HLTEN503A – Contribute to Client Assessment & developing Nursing Care Plans .

1. HLTEN503A – Contribute to Client Assessment & developing Nursing Care Plans. Continence Assessment

2. Definition of Incontinence • Incontinence – accidental or involuntary loss of urine from the bladder (urinary incontinence) or bowel motion, faeces or wind from the bowel (faecal or bowel incontinence). Author - Jackie Laver - Chisholm 2009

3. Facts and Figures • Urinary incontinence affects up to 13% of Australian men & 37% of Australian women. • Faecal incontinence affects up to 20% of Australian men & 12.9% of Australian women. • Faecal incontinence is one of the 3 major causes for admittance to a residential aged care facility (after decreased mobility & dementia). • Around 77% of nursing home residents are affected by incontinence. • Around 40% of men over 85 y/o have some level of urinary incontinence. • Urge incontinence associated with prostate disease is about 50% for those over 85 y/o. • Women comprise over 70% of people affected by incontinence, caused primarily by childbirth & menopause. • 40-60% of residents in aged care will wet the bed nightly. • (Continence Foundation of Australia – www.continence.org.au) Author - Jackie Laver - Chisholm 2009

4. Risk Factors • Pregnancy & childbirth • Menopause • Obesity • UTI’s • Constipation • Sx – prostatectomy & hysterectomy. • Reduced mobility • Dementia, CVA & diabetes • MS, arthritis & Parkinson’s disease. • Some medications. Author - Jackie Laver - Chisholm 2009

5. Urinary Incontinence • Basic anatomy of the urinary tract: • 1. Kidneys • 2. Renal arteries. • 3. Ureters. • 4. Bladder. • 5. Urethra. Author - Jackie Laver - Chisholm 2009

6. A Normal Bladder • Empties 4 – 8 times per day. • Can hold up to 400 – 600 ml of urine – the sensation to empty occurs at 200-300 ml. • May wake you up at night to empty – once or more as you age. • Tells you when it is full, but gives you enough time to find a toilet. • Empties fully each time you pass urine; and • Does not leak urine. Author - Jackie Laver - Chisholm 2009

7. Types • 1. Stress – the leaking of small amounts of urine associated with increasing pressure inside the abdomen – eg. Coughing, sneezing, laughing, lifting, or playing sport. Occurs mainly in women, and sometimes men after prostate surgery. • 2. Urge – the sudden and strong need to urinate- often associated with frequency (a sign of a UTI) and nocturia. They tend to get little or no warning and wet themselves before they get to a toilet. • 3. Overflow – when the bladder is over full and does not empty properly, & leakage occurs as a result. Author - Jackie Laver - Chisholm 2009

8. Types • 4. Functional – when a person does not recognise the need to go to the toilet & does not recognise where the toilet is. They cannot get to the toilet in time and often pass urine in inappropriate places. • 5. Reflex – when a person loses control of their bladder without warning – usually due to neurological impairment. Author - Jackie Laver - Chisholm 2009

9. Causes of Stress Incontinence • Women – pregnancy & childbirth stretch & weaken the pelvic floor muscles that support the urethra causing incontinence with activities that push down on the bladder. During menopause, the decreasing hormone oestrogen causes thinning of the urethra. • Men – after prostate surgery – this can resolve over 6-12 months. • Others – diabetes, chronic cough, constipation & obesity. Author - Jackie Laver - Chisholm 2009

10. Stress Incontinence Author - Jackie Laver - Chisholm 2009

11. Urge Incontinence • Causes – often due to having an over active or unstable bladder. • Can be linked to stroke, Parkinson’s disease, MS and other conditions that impair the brain’s ability to send massages to the bladder via the spinal cord. This affects the person’s ability to continue to hold and store urine. • May also occur as a result of chronic constipation, or enlarged prostate gland, or a history of poor bladder habits. • Sometimes the cause of an overactive bladder is simply unknown. Author - Jackie Laver - Chisholm 2009

12. Overflow Incontinence • Causes – • a blockage to the urethra by a full bladder, • an enlarged prostate, • a prolapse of the pelvic organs which can block the urethra, • Damage to the nerves that control the bladder, urethra sphincter & pelvic floor muscles, • Diabetes, MS, CVA, Parkinson’s – diseases interfering with the sensation of a full bladder and with bladder emptying, • Some medications – including over the counter medication & herbal products. Author - Jackie Laver - Chisholm 2009

