BLADDER ASSESSMENT - Independent Study Monograph I. Assessment of Bladder and Bowel

A multidisciplinary effort is the best approach to the evaluation of urinary incontinence. The assessment of the UI problem, or risk for UI should include a comprehensive medical history and physical assessment that includes observation and examination to seek the underlying causes and contributing factors for incontinence. By doing this, the facility can develop and implement more individualized programs to enhance residents‘ quality of life and functional status. The facility may document assessment information in any of several places throughout the resident‘s medical record including: the admission assessment, hospital records, history and physical, physician‘s orders, social service or psychological history, Minimum Data Set (MDS), laboratory results, and any flow sheets or forms the facility uses. For newly admitted residents, it is important to determine the resident‘s bladder function prior to admission and it is important to involve family members and/or a previous caregiver in this assessment.

As noted previously, UI can be the result of any dysfunction in the lower urinary tract, the nervous system, lack of coordination between the systems but can also be due to cognitive and functional impairments, lack of motivation, or barriers in the environment.

Each resident with urinary incontinence should be evaluated by the nurse for possible inclusion in a Bladder Restorative and Rehabilitation Program and the appropriate type of program. Examples of Records are found in at the end of this monograph.

CMS defines UI as ―any wetness on the skin.‖ The MDS criteria for coding UI is a follows:

As noted by the Quality Indicators, a resident with UI must have a targeted history and physical examination and what follows is the components of this evaluation.

History

Signs and symptoms (e.g., urgency, frequency, nocturia, nocturnal enuresis, and episodes of urine leakage).

Onset, severity, and pattern of urine leakage. Determine resident‘s perception of UI as a problem.

If UI was present before admission, investigate previous treatments (e.g. medications, surgery) and management of urine leakage (e.g. absorbent products, toileting devices). Observe the resident toileting to determine:

o Usual routine for toileting

Bladder and Bowel Master Series

 Level 1 – supervision  Level 2 – limited assistance  Level 3 – extensive assistance  Level 4 – total dependence

o Awareness of the urge sensation and need to void.

o Holding time: when the bladder feels full, how long can the resident hold urine and delay voiding before urine leakage becomes impossible to prevent. Holding time includes the ability to delay voiding long enough for the staff to arrive and offer toileting.

Assess urine stream for associated lower urinary tract symptoms such as weak stream, hesitancy, post void dribbling, feeling of incomplete bladder emptying and intermittency. Descriptions include:

o Dysuria: painful or difficult urination, often described as “burning when passing my urine,” which may indicate a UTI.

o Frequency: voiding more than 8 times in a 24-hour period, a symptom of OAB.

o Nocturia: wakening from sleep with the need to void more than twice a night which may indicate incomplete bladder emptying, nocturnal polyuria (see Monograph IV).

o Nocturnal enuresis: urine loss while asleep (bedwetting). Staff may think the resident has nighttime incontinence, but this may be a sign of urinary retention (see

Monograph IV).

o Urinary retention or incomplete bladder emptying: the inability to completely empty the bladder of all urine may complain that there is a feeling that urine remains in the bladder or of stomach pain or discomfort. This needs immediate attention as it can be caused by a blockage in the urethra or prolapsed of the bladder and if left untreated, can cause a UTI. o Hesitancy: difficulty in starting or initiating urine stream and delay in onset of voiding

or in initiating urine stream when person wants to void. May indicate incomplete bladder emptying.

o Intermittent stream: stopping and starting of urine stream when voiding which may indicate some type of blockage in the urethral (e.g. large prostate).

NOTE: The following are questions that can be asked during history taking to determine type of UI:

3. Do you ever find the resident wet? (Any type)

4. Do you ever find the bed wet or have urine stains? (Any type) 5. Does the resident smell like urine? (Functional UI)

6. Does the resident leak urine on the way to the bathroom? (UUI or OAB) 7. Does the resident leak urine with coughing, laughing, exertion? (SUI) 8. Does the resident have post void dribbling? (overflow)

9. Does the resident use pads, tissue paper, or cloth for protection? (Any type)

10. Does the resident dribble urine after voiding or complain that the bladder always feels full? (Overflow UI)

Bladder and Bowel Master Series

o Postvoid dribbling: small amount of urine loss after voiding, men will complain that

this occurs as they leave the toilet and women complain that it happens when rising from the toilet. Staff may think the resident has incontinence, but this may be a sign of urinary retention.

o Slow, weak or “poor” stream: decreased or reduced urine stream when compared to

previous performance (rare in women). Men will complain that they feel the bladder is not emptying.

o “Sprayed” or “split” stream: symptoms of double stream or spraying of the urinary

stream when voiding which may indicate some type of blockage in the urethral (e.g. large prostate).

o Straining to void: the need to “bear” or push down to urinate. The urinary weak and

intermittent. This may indicate urinary retention. Assessment of all transient causes of UI.

