The adult brief (diaper) is used for severe UI and may be indicated if the resident has double incontinence, both FI and UI, and is non-ambulatory. Some products have a wider back that can offer more protection and should be used at nighttime when there is an increase in bladder volume (See Monograph IV). Two piece products (e.g. pad and pant system) are very helpful with residents who have moderate levels of incontinence. There are also plus size or bariatric size for residents who may need a larger pad (e.g. obese residents). Avoid applying absorbent products too tightly, as an occlusive environment traps heat, and elevates skin temperature and moisture, which then produces friction and promotes microbial overgrowth. With the current polymer technology found in quality incontinence products, it is not uncommon to see change rates between 3.5 to 4.5 times per day without experiencing a decrease in quality of care or adverse skin effects. It is felt that absorbent products do not cause UTIs, especially if they contain SAP, and are changed after a FI episode. Staff should avoid the use of plastic and reusable cloth products, since these products trap in heat and moisture, leading to skin breakdown. Reusable products are not recommended for persons with FI because of stool staining. Avoid leaving a resident “open to air” at night as it has never been shown to be beneficial in preventing skin breakdown. o This “open to air” at night is a term for an old care practice that is still used in many LTC facilities. This is when the resident is positioned during nighttime sleeping hours, on a disposable, reusable underpad, without an absorbent product. Some nurses believe that the uncovered skin will be allowed to breathe, allowing a better climate for the skin. Most health care experts agree that this practice is not beneficial for the resident with either UI or FI and it should be avoided. Institute a skin breakdown prevention program when using incontinence products. Residents with incontinence, whose urine leakage is being contained through use of an absorbent product, are at increased risk for skin breakdown. Moisture from urine, stool, and repeated washing, cause increases in the friction coefficient of the skin, resulting in © 2012 Diane K. Newman

Monograph IV

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Bladder and Bowel Master Series mechanical injuries, such as skin chaffing from contact with linens, absorbent products, and water soluble irritants, like detergents. Skin moisture can also lead to maceration and epidermal injury. In residents using incontinence products, apply moisture barrier products. Skin barrier products repel irritants and moisture by providing a water-repellant coating to the skin. These can be used for prevention of skin breakdown or therapy for skin damage due to incontinence. MYTH: Open to air protects the skin. When a resident is left to open air, the urine and feces are not properly contained. Without the wicking action of a “body closed” absorbent product, positioned close to the perineum, urine leakage may run into the folds of the skin. Prolonged exposure to urine and fecal skin left in the skin creases and on perineal surfaces can lead to discomfort, skin irritation, maceration and eventual skin breakdown especially with prolonged exposure.

© 2012 Diane K. Newman

Monograph IV

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Bladder and Bowel Master Series Use of Toileting Devices Definition: Hand-held containers and devices, often referred to as “portable toilet substitutes,” can be used by the resident or nursing staff to collect urine. There are two general categories; one includes commode seats or bedside commodes, and the others are hand held devices (e.g. bedpan, urinal). Teaching the resident to use a toileting device is an important part of restorative nursing and bladder rehabilitation. Objective: To promote self-toileting through the use of devices when: Toilet facilities are inaccessible Doorways and bathrooms are too narrow for access (e.g. if using a walker, wheelchair) Nocturnal frequency and urgency is a significant problem Decreased mobility Complications: Incontinence-associated dermatitis (IAD), pressure ulcer Considerations: Involve a physical or occupational therapist to modify the resident’s environment. NOTE: In one study, toilet height for 45.2% of nursing home residents was higher than the optimal height (defined as 100% to 120% of the resident's lower leg length), which could consequently increase risk of falls and difficulty toileting. Toilets and Commode Chairs – o Many different commodes exist that can ease toileting. Some have drop arms and adjustable heights to allow for tailoring the commode to the resident’s needs (see Figure 1). Other commodes are backless and can be placed on a toilet for quick adaptation in a bathroom. o There are general areas that need consideration when selecting a commode that include:  Height and weight of the person using the commode.  A plastic seat with a large soft surface area may allow even distribution of bodyweight.  Seats with grab bars on either side can prevent falling and provide assistance when rising.