13. Functional • Causes – dementia, poor eyesight, poor mobility, poor dexterity, or unwillingness to go to the toilet because of depression, anxiety or anger. • Environment can play a part – poor lighting, low chairs that the resident cannot get out of, and toilets that are difficult to access. Author - Jackie Laver - Chisholm 2009

14. Other Causes • 1. Obesity – places greater strain on the pelvic floor muscles, causing muscles, nerves and other structures of the pelvic floor to weaken. As little as a 5% weight loss can improve urinary function by 50%. • 2. Prostate disease – the prostate is a small organ that produces fluid that protects and feeds sperm. It sits just beneath the bladder, surrounding the urethra. As it enlarges later in life, it can cause obstruction of the urethra, causing hesitancy, weak flow, straining, dribbling, urinary retention, overflow. • An enlarged prostate is not always cancer – it is usually benign. • After prostate surgery, the bladder neck sphincter is often damaged, causing stress incontinence. • Pelvic floor exercises prior to and after surgery will help the recovery of urinary function. Author - Jackie Laver - Chisholm 2009

15. Other Causes Continued • 3. Dementia – this is a progressive decline in a person’s functioning. It can include a loss of memory, intellect, rationality, social skills and normal emotional reactions. The common symptoms are: • Progressive & frequent memory loss • Confusion • Personality change • Apathy & withdrawal • Loss of ability to attend to ADL’s. • These symptoms may bring on the onset of incontinence. The brain sends messages to the bladder & bowel on when to empty – one has to be aware of these sensations, and have to capacity to know how & when to respond. Author - Jackie Laver - Chisholm 2009

16. Other Causes Continued • The changes in a person’s brain can interfere with their ability to : • Recognise the need to go to the toilet • Be able to wait until the appropriate time to go to the toilet • Find the toilet • Recognise the toilet • Use the toilet properly. Author - Jackie Laver - Chisholm 2009

17. Other Causes Continued • 4. Parkinson’s Disease – a progressive disorder of the central nervous system causing abnormal movement. It affects more men than women. • It is caused by a decrease in the amount of dopamine produced by cells in the brainstem called substantia nigra. The cells deteriorate – the cause is unknown. Dopamine is a neurotransmitter and is needed for the transmission of messages between nerve cells. • This can affect both bladder and bowel function as the muscles of the bladder and bowel become weak or damaged. • S & S include – decreased urge to empty the bladder or pass a bowel motion. - chronic constipation - not being able to hold on until they get to the toilet. Author - Jackie Laver - Chisholm 2009

18. Other Causes Continued • 5. Multiple Sclerosis - a chronic, disabling disease that randomly attacks the central nervous system. The body attacks its own myelin sheaths, which protect the nerves. • S & S- can include – extreme fatigue, impaired vision, loss of balance, slurred speech, tremors, stiffness, bladder & bowel problems, altered gait, STM loss, mood swings, paralysis. • S & S of bladder & bowel problems may include: • 1. Frequency or urgency • 2. difficulty in starting flow, or in emptying the bladder • 3. Nocturia • 4. Inability to hold in the urine. • 5. Constipation – from decreased bowel motility, and some of the Parkinson’s medications. Author - Jackie Laver - Chisholm 2009

19. Other Causes Continued • 6. Diabetes - a name given to a group of diseases associated with too much glucose in the blood. Common types are – • 1. Type 1 – death of the beta cells in the Islets of Langerhans in the pancreas, causing rapid decrease in the amount of insulin produced. These people must have insulin injections every day for life. • Type 2 – also known as ‘insulin resistance’. Caused by sedentary lifestyle & increased weight, particularly around the middle, with a strong hereditary factor. • GDM – gestational diabetes. Develops in pregnancy related to hormones, and reverts once the baby is born. Is a strong indicator for the further development of type 2 DM later in life. Author - Jackie Laver - Chisholm 2009

20. Other Causes Continued • Diabetes can affect continence in a number of ways – • 1. Neuropathy – can affect they way the bladder functions by decreasing the sensations of the bladder being full and needing to empty. The bladder can become overstretched. • 2. Polydipsia – (increased thirst) - occurs with high BGL’s, resulting in drinking more fluids & increasing the need to urinate. • 3. Increased UTI’s – high BGL’s predispose to increased UTI’s. Author - Jackie Laver - Chisholm 2009