Daily diet/fluid intake

o Total fluid intake including types (e.g. caffeinated beverages)

o Note if resident is voluntarily restricting fluid intake to avoid urine leakage Bowel history (history of persistent constipation, bowel impaction, diarrhea, bowel

incontinence)

o Defecation frequency and pattern, straining at stool, painful defecation o Strategies used to maintain bowel regularity

o Use of laxative or enemas

Previous pelvic surgery (hysterectomy, prostate surgery) In men, determine history of BPH or other prostate conditions

Relationships of incontinence to other chronic neurologic conditions:

o Brain – Higher cortical inhibition of the bladder is impaired, causing neurogenic detrusor overactivity. Conditions include: stroke, Parkinson‘s disease, multiple sclerosis.

Dementia is an independent predictor of UI.

o Spinal cord – Neurogenic detrusor overactivity or urinary retention can result. Conditions include: multiple sclerosis, cervical or lumbar stenosis or disk herniation, and spinal cord injury.

o Peripheral innervation – Urinary retention and low functional bladder capacity can result Conditions include: diabetic neuropathy, nerve injury.

Physical Observation and Examination

General

o Presence of dehydration (symptoms include dry mouth, falling, weakness and fatigue, decreased urine output, headache, weight loss and increased confusion). Pedal edema and signs of congestive heart failure indicate problems with fluid redistribution that may cause nocturia and nocturnal enuresis.

Abdominal observation and examination

o Listen for bowel sounds. Normal bowel sounds consist of clicks or gurgles occurring every 5 to 15 seconds. More frequent bowel sounds are hyperactive, which indicate increased bowel motility. Sluggish bowel sounds, 3 or fewer/minute, indicate decreased motility. Prolonged gurgling sounds may result from increased motility seen with diarrhea. If no bowel sounds are heard for 5 minutes in any quadrant, they

Bladder and Bowel Master Series

are described as absent.

o Palpate for presence of masses (may indicate hard stool in the colon or bowel impaction) or organomegaly. If a mass is felt, note its size, shape, consistency, texture, and location. Note if resident complains of tenderness, discomfort or fullness during palpation.

o Determine presence of suprapubic distension indicating urinary retention. A distended bladder may rise above the symphysis pubis (pelvic bone) and it may be possible to palpate or percuss the bladder above the level of the symphysis pubis if it contains 150 mLs or more of urine. In general, palpation is not accurate in determining PVR.

Genitalia observation and examination: External observation of the perineum in both male and female residents is always appropriate.

o Examine the resident to note the presence of any urinary or bowel appliances.

o Assess the perineal skin (area between the urinary meatus and anus) and gluteal area is important because UI and/or bowel incontinence can cause redness and rash. The combination of urinary and bowel incontinence results in increased skin wetness (due to urine) and permeability (due to bowel enzymes), thus promoting perineal skin breakdown.

o External perineal skin – women

 Assess for rash, skin lesions, odor, and discharge.

 Separate the labia and visualize the urinary meatus. A urethral caruncle will present as a cherry-red bulge from the opening of the meatus and if present, can contribute to irritative voiding symptoms (e.g. urgency, frequency).  Note any redness, inflammation, erythema ulceration, urethral or vaginal

discharge, swelling, or nodules. Excoriations and maceration of the vulva may occur with constant wetness or may be secondary to infection.

 Observe the vulva for signs of hypoestrogenism (urogenital atrophy), such as atrophy of the vulvar skin, agglutination of the labia minora or a urethral caruncle. Note if the perineum (vulvar and, urethral area) appears atrophic and the vaginal mucosa looks dry, pale, inflamed and may be red, petechial, or ecchymotic. The area may bleed easily.

o External perineal skin – men

 Note penile discharge, redness or rash along the penile shaft.

 In the uncircumcised man, the foreskin should be retracted and the glans and meatus should be assessed. Note the size and position (should be located at the tip of the glans) of the meatus. Retracting the foreskin is a very important component of personal hygiene in the uncircumcised man. A cheesy, whitish material called smegma may accumulate normally under the foreskin. The foreskin should be replaced back over the glans. In uncircumcised men, a condition called phimosis can be present if the orifice of the foreskin is constricted preventing replacement of the foreskin over the glans or tip of the penis.