© 2012 Diane K. Newman

Monograph IV

Figure 1 Portable commode with risers

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Bladder and Bowel Master Series Bedpans - Often the use of a fracture pan makes the resident more likely to be able to urinate without pain, especially in the period after a fracture or hip repair. Resident should not be left on the bedpan for more than 15 to 20 minutes, as this device does not allow correct positioning for complete bladder emptying. Urinals have the potential to enable residents who experience difficulty accessing a toilet to regain continence. These devices are useful for residents who have severe mobility restrictions or in those residents who are confined to a bed or chair. Most urinals have handles so they can be placed next to the resident, can be hung on a bedrail, wheelchair, walker, or can be laid flat on the bed. o Male Urinals - Residents with decreased manual dexterity or with a retracted penis may have difficulty with regular, standard male urinals. A physical or occupational therapist can recommend a urinal that has a funnel opening and flange that extends into the urinal (called “rehab urinals”) which does not allow for backflow or spillage, even when held almost upside down. These urinals have a flat bottom allowing for placement on a bed or bedside table. o Female Urinals - It may be difficult to find a female urinal that can be used effectively by women with poor mobility or who are non-ambulatory. Find one that is easy to use and has a flat side to facilitate non-ambulatory use of the urinal. Women in wheelchairs, after positioning themselves in front of the toilet, can use a funnel-shaped urinal that cups the perineum or vulva area and is more likely to be successful when used in the standing or squatting positions. Toilet-assisted technology, such as a standing lift, can be used to transfer the resident between beds, wheelchairs, or commodes. The lift is equipped with safety devices to prevent falls.

© 2012 Diane K. Newman

Monograph IV

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Bladder and Bowel Master Series External Devices and Products Definition: External catheters and devices can be used for drainage or collection of urine. There are ones for men that are applied externally on the penis (referred to as a condom catheter) or pouches that adhere externally to the perineum (e.g. female pouch, retracted penis pouch). The external catheter or pouch is a non-invasive device, is not inserted into the body, and makes no contact with the inside of the urethra or bladder. These types of catheters and urine collection devices are disposable and must be removed and/or changed at least 24 to 48 hours. According to MDS Version 3.0: In men, condom catheters, and in females, external urinary pouches, are commonly used intermittently or at night only. This use should be coded as external catheter. The male external catheter is placed over the penis, in the same way as a condom used for birth control. Unlike a normal condom, a male external catheter has an open drainage funnel or plug to which a drainage tube is attached. This allows the urine to pass into a drainage bag. Most male external catheters have either adhesive on the inside surface of the catheter or have adhesive strips that can be wrapped around the penile shaft and the catheter is rolled over the secure it (see Figure 2). Catheter material can be latex, polyvinyl or silicone. There are also external pouches with pectin-based skin

Figure 2 External condom catheter, selfadhesive or adhesive stripes

barriers for both men and women. These external systems are usually connected to larger bedside collection drainage bags or a smaller that can be either fastened around the leg (called a leg bag) (see Figure 3). The most common disadvantage with these catheters appears to be failure to stay in place due to incorrect sizing and placement. Objective: To allow for collection of urine in residents who have UI that cannot be otherwise treated. Complications: Ischemia, skin irritation, maceration, and ulceration, and UTIs that result from improper application and prolonged use of these devices and can include Procedure: © 2012 Diane K. Newman

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Figure 3 External catheter connected to a leg bag Page 20 of 35