21. Other Causes Continued • 7. Asthma – one of the COAD’s. Airways become narrowed in response to certain triggers, causing: • SOB • Chest tightness • Wheeze • Chronic cough – incontinence can occur related to coughing • 8. Arthritis – Inflammation of the joints between bones • Incontinence can occur due to joint degeneration & pain, causing an inability to get to the toilet on time. Author - Jackie Laver - Chisholm 2009

22. Other Causes Continued • 9. CVA – caused when the blood supply to the brain is suddenly disrupted. Can be either a clot or a bleed. The brain controls everything we do. • Incontinence can occur following a CVA due to: • 1. Hemiplegia – inability to get to the toilet. • 2. Nerve dysfunction – inability to sense the need to go to the toilet. • 3. Decreased cognition – inability to recognise the need to go the toilet. • 4. Decreased mobility – causing constipation. Author - Jackie Laver - Chisholm 2009

23. Continence Management • Principles of Management: • 1. Identify the cause and treat appropriately. • 2. The person’s hygiene needs must be attended to, and • 3. Maintain dignity & self esteem. Author - Jackie Laver - Chisholm 2009

24. Continence Management • 1. Stress Incontinence : • Cause : weak pelvic floor • Treatment : Pelvic floor exercises. • Management : Pads & regular toileting, commodes. • Cause : Chronic cough • Treatment : Reduce the cough. Asthma management program – preventers & treatment. • Cause : Constipation • Treatment : Bowel management program. • Cause : Obesity • Treatment : Weight management program. Author - Jackie Laver - Chisholm 2009

25. Continence Management • 2. Urge Incontinence. • Cause : UTI • Treatment : increase fluids, antibiotics. • Management : pads, until cause fixed, pelvic floor exercises, urinals at night for men. • Cause : over active bladder from CVA, Parkinson’s, MS – impairs the brain’s ability to send messages to the bladder. • Treatment : medications to control nerve impulses, pads, pelvic floor exercises. Author - Jackie Laver - Chisholm 2009

26. Continence Management • Cause : prostate disease. • Treatment : surgery. Pads or condom drainage can help at night if surgery is not an option. Urinals can be used if dexterity is adequate. Author - Jackie Laver - Chisholm 2009

27. Continence Management • 3. Overflow : • Cause : enlarged prostate gland • Treatment : surgery. • Cause – prolapsed pelvic organs • Treatment – surgery. • Cause - Nerve damage (from MS, Parkinson’s, CVA, diabetes) • Treatment – Pads and regular toileting, urinals. Author - Jackie Laver - Chisholm 2009

28. Continence Management • 4. Functional : • Cause – dementia • Management – regular toileting +/- pads. • Cause – Poor mobility or dexterity • Management – Regular toileting & pads. Ensure resident is within easy reach of toilets, and answer bells or calls promptly. Commodes can be helpful. • Environment – poor lighting, low chairs. • Management – ensure adequate lighting, glasses on, high level chairs with arms on them to aid in mobility. Author - Jackie Laver - Chisholm 2009

29. Continence Management • Other causes – • 1. Obesity – places greater strain on the pelvic floor muscles, causing muscles, nerves and other structures of the pelvic floor to weaken. As little as a 5% weight loss can improve urinary function by 50%. • 2. Prostate disease – the prostate is a small organ that produces fluid that protects and feeds sperm. It sits just beneath the bladder, surrounding the urethra. As it enlarges later in life, it can cause obstruction of the urethra, causing hesitancy, weak flow, straining, dribbling, urinary retention, overflow. • An enlarged prostate is not always cancer – it is usually benign. • After prostate surgery, the bladder neck sphincter is often damaged, causing stress incontinence. • Pelvic floor exercises prior to and after surgery will help the recovery of urinary function. Author - Jackie Laver - Chisholm 2009

30. Continence Management • 3. Dementia – this is a progressive decline in a person’s functioning. It can include a loss of memory, intellect, rationality, social skills and normal emotional reactions. The common symptoms are: • Progressive & frequent memory loss • Confusion • Personality change • Apathy & withdrawal • Loss of ability to attend to ADL’s. • These symptoms may bring on the onset of incontinence. The brain sends messages to the bladder & bowel on when to empty – one has to be aware of these sensations, and have to capacity to know how & when to respond. Author - Jackie Laver - Chisholm 2009

31. Continence Management • The changes in a person’s brain can interfere with their ability to : • Recognise the need to go to the toilet • Be able to wait until the appropriate time to go to the toilet • Find the toilet • Recognise the toilet • Use the toilet properly. Author - Jackie Laver - Chisholm 2009