Independent Study Monograph I. Assessment of Bladder and Bowel

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Bladder and Bowel Master Series

Independent Study Monograph I

Assessment of Bladder and Bowel

By

Diane K. Newman,

DNP, ANP-BC, FAAN

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

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.

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PURPOSE

Assessment of Bladder and Bowel is Independent Study Monograph I 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 has been prepared for you, the nurse. Its goals are to:

1. To increase your knowledge of the problem, causes of bladder bowel problems.

2. To provide the essentials of resident evaluation, and the prospects for managing these

conditions.

3. 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 I, Assessment of Bladder and Bowel, is a comprehensive review

of the problems of urinary and fecal incontinence, and other bowel disorders seen in residents in the long term care setting. It includes key elements of an appropriate bladder and bowel

assessment.

I wish success for you, your staff, and your residents!

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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 32-20. 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 1.5 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, 11

out of 14 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.

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TABLE OF CONTENTS

Learning Objectives………..…..………….………...…….…..….4

Incontinence in the Nursing Home………..…..………….………...…….………5

Long Term Care Regulations.…….………...8

Understanding Bladder Function……….……..16

Incontinence is Not A Normal Part of Aging….……….……...20

Identifying Residents ―At-Risk‖……….………..….22

Causes of Transient Urinary Incontinence……….…..………..24

Types of Chronic or Persistent Urinary Incontinence………….…..……….27

Bladder Assessment………….…..………32

Clinical Pathway for Management of UI………...40

Understanding Bowel Function………..……..……….………41

Review of Common Bowel Disorders………...44

Fecal Incontinence……….……...,….,………..44 Constipation………..……...45 Fecal Impaction……….……...,….,………..47 Diarrhea………..……...48 Appendix I – References Appendix II – Glossary Appendix III – Care Plans

1. Urinary Elimination, Altered Patterns Related to Transient/Acute Causes of Incontinence 2. Overflow Incontinence Related to Incomplete Bladder Emptying or Urinary Retention

from Neurogenic Bladder or Urethral Blockage

3. Functional (urinary or bowel) Incontinence Related to Decreased Mobility or Cognition Appendix IV – Post Test

Appendix V – Independent Study Evaluation Form Sample A: Bladder and Bowel Record

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LEARNING OBJECTIVES

At the end of this Independent Study Monograph, the participant will be able to:

1. Review the prevalence, risk factors and impact of urinary and fecal incontinence in the nursing home setting.

2. Detail requirements to include the MDS Version 3.0 and other regulations that relate to bladder and bowel assessment and management.

3. Review coding of MDS Version 3.0 Section H: Bladder and Bowel and its relation to care area assessments and triggers.

4. List the parts of the urinary system, the age-related changes that occur in the lower urinary tract.

5. Characterize the causes and types of urinary incontinence, including signs and symptoms of transient and chronic incontinence, assessment, and management pathway.

6. Identify parts of the bowel system, components of bowel dysfunction, and common bowel disorders seen in residents in nursing homes.

7. Describe how to conduct a bladder and bowel assessment in nursing home residents.

NOTE:

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INCONTINENCE IN THE NURSING HOME

Bladder and bowel dysfunction as urinary (UI) and bowel (FI) incontinence, and associated bowel disorders, have major impact on residents in nursing homes. Urinary incontinence is one of the main reasons for placement of older adults into institutionalized care and it is the primary reason why many elderly are not accepted into the less expensive and less restrictive

environment of assisted living facilities.

UI- Prevalence:

The prevalence of UI in nursing homes remains high, despite many years of research and clinical efforts to cure or improve it. According to the CMS database (reporting period ending March 2004), the prevalence of nursing home residents who are incontinent of urine and/or bowel is 58.6%. This results in a national cost of $8.5 billion. The costs of nursing home care in the United States was estimated at $150 billion (in 2007 dollars), with 62% assumed by taxpayers in the form of Medicare and Medicaid payments. UI is a risk factor for nursing home admission and a significant factor in decisions to move a family member from their home. The prevalence of UI is considered an indicator of quality nursing care in the nursing home setting.

Directors of Nursing in long term care (LTC) facilities judge UI as having the greatest effect on cost of care. With the elderly living longer and the census of those living 65 years and older expected to double in the next 30 years, incontinence is an area of great concern to the LTC industry.