Bladder and Bowel Master Series There are several different types of external condom catheters from which to choose. The size and type of catheter depends on the size of the penis and condition of the skin. Applying an external condom catheter: Assess for adequate penile length to support the device. If not, consider a pouch. There are several sizes of condom catheters, so the use of a measuring or “sizing” guide supplied by manufacturers is recommended. When choosing a size, allow for nocturnal erections. Assess the condition of the skin to determine if a skin barrier product needs to be applied prior to the placement of the device to protect the penile skin from breakdown caused by repetitive application and removal of an adhesive device. Always apply any type of external device to a clean, dry surface and trim all hairs (do not shave them but cut them) from the penile shaft. Applying an external condom catheter: o The self-adhesive external catheter has a sticky Figure 4 film on its inner surface which attaches the male Self adhesive external catheter to the penis. The catheter can be external condom rolled up and fixed in place. with a stripe to roll o If the type of external catheter used does not have on the condom adhesive on the internal surface, an adhesive strip is used which attaches the catheter to the penis. The adhesive strips are placed onto the penis (encircling it) and the male external catheter is rolled over the penis attaching to the adhesive strips. If an adhesive strip is applied to the penile shaft circumferentially, monitor skin for pressure and ulceration. Examine for tightness, fit should be snug but not constrictive. o Roll the condom catheter down the penile shaft leaving 1 inch between end of penis and the catheter. Some have a stripe on the catheter that assists in its application (see Figure 4). Do not allow a roll of the condom catheter to occur at the base of the penis since this can easily cause ulceration and pressure under the penile shaft. o Use the heat of the hand to help the self-adhesive condom catheter “stick.” Also, a medical adhesive (used when applying ostomy bags) can be applied around the penile shaft to insure that the catheter “adheres” to the penis. The adhesive must be dry before rolling on the catheter. Prior to placing a new device, the penis should be inspected for any skin irritation, redness or open areas. A convenient time to change is during the resident’s bath time. During external catheter use, monitor the male resident for adverse effects such as contact dermatitis, maceration of the tip of penis, ischemia, edema, and obstruction, most of which are the result of improper and prolonged use of these devices. Residents with

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Bladder and Bowel Master Series decreased sensation may not be aware of adverse effects. Urinary tract infection is also a complication seen with prolonged use. Figure 5 Female Urine Collection Pouch

External Pouches:

External collection devices or pouches are available for men and women and may be appropriate for a nursing home resident. These pouches are similar to ostomy pouches. Figure 6 o Available pouches for women include Retracted Penis Pouch flexible vinyl form-fitting devices which are placed over the labia to funnel urine away from the perineum into a drainage bag (see Figure 5). o There is a pouch for male residents who have a retracted penis as it fits over the perineum (see Figure 6). o These devices tend to be more successfully used in immobile residents. Applying a pouch: o Starting with a clean and very dry surface. o Trim pubic hairs. o Apply a medical adhesive (commonly used with ostomy bags) over the labia to insure that the pouch “adheres” to the perineum. The adhesive must be dry before applying the pouch. Once the catheter or pouch is in place, obtain a connecting tube for connection to the drainage bag. It is important to choose the drainage bag that best meets the needs of the resident best. The bag will be either a smaller leg bag or larger bedside drainage bag that has a capacity from 500 to 1000 mLs. A resident might use a smaller bag during the day and a larger one at night. A leg bag is the best choice for active residents. The leg bag needs to be attached properly, in order to allow urine to flow into the bag without difficulty. It can be placed at different positions on the leg: thigh, calf, knee, and is most commonly fastened around the thigh or calf with two straps or a sleeve to hold the bag safely in place which providing comfort in use (see Figure 3). If a larger bedside drainage bag is used, it should be placed below the bladder to permit the flow of urine.

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Bladder and Bowel Master Series Troubleshooting External Catheter Problems with Practical Solutions Problems Pressure sore on the shaft of the penis

Possible Reasons Condom is too small Pressure from the adhesive stripe/tape is too strong

Pressure sore at the foreskin

Pressure from the condom is too high (e.g. due to an erection)

Leg bag drainage problems – urine flow disrupted

The catheter is trapped beneath the elastic trim of the under garment Clothing is too tight The tube is too long or kinked The leg bag is not secured properly The leg bag is not positioned correctly The leg bag contains air Condom does not fit well Hairs may be caught between the condom and the skin – thereby producing small leakages The connecting tube and the male external catheter are not compatible

Condom is leaking

The connecting tube keeps slipping away from the catheter Skin irritation or sores

Skin too damp

© 2012 Diane K. Newman

Sensitivity / allergy for skin care products or material

Condom was applied too soon after a bath or shower

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Possible Solutions Select a larger size condom The adhesive stripe/ tape should not be applied circular but following a spiral pattern Unroll the urinary sheath 4-6 cm to ensure that there is sufficient space between the foreskin and the tip of the condom Select more loose fitting clothes Check the tube Check the leg bag for security and position Replace the drainage bag

Measure again and select the correct size Trim pubic hair

Choose compatible materials Tighten up the connecting a little further into the funnel tip of the condom for more security Replace condom with one made of different material. Use a different brand of adhesive Ideally, wait at least 15 minutes after a shower or a bath before applying the condom