 The scrotum is a loose, wrinkled pouch that contains 2 testicles. The left one may be lower than the right. Each testis has a soft, comma-shaped epididymis.

Bladder and Bowel Master Series

fingers to determine the presence of any abnormal mass. Size, shape, consistency, and tenderness is noted.

Pelvic observation and examination -women:

o Assess for the presence of prolapsed pelvic organs called pelvic organ prolapse (POP), a general term for prolapse of the pelvic organs. Women with POP will complain of urinary urgency, frequency and describe a bulging feeling in their vagina or perineum. Assessment of POP should performed by having the woman strain or bear down like having a bowel movement. The following describe the organ prolapsing:

 Bladder (cystocele) - when the anterior wall of the vagina, together with the bladder above it, bulges into the vagina and sometimes out the introitus.

 Uterus (uterine prolapsed) - weakness of the supporting structures of the pelvic floor causes descent of the uterus and cervix into the vagina.

 Vaginal vault prolapse—the walls of the vagina fall in on themselves and out of the vagina.

 Rectum (rectocele) - protrusion of the posterior vaginal wall and the rectum behind it.

o If the resident is a candidate for pelvic floor muscle strengthening, a pelvic floor muscle (PFM) assessment should be part of the pelvic examination. Digital measurement of the PFM strength can be performed by inserting the index finger into the vagina to the level of the first knuckle. The resident is asked to tighten or pull in and upward with her vaginal and/or rectal muscles. If able to contract the pelvic floor muscles, proceed to having her repeat contracting the muscles, holding the contraction for a count of 5, then relaxing the muscle for a count of 5. Repeat this several times until resident learns this exercise.

Rectal observation and examination:

o Inspect outside of the anus, noting any stool smearing or liquid stool seepage. o Inspect the perianal areas for lumps, ulcers, inflammation, rashes or excoriation. o Assess rectal sphincter tone. As the sphincter relaxes, gently insert index finger into

the anal canal in a direction pointing toward the umbilicus. Note if the resting sphincter tone is weak, moderate or strong. To assess the strength of the sphincter muscle, ask the resident to tighten their rectum around examiner‘s finger. The

examiner should feel the sphincter tighten around entire circumference of finger. This is another method for determining if resident can perform a PFM contraction.

o Note the presence of hard stool in the rectal vault which may indicate bowel impaction.

o Note size of the prostate as an enlarged or abnormal consistency of the prostate gland in men should be noted and abnormal findings should be discussed with the physician to determine if the resident should be referred to an urologist.

Bladder Record

To determine voiding pattern and incontinence frequency rate, nursing staff observes the resident every hour noting the following on a Bladder and Bowel Record:

Bladder and Bowel Master Series

o Time, frequency and volume of each void (day and nighttime)

o Note if resident is ―wet‖ or ―dry‖ and if wet, estimate the quantity of urine loss o Note duration of void and quality of urinary stream

o Whether absorbent incontinence pad was saturated or dry The resident is monitored usually for 72 hours

Diagnostic Testing

If an infection is suspected, a urinalysis should be completed. Because many residents

(approximately 30 to 50%), especially female residents, have chronic asymptomatic bacteriuria, the research-based literature suggests treating only symptomatic UTIs. Therefore, if bacteriuria and the resident does not have any symptoms, antibiotics should not be given.

Urinalysis

o Obtain a ―clean catch‖ urine specimen. Only use catheterized specimen if unable to

obtain clean catch. Note urine characteristics: color, odor, presence of sediment.

o Perform a Dipstick urinalysis. If the Dipstick urinalysis is positive for nitrites (indicating bacteriuria) and white blood cells (WBCs) or has a positive leukocyte esterase (an

enzyme present in WBCs indicating pyruia) assess the resident for shows signs and symptoms of a UTI. If all present, send a urine specimen for urine culture. A negative leukocyte esterase or the absence of pyuria strongly suggests that a UTI is not present. A positive leukocyte esterase test alone does not prove that the individual has a UTI.

 Bacteriuria is defined as the presence of bacteria in the urine. Bacteriuria in the elderly is common (prevalence rates of 25% - 50% for women, 15% - 40% for men), but most elderly individuals with bacteriuria are asymptomatic. Factors contributing to an increased incidence of bacteriuria in the elderly female include increased residual urine, genitourinary atrophy, bowel incontinence, pelvic organ prolapse and chronic diseases such as diabetes.