UI- Incidence

Incidence refers to the new cases of UI that developed during a specified period of time. It is known that the incidence of UI increases, as residents who are continent at admission tend to become incontinent over time. Incidence statistics are important because they can help identify risk factors for UI. It is also known that once incontinence develops, it tends to persist. Daytime (from 7:00 a.m. to 7:00 p.m.) incontinence for the first year after nursing home admission has been reported to be 27%. Gender differences have also been noted as 21% of women and 51% of men have UI. Incidence of UI has been associated with being male, having dementia, fecal incontinence, and an inability to transfer or walk independently.

CMS’s RAI Version 3.0 Manual Definitions: Urinary Incontinence: the involuntary loss of urine.

Continence: Any void into a commode, urinal, or bedpan that occurs voluntarily or as the result

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UI - Impact on Quality of Life:

Incontinence in nursing home residents results in loss of dignity and quality of life, as well as the sequelae of skin breakdown, urinary tract infections, and falls. Injuries can also occur in staff resulting from the heavy lifting entailed in care of the incontinent resident. UI is independently associated with isolation, depression, anger, frustration and loneliness. UIis associated with lower sleep scores, especially for residents with overactive bladder (OAB), and has a significant effect on social well-being.

UI - Risk Factors

Urinary incontinence is considered to be a ‗geriatric syndrome‘ because many of its causative factors are not directly related to the urinary tract. Immobility and dementia are the most critical factors contributing to the development of UI in nursing home residents. Immobility increases the likelihood of incontinence among nursing home residents by preventing them from getting to the toilet; dementia reduces their motivation to do so.

Urinary incontinence symptoms of OAB can increase the risk of falls in several ways: Because most falls occur in the early hours of the morning, residents most at risk of

falling are those who need to use an assistive device for walking and who need to toilet at night

Another factor is the incontinence episode itself and the increased risk of a slip on soiled or wet floor surfaces.

Nocturia, awakening at night because of the need to urinate, is one of the most common causes of poor sleep in older people and carries with it a higher risk of daytime

drowsiness, falling and fractures in older adults. Nocturia and nocturnal enuresis (incontinence while asleep) are discussed in Monograph IV.

Urinary urgency and nocturia can be particularly problematic when night lighting may be poor and the older person not fully awake.

While incontinence prevalence is high in this population group and its consequences can be profound, the recognition of its importance is low, and its assessment is poor. Nurses play a key role in assuring appropriate assessment of nursing home residents to prevent and treat UI. Nursing assistants staff are the primary care givers of residents with UI as they are the involved in toileting programs and manage urine leakage. They feel that their involvement with UI outranks that of all of the medical problems. Changes at the organizational level and inpatient care are needed to make dignity of nursing home residents central to UI quality improvement efforts. Changing long-held beliefs and attitudes in tandem with increasing nurses' self-efficacy to assess an incontinent resident is important in any quality improvement program. Not feeding or clothing nursing home residents when nursing units are short staffed is unacceptable; yet, continence efforts are often the first to be overlooked. Rather than using dryness levels as the sole primary outcome, refocusing on preserving dignity and quality of life may achieve the desired outcome: appropriate continence care. Continence should be viewed as a dignity issue,

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especially when nursing home residents express preference for care that promotes comfort, does not depend on staff, and is not embarrassing.

FI – Prevalence

The prevalence of liquid or solid fecal incontinence (FI) is approximately three times as great in nursing home residents as in the non-institutionalized population aged 70 and older. In this population, FI may be a marker of declining health and increased mortality. Long-lasting FI has been associated with reduced survival. Similar to what is seen in residents with UI, immobility and dementia, preclude residents from getting to the toilet in time and are important risk factors for the development of FI. Overflow FI and related bowel disorders, constipation and fecal impaction, are also common events in nursing home residents.

Constipation has been defined as two or fewer bowel movements per week, presence of hard stools, straining at defecation, or incomplete stool evacuation. Constipation plays an integral role in the development of fecal impaction and FI among this population. The incidence of constipation increases with age and is also attributable to immobility, ―weak straining ability‖, the use of constipating drugs, and neurological disorders. Constipation can result from a

combination of lack of dietary fiber intake, poor fluid intake and dehydration, and the concurrent use of various ―constipating‖ medications.

Fecal impaction, a leading cause of FI in the institutionalized elderly, results largely from the person‘s inability to sense and respond to the presence of stool in the rectum. Decreased mobility and lowered sensory perception are also common causes.