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Bladder and Bowel Master Series

IMPORTANCE OF A PERINEAL SKIN CARE PROGRAM Definition: A perineal skin care program must prevent excessive skin wetness and minimize contact with urine and feces. Both urine and feces contain substances that may irritate the skin. Irritation or maceration resulting from prolonged exposure to urine and feces may hasten skin breakdown, and moisture may make skin more susceptible to damage from friction and shear during repositioning. Objective: To prevent skin breakdown or the development of skin conditions (e.g., IAD) through regular inspection and skin care. Procedure: The perineal and peri-anal areas should be cleansed daily, after removal of an incontinence product and after every bowel movement, liquid stool or FI episode. This is necessary, as fecal enzymes (lipase and protease) convert urea to ammonia, causing an increase in the skin’s permeability, thereby increasing the potential susceptibility for other enzymes to irritate the skin. Great resident and explain procedure. Wash hands and apply gloves. Remove soiled garments, linens and pads as needed – be careful not to dislodge a tube or catheter. Position resident in a side-lying position to expose soiled area. With a washcloth or wipes, gently cleanse the genital area including the peri-anal area (skin around the anus). o In women, always cleanse from front to back (see Figure 5) to avoid spreading bowel bacteria from the rectum to the vagina and from the rectum to the urethra. Check skin folds by gently separating the fold (check for rash, etc.). Assess need for skin care product (e.g. protective moisturizer if redness present) After washing, let the skin dry rather than rubbing with a towel. This will avoid irritation and skin tears. Place soiled underpad/bedclothes in the proper disposal receptacle. Figure 5 Correct way to wash perineum in women © 2012 Diane K. Newman

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IMPORTANT POINTS ABOUT CLEANSING THE PERINEAL AREA:

Soap and water applied with a washcloth, has traditionally been thought of as a gold standard for skin hygiene. However, this procedure is not felt to be the best for residents with incontinence. Soap and water with a washcloth will cleanse the skin, but repeated use tends to dry the skin and most soap and cleansers have a high, alkaline pH. Soap removes the skin’s natural lipids; it also decreases natural lubricants, which leads to increased epidermal water loss. So avoid use of bar soaps. Soap bars are also reservoir for bacteria. Bar soaps and the residue created by soap stored in a moist soap dish or wash basin may harbor bacteria and a bar of soap may be used on multiple residents contributing to the spread of bacteria. Bar soaps used with washcloths can be very irritating, cause increased friction, and may remove oils from the skin, reducing the skin's barrier properties. Consider use of a liquid soap. It is also easier to dispense proper amounts of soap in liquid form. Avoid using water basins as they also harbor bacteria. Alcohol and alkaline agents should be avoided when picking a cleanser since they can be irritants and sensitizers, especially if skin integrity is compromised.

Skin Care Program: Staff should use skin products such as gentle pH balanced cleansers, with appropriate moisturizers and skin protectant products that effectively wash away urine and feces and prevent skin breakdown. o No-rinse perineal washes and cleansers with skin protectant properties (e.g., TENA® Wash Cream) are more skin-friendly than most bar soaps because they are convenient, time saving, and effectively remove the urine and/or feces without resident discomfort. These cleansers are also preferred over the popular bar soaps because the cleaning agents and antiseptics used in these formulations are gentler to the skin than those used in bar soaps. o Wash wipes can also be helpful as it keeps the skin clean and free of irritation from urinary and fecal material. They are soft, smooth and gentle on delicate skin and alcohol free. A 3-in-1 wash cream cleans, moisturizes and protects. These wipes are no rinse pH balanced products and helps maintain skin integrity. They are not greasy or sticky. Wash wipes provide a fresh, more comfortable feeling. o In residents with incontinence, using a skin protectant product will prevent any skin rashes that may occur from urine or feces being against the skin. Always use moisturizers to prevent skin dryness and use a moisture barrier product to protect the skin from breakdown.  Protective skin barriers formulated with petrolatum and zinc can interfere with the fluid absorption of an incontinence product leading to excessive skin moisture, leakage and skin irritation.

