Centers for Medicare and Medicaid Services Urinary Incontinence and Catheters Satellite Broadcast

1. Centers for Medicare and Medicaid ServicesUrinary Incontinence and Catheters Satellite Broadcast October 27, 2004

2. Causes of Urinary Incontinence • Urinary tract conditions • Neurological disorders • Impaired functional status • Environmental barriers

3. Potentially Reversible Causes of Urinary Incontinence • Acute symptomatic urinary tract infection • Atrophic vaginitis • Severe constipation and fecal impaction • Conditions that cause a decrease in mobility and toileting ability • Caffeine intake • Drug side effects

4. Urge Incontinence “Overactive Bladder” • Involuntary Bladder Contractions • Severe Bladder Hypersensitvity • Signs: • Urine loss • Urgency • Frequency > 8x/24 hrs

5. Stress Incontinence • Increase in intra-abdominal pressure • Symptoms: Small losses of urine when: • Coughing • Laughing • Exercising • Changing positions

6. Urethral Obstruction Enlarged prostate Urethral Stricture Fecal Impaction Neurologic Conditions Diabetic Neuropathy Low Spinal Cord Injury Medications Anticholinergics Symptoms Bladder Distention Reduced Urine Flow Dribbling Frequency Overflow Incontinence

7. Functional Incontinence Conditions: • Cognitive Impairment • Chronic Functional Disability • Psychological Impairment • Environmental Barriers Symptoms: • Inaccessible toilet or lack of staff assistance • Nocturnal enuresis • Combined fecal and urinary incontinence

8. Objectives of the Assessment • Identify causes and contributing conditions • Co-morbid conditions and medications • Degree of bother to resident • Resident and family preferences for treatment

9. Goals of Assessment • Determine if the resident is incontinent, nature of lower urinary tract symptoms, and type of incontinence • Determine the type of assessment conducted of the resident’s incontinence status before admission and any interventions • Determine reversible factors • Determine conditions that may require further evaluation • Implement a prompted voiding trial • Determine resident’s risk for complications and preferences for treatment

10. Reversible Causes of UI • Delirium • Impaired mobility • Infection • Fecal impaction • Frequent urination • Medications

11. Key Elements to Include in Resident’s History • Duration and characteristics of the incontinence • Precipitants • Voiding patterns • Previous treatment and/or management

12. Factors that Increase Resident’s Risk for UI • Impaired cognitive function • Impaired mobility • Decreased manual dexterity • Poor upper and lower extremity strength • Visual problems • Neurological conditions • Medications

13. Factors that Increase Resident’s Risk for UI Medications: • Diuretics • Narcotics • Anticholinergics • Psychotropics (Sedatives, Hypnotics, Antipsychotics) • Calcium channel blockers

14. General Physical Assessment Neurological conditions • Mobility • Cognition • Manual dexterity

15. General Physical Assessment Abdominal: • Bowel sounds • Surgical incisions • Masses • Suprapubic bladder fullness

16. General Physical Assessment Female Perineum: • Atrophic tissue changes • Pelvic organ prolapse • Perineal skin condition • Color, odor, discharge • Structural abnormalities

17. General Physical Assessment Perineal assessment for men: • Determine lesions of the shaft/skin • Inspect scrotum for lesions and size

18. Additional Testing Urinalysis - clean catch • Nursing home residents should not be catheterized to collect a urine specimen unless it is an urgent situation • Testing to exclude a UTI should only be done if the incontinence is new or worsening, or other symptoms of UTI Post-Void Residual (PVR) • Risk factors: all men, diabetes, neurological disorders, medications

19. How to Perform PVR PVR: • Conduct within a few minutes of voiding • Record voided and PVR volume • Done through sterile in-and-out catheterization or bladder ultrasound

20. Behavioral Programs Required skills for residents: • Ability to comprehend and follow education and instructions • Identify urinary urge sensation • Learn to inhibit or control urge to void • Kegel exercises

21. Bladder Rehabilitation or Retaining Resident: • Should be able to resist or inhibit the urge to void • Void according to a timetable • Independent in activities of daily living • Experience occasional incontinent episodes • Aware of need to void • Usually assessed as having urge incontinence

22. Lower Urinary Tract Bladder Muscle - Detrusor Urethra Pelvic Floor Muscle

23. Habit Training/Scheduled Voiding • Requires scheduled toileting, at regular intervals, on a planned basis, and match the resident’s voiding habits • Maintain record of resident’s voiding patterns

24. Prompted voiding Resident: • Assessed with urge incontinence • Cognitive impairment • Dependent on facility staff for assistance • Able to say name or reliably pint to one of two objects • Requires training, motivation, effort

25. Risk of Complications for Indwelling Urinary Catheter • Bacteriuria • Febrile episodes • Bladder stones • Epididymitis • Chronic renal inflammation • Pyelonephritis

26. Assessment to Determine if Indwelling Catheter is Medically Justified • Used for short-term decompression of acute urinary retention • If used beyond 14 days, restrict to- • Urinary retention not managed by other means • Presence of multiple pressure ulcers for which healing is compromised by urinary incontinence • Pain or impairment is compromised

27. Assessment to Determine if Indwelling Catheter is Medically Justified If indwelling urinary catheter is not medically justified- • Remove catheter • Complete a voiding trial • Determine best bladder management program for resident