Impact of UI and FI

According to CMS‘s RAI Version 3.0 Manual, incontinence has far-reaching impact on many areas of a resident‘s daily life. It can:

Interfere with participation in activities,

Be socially embarrassing and lead to increased feelings of dependency, Increase risk of long-term institutionalization,

Increase risk of skin rashes and breakdown,

Increased risk of repeated urinary tract infections, and

Increase the risk of falls and injuries resulting from attempts to reach a toilet unassisted.

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LONG TERM CARE REGULATIONS

Nursing homes are required to conduct a comprehensive assessment and screening of residents with incontinence, both urinary and bowel, and evaluate those who are at-risk for developing

incontinence. The desired goal is to improve the quality of care through the maintenance and the restoration of bladder and bowel function.

The Centers for Medicare and Medicaid Services (CMS) has singled out UI in its regulations, mandating that LTC facilities appropriately assess and treat this disorder. The CMS requires comprehensive assessment as the basis for developing a plan of care that will help the resident to attain and maintain the best possible physical, mental, and psychosocial functioning.

CMS Tag F315 – Urinary Incontinence and Catheters

Tag 315 is an objective tool for surveyors to use when investigating residents at risk for urinary incontinence and residents with indwelling catheters. There are three aspects that determine compliance to the F315 Tag including:

1) The facility attempts to assist the resident with urinary incontinence to restore as much normal bladder function as possible.

2) A resident who does not have an indwelling urinary catheter does not have one inserted unless the resident‘s clinical condition demonstrates that it is necessary.

3) The facility provides appropriate treatment and services to prevent urinary tract infections (UTIs).

The CMS publishes the Resident Assessment Instrument (RAI) manual, which helps staff gather information used to asses and plan the care of residents, as well as information used for payment of skilled nursing services provided in a resident‘s Part A stay. Completion of the RAI includes: assessment, decision making, care planning, care plan implementation and evaluation

NOTE:

CMS expects that staff, in both long-term residents and residents in a rehabilitative program nursing homes, use all necessary resources and disciplines to ensure that residents achieve the highest level of functioning possible (quality of care) and maintain their sense of individuality (quality of life).

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Resident Assessment Instrument

The Resident Assessment Instrument (RAI) helps nursing home staff look at residents holistically— as individuals for whom quality of life and quality of care are mutually significant and necessary. Interdisciplinary use of the RAI promotes this emphasis on quality of care and quality of life. CMS recommends that nursing homes involving disciplines (e.g. dietary, physical therapy, occupational therapy, pharmacy) in the RAI process to ensure a comprehensive approach to resident care and team communication. This is especially important in providing restorative bladder and bowel programs which are discussed in Monograph III.

The RAI consists of three basic components: The Minimum Data Set (MDS) Version 3.0, the Care Area Assessment (CAA) process and the RAI utilization guidelines. The utilization of the three components of the RAI yields information about a resident‘s functional status, strengths,

weaknesses, and preferences, as well as offering guidance on further assessment once problems have been identified.

When completing the RAI, staff should use the following nursing process:

Assessment—Taking stock of all observations, information, and knowledge about a

resident from all available sources (e.g., medical records, the resident, resident‘s family, and/or guardian or other legally authorized representative).

Decision Making—Determining, with the resident (resident‘s family and/or guardian or other legally authorized representative), the resident‘s physician and the interdisciplinary team, the severity, functional impact, and scope of a resident‘s problems. Decision making should be guided by a review of the assessment information and the CAA decision-making process. Understanding the causes and relationships between a resident‘s problems and discovering the ―whats‖ and ―whys‖ of resident‘s problems; finding out who the resident is and putting the needs, interests, and lifestyle choices of the resident at the center of care. Care Planning—Establishing a course of action with input from the resident (resident‘s

family and/or guardian or other legally authorized representative), resident‘s physician and interdisciplinary team that moves a resident toward resident-specific goals utilizing

individual resident strengths and interdisciplinary expertise; crafting the ―how‖ of resident care.

Identification of Outcomes—Determining the expected outcomes forms the basis for evaluating resident-specific goals and interventions to help residents achieve those goals. This also assists the interdisciplinary team in determining who needs to be involved to support the expected resident outcomes. Outcomes identification reinforces individualized care tenets by promoting residents‘ participation in the process.