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Bladder and Bowel Master Series APPENDIX I REFERENCES Al-Samarrai, N.R., Uman, G.W., Al-Samarrai, T.A., Alessi, C.A. (2007). Introducing a new incontinence management system for nursing home residents. JAMDA. 8(4)4, 253-261. American Medical Directors Association. (2005). Incontinence Clinical Practice Guideline. AMDA, Maryland. Boongird, S., Shah, N., Nolin, T.D., Unruh, M.L. (2010). Nocturia and aging: diagnosis and treatment. Adv Chronic Kidney Dis. 17(4):e27-40 Booth, J., McMillan, L. (2009). The impact of nocturia on older people - implications for nursing practice. Br J Nurs. 1(10):592-6. Bowers, B., Esmond, S., Jacobson, N. (2000). Relationship between staffing and quality in longterm care facilities: Exploring the views of nurse aides. J Nurs Care Qual. 14:55-64. CMS Manual System, Department of Health & Human Services (DHHS, Centers for Medicare & Medicaid Services (CMS), Pub. 100-07 State Operations Provider Certification, June 28, 2005 Urinary Incontinence Tags F315 and F316. Centers for Medicare and Medicaid Services. Department of Health and Human Services. Delay Effective Date for Revision of Appendix PP, State Operations Manual, Surveyor Guidance for Incontinence and Catheters. Available at www.cms.hhs.gov/medicaid/survey-cert/sc0523.pdf. Accessed May 1, 2005. Fader, M., Clark-O’Neill, S. Cook. D., et al. (2003). Management of night-time urinary incontinence in residential settings for older people: an investigation into the effects of different pad changing regimes on skin health. J Clinical Nursing 12, 374-386 Holroyd-Leduc, Jayna, et. al. (2004). Urinary incontinence and its association with death, nursing home admission, and functional decline. J Am Geriatr Soc, 52(5), 712-718. Johnson, T.V, Abbasi, A., Ehrlich, S.S., Kleris, R.S., Raison, C.L, Master, V.A. (2011). Nocturia associated with depressive symptoms. Urology. 77(1):183-6. Johnson, T.M., Ouslander, J.G., Uman, G.C., Schnelle, J.F. (2001) Urinary incontinence treatment preferences in long-term care. J Am Geriatr Soc. 49(6), 710-718. Kim, S.O, Kim, J.S., Kim, H.S., Hwang, E.C., Oh, K.J., Kwon, D., Park, K., Ryu, S.B. (2010). Age related change of nocturia in women. Int Neurourol J. 14(4):245-9. Mather, K.F., Bakas, T. (2002). Nursing assistants perceptions of their ability to provide continence care. Geriatric Nursing, 23(2), 2002:76-81. Newman, D.K. & Wein, AJ. (2009). Managing and Treating Urinary Incontinence, Baltimore, MD: Health Professions Press:137-174.

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Bladder and Bowel Master Series Newman, D.K. (2004). Urinary incontinence in long-term care facilities: Current clinical practice. The Director; 12(1):30-34. Newman, D.K. Mentioning the Unmentionables (Part 2). (2004). Advance for Providers of PostAcute Care; Jan/Feb,22,24. Newman, D.K. (2004). Incontinence products and devices for the elderly. Urologic Nursing. 24(4), 316-334. Newman, D.K. (2004). Urinary incontinence in long-term care facilities: Current Clinical Practice. The Director; 12(1), 30-34. Newman, D.K. (2003). Urinary Incontinence: prevention and care. Nursing Assistant; 8(14), 1-4. Newman, D.K. (2003). Mentioning the Unmentionables (Part 1). Advance for Providers of PostAcute Care; 89-91,100. Nicolle L. The chronic indwelling catheter and urinary infection in long-term care facility residents. Infect Control Hosp Epidemiol 2001;22:316-321. Palmer, M.H. (2004). Physiologic and psychologic age-related changes that affect urologic clients. Urologic Nursing. 24(4), :247-252. Rogers, M.A., Mody, L., Kaufman, S.R., Fries, B.E., McMahon, L.F Jr, Saint, S. (2008). Use of urinary collection devices in skilled nursing facilities in five states. J Am Geriatr Soc. 56(5):85461. Saint, S., Kaufman S.R., Rogers, M.A., Baker, P.D., Ossenkop, K., Lipsky, B.A. (2006). Condom versus indwelling urinary catheters: a randomized trial. J Am Geriatr Soc.54(7):105561. Schenelle, J.F., et al. (2003). The minimum data set urinary incontinence quality indicators: do they reflect differences in care processes related to incontinence? Medical Care, 41(8):909-922. Schnelle, J.F., Leung, F.W. (2004). Urinary and bowel incontinence in nursing homes. Gastroenterology, 126, 2004:S41-S47. Schnelle, J.F., et al. (2003). A standardized quality assessment system to evaluate incontinence care in the nursing home. J Am Geriatr Soc, 51(12), 1754-1761. Soda, T., Masui, K., Okuno, H., Terai, A., Ogawa, O., Yoshimura, K. (2010). Efficacy of nondrug lifestyle measures for the treatment of nocturia. J Urol. 84(3):,000-4. Wang, T.J., Lee, S.C., Tsay, S.L., Tung, H.H. (2010). Factors influencing heart failure patients' sleep quality. J Adv Nurs. 66(8),1730-40.