28. Risk Factors for Urinary Tract Infections • Fecal incontinence • Urinary retention • Diabetes • Structural abnormalities of the lower urinary tract • Atrophic vaginitis in women

29. Asymptomatic Bacteriuria • Common in geriatric population • Should not be treated • Unnecessary risks of antibiotic therapy • Excess costs • Potential to develop multi-drug resistant bacteria

30. Symptomatic Urinary Tract Infections (UTIs) Residents without an indwelling urinary catheter include at least three of the following: • Fever of at least 2.4 degrees Fahrenheit above the resident’s baseline temperature • New or increased incontinence, burning or pain on urination, frequency or urgency • New flank pain or tenderness • Change in character of urine such as blood, new pyuria or hematuria • Worsening of mental or functional status

31. Symptomatic Urinary Tract Infections (UTIs) Residents with an indwelling urinary Catheter include at least two of the following : • Fever of at least 2.4 degrees Fahrenheit above the resident’s baseline temperature • New flank pain or tenderness • Change in character of urine such as blood, new pyuria or hematuria • Worsening of mental or functional status

32. Assessment for Absorbent Products Assess resident’s; • Functional ability to ambulate, toilet, disrobe, use of assistive devices • Ease in self-toileting Assess product for: • Contain urinary leakage • Comfort • Ease of application/removal

33. Bladder Rehabilitation/Retraining • Goal is to achieve a normal voiding pattern, or • Achieve the longest possible interval • Resident should be able to hold urine until reaching the toilet

34. Prompted Voiding Three components: • regular monitoring with encouragement • prompting the resident to toilet on a scheduled basis • praise and positive feedback when the resident is continent and attempts to toilet.

35. Prompted Voiding (PV) Predictors of responsiveness to PV • Resident’s response to a therapeutic trial of PV • Normal bladder capacity (>200 and <700cc) • Recognizes need to void • Baseline incontinence < 4 times/12hours • Maximum voided volume > 150 cc • Post void residual < 100 cc • Able to void successfully when given toileting assistance Evidence from properly designed and implemented controlled trials by University of Iowa Gerontology Nursing Intervention Research Center

36. Habit Training/Scheduled Voiding Goal is to prevent incontinence from Occurring: Provide access to the toilet based on the resident’s voiding pattern

37. Key Considerations for Medication Therapy for Urge Incontinence and Overactive Bladder • Identify residents with symptoms known to be responsive to medication therapy • Ongoing incontinence despite treatment of reversible causes • Risk for anticholinergic side effects • Costs

38. Anticholinergic Medications Side Effects: • Dry mouth • Constipation • Development or exacerbation of gastroesophageal reflux • Urinary retention • Impaired cognitive function • Delirium

39. Determination of Urinary Tract Infection Review several test results in combination with clinical findings: • Microscopic urinalysis showing the presence of pyuria; or • Positive urine dipstick test for leukocyte esterase (indicating significant pyuria) or • Nitrites (indicating the presence of Enterobacteriaceae)

40. Determination of Urinary Tract Infection Nonspecific symptoms, look for: • Hematuria, • Fever or • Evidence of pyuria

41. Urinary Tract Infection Prevention Strategies • Infection control policies and procedures • Identification of high risk residents • Perineal hygiene, especially for women with fecal incontinence • Hydration • Treatment of atrophic vaginitis

42. Complications of Indwelling Catheters • Urinary Tract Infections • Encrustations • Leakage around catheter • Inadvertent removal of catheter

43. Catheter Related Urinary Tract Infections • Risk • method and duration of catheterization • quality of catheter care • host susceptibility • Most common complication seen with long-term use of indwelling catheters • MRSA • E-coli most common organism • Urosepsis –results from frequent and repeated UTIs

44. Encrustations Risk factors: • alkaline urine • poor mobility • decreased fluid intake

45. Leakage Around Catheter Contributing factors: • Detrusor (bladder) overactivity • Infection • Urethral/catheter obstruction • Catheter or balloon size too large • Constipation or fecal impaction

46. Other Care Practices to Reduce Complications • Educating the resident or responsible party on the risks and benefits of catheter use; • Recognizing and assessing for symptoms of complications; • Attempts to remove the catheter; • Monitoring for post void residual; and • Keeping the catheter anchored to prevent urethral tensions

47. Skin Problems Related to Urinary Incontinence Early: • Irritant dermatitis • Inflammation • Caused by prolonged contact with moisture Advanced: • Blistering • Erosion • Exudate

48. Decline or Lack of Improvement in Continence Practices that prevent or minimize a decline or lack of improvement: • Assessment and documentation of the resident’s baseline continence status • Interventions to improve functional abilities • Environmental modifications • Treatment of the underlying cause • Adjustment of medications • Fluid management program

50. Websites • Qualidigm Medicare Informationhttp://www.ctmedicare.org/qip_med_nursing_res.shtml • AHRQ National Guideline Clearinghouse http://www.guideline.gov/ • National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) http://kidney.niddk.nih.gov/kudiseases/topics/incontinence.asp • Society of Urologic Nurses and Associates http://www.suna.org/ • National Association for Continence http://www.nafc.org/ • The Simon Foundation for Continence http://www.simonfoundation.org/html/