Implementation – Putting that course of action (specific interventions derived through interdisciplinary individualized care planning) into motion by staff knowledgeable about the resident‘s care goals and approaches; carrying out the ―how‖ and ―when‖ of resident care. Evaluation – Critically reviewing individualized care plan goals, interventions and

implementation in terms of achieved resident outcomes and assessing the need to modify the care plan (i.e. change interventions) to adjust to changes in the resident‘s status, goals, or improvement or decline.

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1) Minimum Data Set 3.0 Requirements

The Long Term Care Minimum Data Set (MDS) is a standardized, primary screening and

assessment tool of health status which forms the foundation of the comprehensive assessment for all residents of long-term care facilities certified to participate in Medicare or Medicaid.

The MDS contains items that measure physical, psychological and psycho-social functioning. The items in the MDS give a multidimensional view of the patient's functional capacities, and can be used to present a nursing home's profile. The MDS now plays a key role in the Medicare and Medicaid reimbursement system and in monitoring the quality of care provided to nursing facility residents.

The MDS 3.0 contains numerous and substantial changes that represent a radical shift from the MDS 2.0. These changes provide the nursing home with for incontinence management, especially when it comes to assessment and documentation. The MDS 3.0 is reconfigured and supported by new material, definitions, and assessment processes. The MDS 3.0 has many advantages such as:

Increased resident‘s voice

Increased clinical relevance for assessment Increased accuracy, both validity and reliability Increased clarity and efficiency

45% reduction in the average time for completion

The Bladder and Bowel portion of the MDS is Section H and now covers the following topics: Appliances;

Urinary toileting programs; Urinary continence;

Bowel continence; and

Bowel patterns (fecal impaction item has been dropped)

The intent of the items in this section of MDS 3.0 is to gather information on the use of bowel and bladder appliances, the use of and response to urinary toileting programs, urinary and bowel continence, bowel training programs, and bowel patterns. Each resident who is incontinent or at risk of developing incontinence should be identified, assessed, and provided with individualized treatment and services to achieve or maintain as normal elimination function as possible

MDS 3.0 appears to eliminate the confusion about wording of continence items such as coding residents with catheter as continent. It covers trial toileting programs, and replaces ―usually‖ with definite numbers. In response to expert input, constipation is addressed with a yes/no

response to bring staff attention to it as a common side effect of medications and immobility, and as a sign of possible dehydration.

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The CMS added definitions related to bladder and bowel problems which are very helpful. Section H places an emphasis on the accurate assessment of urinary and bowel continence and the interventions used to manage incontinence

(http://www.youtube.com/watch?v=bnUtBrQWW1s). This section emphasizes outcomes—the resident‘s response to the trial toileting program.

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2) Care Area Assessments (CAAs) and Care Area Triggers (CATs)

MDS 3.0 replaces Resident Assessment Protocols (RAPs) with Care Area Assessments (CAAs) which allow for more in-depth assessment of residents. The biggest difference between the old and new MDS assessment process is that MDS 2.0 required that RAPs be the tool for conducting the thorough assessment but the new MDS does not mandate a specific assessment tool. CMS instead wants providers to use ―tools that are current and grounded in current clinical standards of practice‖ for further assessment of potential areas of concern. These areas of concern were formerly known as ―triggered care areas‖ and MDS 3.0 has assigned an acronym to this phrase: Care Area Triggers (CATs). Completing the MDS only identifies CATs, which indicate

caregiving needs and problems. CATs identify conditions that may require further evaluation because they may have an impact on specific issues and/or conditions, or the risk of issues and/or conditions for the resident. Each triggered item must be assessed further through the use of the CAA process to facilitate care plan decision making, but it may or may not represent a condition that should or will be addressed in the care plan. The significance and causes of any given trigger may vary for different residents or in different situations for the same resident. Different CATs may have common causes, or various items associated with several CATs may be connected. In relation to bladder and bowel problems, Urinary Incontinence and Indwelling Catheter is one of 20 CAAs. The table on the following page is the CAA section on UI and Indwelling Catheters:

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3) Utilization Guidelines.

The Utilization Guidelines provide instructions for when and how to use the RAI. These include instructions for completion of the RAI as well as structured frameworks for synthesizing MDS and other clinical information (available from

http://cms.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf). Urinary Incontinence and Indwelling Catheter

Urinary incontinence is the involuntary loss or leakage of urine or the inability to urinate in a socially acceptable manner. There are several types of urinary incontinence (e.g., functional, overflow, stress, and urge) and the individual resident may experience more than one type at a time (mixed incontinence). Although aging affects the urinary tract and increases the potential for UI, urinary incontinence itself is not a normal part of aging. Urinary incontinence can be a risk factor for various complications, including skin rashes, falls, and social isolation. It is often at least partially correctable. Incontinence may affect a resident‘s psychological well-being and social interactions. Incontinence also may lead to the potentially troubling use of indwelling catheters, which can increase the risk of life-threatening infections.