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Bladder and Bowel Master Series APPENDIX II GLOSSARY Absorbent incontinence products: Pads and garments, either disposable or reusable, worn to contain urinary incontinence. Absorbent products include shields, guards, undergarment pads, protective underwear, combination pad-pant systems, brief (diaper-like) garments, and bed pads. Bladder: The bladder is a muscular organ, which lies in the pelvis and is supported by the pelvic floor muscle. The bladder has only two functions; to stretch to allow the storage of urine and to contract to enable the expulsion of urine. The term detrusor is used to refer to the smooth muscle structure of the bladder. Bladder capacity: The amount (maximum volume) of urine that the bladder can hold. Often referred to as bladder volume. Bowel incontinence: The accidental and involuntary loss of liquid, solid stool or gas from the anus. Bowel impaction: A mass of stool (feces) that remains packed in the rectum rather than being passed normally. Impaction can contribute to urinary incontinence by irritating the urethra causing urge UI or by blocking the urethra preventing the bladder from emptying completely causing overflow incontinence. Bowel movement: The act of passing feces through the anus. Bowels: Intestines. Catheter: A small rubber, silicone or polyvinyl tube used to drain urine from the bladder. Condom (external) catheter: A condom like device placed over the penis to allow bladder drainage and collection of urine. Constipation: Infrequent or difficult passing of hard and dry feces or stool. Continence: The ability to voluntary control voiding or defecation until an appropriate time and place can be found to void or have a bowel movement. Daytime frequency: Number of voids recorded during waking hours which includes the first void after waking and rising in the morning. Defecation: The act of emptying the bowels or having a bowel movement. Dribbling: Refers to urine loss after completion of voiding and is referred to as “post-void dribbling.” Dysuria: Discomfort or pain and/or a burning or smarting sensation accompanying voiding. © 2012 Diane K. Newman

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Bladder and Bowel Master Series Edema: Excessive accumulation of clear, watery fluid in interstitial tissue spaces. Enuresis: The involuntary loss of urine (urinary incontinence). Feces (stool): Waste material which are composed of bacteria, undigested food and material that passes through the intestines. Flatulence: The release of intestinal gas through the anus. Frequency: An abnormally frequent (usually > 8 times in a 24 hour period) desire to void, often of only small quantities (e.g., less than 200ml). Gas: Material that results from: swallowed air, air produced from certain foods or that is created when bacteria in the colon break down waste material. Gas that is released from the rectum is called flatulence. Hesitancy: Difficulty starting the urine stream resulting in a delay between initiation of urination by relaxation of the urethral sphincter and when urine stream actually begins. Incontinence: The accidental or unwanted loss of urine or feces (stool). A person may have urinary or bowel incontinence or both (sometimes called double incontinence). Insomnia: Difficulty initiating and/or maintaining sleep or nonrestorative sleep. It is the most common cause of sleep disturbance in later life. Mixed urinary incontinence (MUI): The combination, in a patient, of urge urinary incontinence and stress urinary incontinence (see urge incontinence, stress incontinence). Neurogenic Bladder: An atonic or unstable bladder associated with a neurological disease condition, such as diabetes, stroke or spinal cord injury. Nighttime frequency: Complaint of needing to void one or more times per night between the time the resident goes to bed with the intention of sleeping and the time the resident wakes with the intention of rising. Nocturia: Waking up two or more times at night due to the need or urge to void. Nocturnal enuresis: complaint of loss of urine during sleep. In children it is called bedwetting. Overactive bladder: A condition characterized by involuntary detrusor contractions during the bladder filling phase, which may be spontaneous or provoked, and which the resident cannot suppress. Overflow urinary incontinence: The involuntary loss of urine associated with over distension of the bladder. Overflow incontinence results from urinary retention that causes the capacity of © 2012 Diane K. Newman