 Urinary tract infection (UTI) is a clinically detectable condition associated with bacterial invasion of some part of the urinary tract, including the urethra

(urethritis), bladder (cystitis), ureters (ureteritis), and/or kidneys (pyelonephritis). Infections of the urethra and bladder are classified as lower tract UTIs and those involving the ureters and kidneys are classified as upper tract UTIs. UTI is the most common infection experienced by residents. Symptomatic UTI is frequent but less common than asymptomatic UTI. The most common organism in women is Escherichia coli (E coli) and in men Proteus Mirabilis. In men, benign

prostatic hypertrophy (BPH) and chronic prostatitis promotes infection are caused by urethral obstruction, poor urine flow and recent instrumentation (e.g.

catheterization). In women, estrogen deficiency and the close proximity of the anus to the urinary meatus may cause contamination of the bladder with E coli are

According to CMS RAI Manual Version 3.0: Voiding records should:

1. Help detect urinary patterns or intervals between incontinence episodes.

Bladder and Bowel Master Series

contributing factors. In both men and women, incomplete bladder emptying, secondary to the neurologic disease, can lead to UTIs.

 Sepsis refers to the systemic inflammatory response to infection. It may include symptoms such as fever, hypotension, reduced urine output, or acute change in mental status. Urosepsis can result from bacteria spreading into the bloodstream from the bladder, kidneys, etc. Mortality from urosepsis has been documented as being more than three times higher in catheterized residents than in

noncatheterized residents. Urine culture and sensitivity (urine C&S)

o No one lab test alone proves that a UTI is present. For example, a positive urine culture will show bacteriuria, but that alone is not enough to diagnose a symptomatic UTI. However, several test results (urinalysis with a urine culture), in combination with clinical findings can help to identify UTIs.

o A urine culture result of a single predominant pathogen is sufficient for the diagnosis of symptomatic UTI based on the following result:

 1,000or 103

CFU (colony forming units)/mL - clean catch, midstream specimen. o The most common infecting organisms are E-coli, most common in female residents and

Proteus mirabilis in male residents.

o In addition to a positive urine culture, the resident without an indwelling catheter has to have at least three of the following signs and symptoms to treat for a UTI:

 Fever (2.4 degrees Fahrenheit above the baseline temperature) or chills  New or increased burning pain on urination, frequency or urgency  New flank or suprapubic pain or tenderness

 Change in character of urine (e.g. new bloody urine, foul smell, or amount of sediment) or as reported by the laboratory (new pyuria which is increased leukocytes in the urine or microscopic hematuria)

 Worsening of mental or functional status, i.e., confusion, decreased appetite, unexplained falls, incontinence of recent onset, lethargy, decreased activity o In addition to a positive urine culture, the resident with an indwelling (urethral or

suprapubic) has to have at least two of the following signs and symptoms to treat for a UTI. Symptoms are:

 Fever (2.4 degrees Fahrenheit above the baseline temperature) or chills  New flank pain or suprapubic pain or tenderness

 Worsening of mental or functional status

 Local findings such as catheter obstruction, leakage, or mucosal trauma (may also be present

Post void residual (PVR) urine (the amount left in the bladder 10 to 15 mins after voiding): o Should be determined in residents with risk factors for urinary retention (diabetes, spinal

cord injury disease, benign prostatic hypertrophy [BPH])

Bladder and Bowel Master Series

o PVR can be obtained by sterile in-and-out catheterization but the preferred method is using a portable bladder scanner that is a noninvasive method that is very accurate. o Normal PVR is between 50 mL and 100 mL and findings of between 150 mL and 200

mL bear repeat measurement. Abnormal PVR is > 200 mL and those residents should be referred to the urologist.

Cognitive, Functional & Environmental

Cognitive and functional impairment causing immobility are primary risk factors for UI, but not good predictors of a resident‘s responsiveness to toileting programs. These can interfere with independent toileting and bladder retraining so a comprehensive evaluation of cognition, mobility and the resident‘s environment are an important part of the initial assessment. Other disciplines, besides nursing (e.g., dietary, and/or social services, and physical/occupational therapy department), can assist in gathering this data.

Cognitive Ability Assessment:

o Ability to understand instructions, motivation and affect. o Ability to recognize bladder fullness (urge sensation). o Ability to locate toileting facility/bathrooms.

o Motivated to self-toilet, regain continence and restore bladder function. Functional Ability Assessment:

o Ability to accomplish toileting (e.g., manual dexterity, ability to disrobe). o Evaluate fall risk.

o Evaluate need or benefit of toileting devices, such as bedside commode or urinal

In document Independent Study Monograph I. Assessment of Bladder and Bowel (Page 33-42)