This CAA is triggered if the resident is incontinent of urine or uses a urinary catheter. When this CAA is triggered, nursing home staff should follow their facility‘s chosen protocol or policy for performing the CAA.

Urinary Incontinence and Indwelling Catheter CAT Logic Table Triggering Conditions (any of the following):

1. ADL assistance for toileting was needed as indicated by: (G0110I1 >= 2 AND G0110I1 <= 4) 2. Resident requires a indwelling catheter as indicated by: H0100A = 1

3. Resident requires an external catheter as indicated by: H0100B = 1 4. Resident requires intermittent catheterization as indicated by: H0100D = 1

5. Urinary incontinence has a value of 1 through 3 as indicated by: H0300 >= 1 AND H0300 <= 3

Successful management will depend on accurately identifying the underlying cause(s) of the incontinence or the reason for the indwelling catheter. Some of the causes can be successfully treated to reduce or eliminate

incontinence episodes or the reason for catheter use. Even when incontinence cannot be reduced or resolved, effective incontinence management strategies can prevent complications related to incontinence. Because of the risk of substantial complications with the use of indwelling urinary catheters, they should be used for appropriate indications and when no other viable options exist. The assessment should include consideration of the risks and benefits of an indwelling (suprapubic or urethral) catheter; the potential for removal of the catheter; and

consideration of complications resulting from the use of an indwelling catheter (e.g., urethral erosion, pain, discomfort, and bleeding). The next step is to develop an individualized care plan based directly on these conclusions.

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Quality Indicators (QIs)

According to CMS, the MDS Quality Measure/Indicator (QM/QI) is part of the Nursing Home Quality Initiative (NHQI)

(https://www.cms.gov/MDSPubQIandResRep/03_qireports.asp#TopOfPage). Reporting is by state and summarizes the average percentage of nursing home residents who activate (trigger) one of 30 quality measures/indicators during a quarter. QM/QIs are triggered by specific responses to MDS elements and identify residents who either have or are at risk for specific functional problems needing further evaluation.

QM/QIs measure potential good and poor care. The QM/QI program was designed to signal the presence or absence of potentially poor care practices or outcomes. QM/QIs cover eleven (11) ―domains,‖ or broad areas of care. Quality indicators are instrumental in the state and federal nursing home survey processes. These surveys are generally done annually, but can be done more often if there is a red flag in any of the quality indicators, based on the MDS data submitted to CMS. A high score for the QM/QI indicates high incidence or prevalence of the problem.

Some nursing homes have a higher number of residents who are frailer and sicker. In order to take this fact into account, some of the QIs are "risk adjusted". The residents in a facility are grouped into "high risk" and "low risk" for a certain problem, and the QI is assessed separately in each of these groups. The high risk group includes only residents who have other medical

conditions that may make them more susceptible to developing the problem. The periods of time for the quality measures follow:

1. For the chronic care measures, calculations are based on any resident with a full or quarterly MDS in the target quarter.

2. For post-acute care measures, calculations are based on any resident with a 14-day PPS MDS in the 2 consecutive target quarters.

The current nursing home quality measures related to bladder and bowel conditions are long stay QMs and include:

Percent of Long-stay Residents with a Urinary Tract Infection

Percent of Low-Risk Residents Who Lose Control of their Bowels or Bladder Residents Who Have/Had a Catheter Inserted and Left in Their Bladder

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Quality Measure

Numerator Denominator Exclusions Covariates

Incontinence (Low Risk) Residents who are incontinent of bowel (H1a=3 or 4) or bladder (H1b = 3 or 4)

All residents with target assessment and not qualifying as high risk, except those with exclusions

1. High risk residents: a) Severe cognitive

impairment (B4 =3 & B2a =1) OR

b) Totally dependent in mobility ADLs G1a(A), G1b(A), AND G1e(A) all = 4 or 8) 2. Admission assessment (AA8a = 01) 3. Comatose (B1 = 1 or missing) 4. Indwelling catheter (H3d checked or missing) 5. Ostomy (H3i checked or

missing)