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Bladder and Bowel Master Series the bladder to be overwhelmed causing continuous or intermittent leakage of a small amount of urine. Stress urinary incontinence (SUI): A form of urinary incontinence characterized by the involuntary loss of urine from the urethra during physical exertion; for example, during coughing. Urine leakage occurs in the absence of a detrusor (bladder) contraction or an over distended bladder (see hypermobility of bladder neck and intrinsic sphincter deficiency). Super absorbent polymer (SAP): A kind of macromolecule materials that has very high absorbent capacities. SAP can quickly turn to gel when it meets water or urine moisture. SAP can hold up to 100n times its weight in water. It is innocuous; has no side-effects and does not stain. SAP is used widely in environment protection, agriculture, forest, horticulture, sanitary napkins, incontinence, baby diapers, ice cushions, ice caps, soil-less plants, etc. Urge: he sensation from the bladder producing the desire to void. Urge urinary incontinence (UUI): The involuntary and accidental loss of urine when the person is aware of the need to get to the bathroom but is not able to hold the urine long enough to get there. Usually it is associated with an abrupt and strong desire to void (urgency). Urgency: A sudden, strong or intense desire to void immediately, Urgency is usually accompanied by frequency. Urinary incontinence (UI): Involuntary or unwanted or accidental loss (leakage) of urine. Urinate: To void or to pass urine. Urination: The act of passing urine. Void: A synonym for urinating, sometimes called “peeing” or “passing water.”

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Bladder and Bowel Master Series APPENDIX III CARE PLAN Nursing Diagnosis – Urinary elimination: nighttime incontinence Nursing Goal: To assess resident for nighttime urinary incontinence To implement a incontinence care program for night staff Signs & Symptoms: Nocturia Nocturnal enuresis Frequent awakenings Daytime sleepiness Intervention

Rationale

Avoid napping during the day or limit the nap to 30 to 45 minutes.

Frequency of daytime napping is the most frequent cause of inability to fall asleep and increase the number of awakenings at night. Napping can disturb the normal pattern of sleep and wakefulness.

Establish a good sleep environment. The bed should be comfortable.

Uncomfortable bedding can prevent good sleep.

Find a comfortable temperature setting for sleeping and keep the room well ventilated.

A cool (not cold) bedroom is often the most conducive to sleep.

Block out all distracting noise, and eliminate as much light as possible.

Nighttime waking episodes lasting four minutes or longer are associated with noise and light.

Consider use of compression stockings for peripheral edema. If edema is present, encourage resident to lie legs elevated in the afternoon may help reduce fluid build up

Increase daytime fluid excretion if there is evidence of excessive night-time fluid diuresis in the body.

Avoid alcohol 4 to 6 hours before bedtime. Avoid stimulants such as caffeine, nicotine, and alcohol too close to bedtime.

While alcohol is well known to speed the onset of sleep, it disrupts sleep in the second half as the body begins to metabolize the alcohol, causing arousal.

Avoid eating a heavy meal for at least 3 hours before going to sleep. Instead,

Food, eaten right before sleep, can be disruptive.

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Bladder and Bowel Master Series consider serving evening meal no later than 6PM and offer a light snack before bed.

A snack consisting of warm milk and foods high in the amino acid tryptophan, such as bananas, may promote sleep.

Institute fall-risk prevention for the ambulatory resident with nocturia.

Ensure open and unobstructed path to the bathroom. Use a nightlight bright enough for safety but low enough to promote sleep.

Institute strategies that may decrease nocturnal polyuria, such as decreasing fluid intake in the evening hours or for at least 3 to 4 hours before bedtime.

Residents with nocturia usually produce more urine during the night and may awaken to void or experience nighttime incontinence because of an increase in urine production. The high volume may be related to excessive fluid intake, particularly late in the day.

Encourage exercise (e.g. walking) in the morning or late afternoon. A relaxing exercise, like yoga, can be done before bed to help initiate a restful night's sleep.

Exercise can promote good sleep.

Establish a regular, fixed relaxing bedtime routine and a fixed awakening time.

The body "gets used" to falling asleep at a certain time, but only if this is relatively fixed. Avoid emotionally upsetting conversations and activities before sleep.

Ensure adequate exposure to natural light.

This is particularly important for nursing home residents who may not venture outside frequently. Light exposure helps maintain a healthy sleepwake cycle.

At the appropriate bedtime, the TV should be turned off and the resident should go to bed. Some residents may find that the radio helps them go to sleep.

Many people fall asleep with the television on in their room. Television is a very engaging medium that tends to keep people up. Since radio is a less engaging medium than TV, this is probably a good idea.

Outcomes: Resident will: Promote good sleep hygiene for resident with nocturia. Be free of adverse effects of nocturia and nocturnal enuresis. Staff will Provide appropriate care to prevent or minimize nocturia and nocturnal enuresis.

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Bladder and Bowel Master Series Appendix IV CONTINUING EDUCATION ACTIVITY POST TEST Date:

Name:

___________________________________________

After reading this Independent Study Monograph, participants should select and circle the single most appropriate answer to each of the following questions. 1. The definition of nocturia is: a) Strong urge to urinate b) More than 2 voids per night. c) Urine leakage while going to the toilet during the night. d) Bladder retraining 2. The definition of nocturnal enuresis is: a) Urine leakage during sleep. b) Urine leakage when coughing. c) Urine leakage while ambulating to the bathroom. d) Urine leakage when standing. 3. Causes of nocturia include: a) Increased urine production while asleep. b) Increased weight. c) Increased bladder capacity. d) Increased amounts of antidiuretic hormone while asleep. 4. Strategies that can promote good sleep hygiene include: a) Encouraging the resident to take several naps during the day. b) Keeping the lights on in the resident’s room during the night. c) Decreasing caffeinated beverages. d) Drinking alcohol before going to bed. 5. Consequences of nighttime voiding includes: a) Skin breakdown b) Falls c) Daytime aggression d) All of the above 6. Alternative ways to manage nocturia can promote adequate sleep. a) True b) False 7. Peripheral edema, especially leg and ankle swelling, can be reduced by having the resident sit in a chair in the late afternoon. a) True b) False © 2012 Diane K. Newman

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Bladder and Bowel Master Series 8. Strategies for managing urine leakage during the night include: a) Use of absorbent products. b) Leaving the resident “open to the air” while asleep c) An indwelling (Foley) catheter. d) Use of a urinal in male residents e) A and D f) B and C 9. Medications can result in nighttime voiding problems: a) True b) False 10. Alternative toileting devices that may be used include: a) Incontinence products b) Bedside commode c) External condom catheter or pouch d) All of the above

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Bladder and Bowel Master Series Appendix V - Independent Study Evaluation Form Nighttime Management of Incontinence SUNA Approval # 32-23 (Please print or type)

Name:___________________________________________Date:_____________ Facility/Employer Name: ____________________________________________ Address: __________________________________________________________ Phone#: _________________RN License: ____________

State: ___________

The goal of this Independent Study, Nighttime Management of Incontinence, is to educate nurses and other health care professionals about nocturia and nocturnal enuresis, their causes and nursing management in the long term care setting. Learning Objectives: Please evaluate the individual components of this educational activity but rating the following questions. Please fill in bubbles completely.

The content was balanced (free of commercial bias). Describes the causes and consequences of nighttime voiding and incontinence (nocturia, nocturnal enuresis). Details strategies for reducing nocturia and nocturnal enuresis. Explains the indications and applications of absorbent products, toileting devices, and external catheters. Characterizes the use of absorbent products for residents with nighttime incontinence. Defines the reason for not using an “open to air” technique for managing nighttime incontinence.

4 Strongly agree

3 Agree

2 Disagree

1 Strongly disagree

















































Comments:_______________________________________________________________

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