6. QM not triggered and missing data for H1a or H1b or any high risk items [B4 or B2a and G1a(A), G1b(A), or G1e(A)] NA Indwelling Catheters Residents with indwelling catheters (H3d is checked)

All residents with a target assessment, except those with exclusions 1. Admission assessment (AA8a = 01) 2. Missing data on H3d 1. Bowel incontinence on prior MDS (H1a = 4) 2. Pressure sores on prior MDS (M2a = 3 or 4) Urinary Tract Infections Residents with urinary tract infection (I2j = checked)

All residents with a target assessment, except those with exclusions

3. Admission assessment (AA8a = 01)

4. Missing data for UTI (I2j is missing)

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UNDERSTANDING BLADDER FUNCTION

Although numerous conditions can give rise to UI, it is not difficult to identify the major causes. One needs to look at the excretory structures, the bladder and urethra, the neurologic system, the brain, and the pathways of communication between the brain and the structures.

Urinary System

The urinary system is a highly efficient mechanism for removing waste products from the blood and excreting them from the body. The urinary system consists of two kidneys; two ureters, a urinary bladder, and a urethra (see Figure 1). The paired, fist-sized kidneys filter impurities from the blood at a rate of one-fifth of the total blood volume every minute, and then convert them into urine. They also regulate the chemical make-up of the blood and preserve the correct balance between salt and water in the body. Urine is transported from the kidneys through the ureters down to the bladder.

The bladder is a hollow muscular sac that acts as a reservoir for the urine until elimination is convenient (see Figure 2). The bladder lies in the pelvis behind the pelvic bone when empty and rises above this level when full. The bladder fills and expands with urine until it reaches

capacity and the pressure inside increases. The wall of the bladder is formed by the detrusor muscle, which consists of an interwoven latticework of smooth muscle cells. At the base of the detrusor muscle is the bladder neck or trigone, a triangular area located within the bladder wall. The trigone may contain most of the sensory nerves of the bladder. The ureters enter the bladder at the trigone.

Figure 1 Urinary Tract

Figure 2 Bladder and Urethra

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The urethra is a small vascular tube that leads from the floor or neck of the urinary bladder to the outside of the body (see Figure 3). It is the passageway through which urine exits the body. The urethral orifice or urinary meatus is the opening of the urethra to the outside of the body. In women, it is located between the clitoris and the vaginal opening. The female urethra is approximately 4 cm (1.5 inches) in length. In men, the urethra leaves the bladder, passes downward through the prostate gland, the urogenital diaphragm, and finally passes along the length of the penis until it ends at the urethral opening at the tip of the penis. The male urethra is approximately 25 cm (8 inches) long.

Female Pelvis Male Pelvis

The urethra is surrounded by two sphincter muscles which prevent urine from leaving the bladder (see Figure 4). A sphincter is a ring-like band of muscle fiber which closes off natural body openings, such the anus and the urethra. The inner ring of muscle, or internal sphincter, is involuntary, while the outer ring or external sphincter is under voluntary control. So the

sphincters stay contracted, when sitting, standing or walking, so urine does not leak out of the bladder or urethra. The sphincter relaxes when messages (impulses) are sent from the brain through the nerves to the pelvic floor muscles and voiding then occurs.

The external sphincter lies below the internal sphincter. It is primarily a striated muscle and can be

consciously controlled. The person voluntarily relaxes this sphincter to urinate, or voluntarily contract it to prevent urine leakage when abdominal pressure is increased, such as during coughing or sneezing.

Figure 3

Side view of the male and female pelvis

Figure 4 Urinary Sphincters

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The external sphincter is supported by the pelvic floor muscles, a group of muscles that extend from the front (anterior) to the back (posterior) of the pelvis, forming a sling. The PFMs are under voluntary control and play an important role in maintaining continence. They can become weakened from childbirth, lack of use, a decrease in the hormone estrogen, aging, surgery, and injury.

The kidneys filter approximately 1,200mLs or 20% of the cardiac output every minute. An average person produces between 700mLs and 2,000mLs (23 to 66 ounces) of urine per day. The normal adult bladder will collect approximately 250mLs (8 ounces) of urine before pressure within the bladder (intravesical pressure) rises and the initial urge to void is felt. The capacity of the bladder, the amount of urine it can hold, is around 450mLs or 15 ounces.

The sympathetic nervous system assists with bladder filling and prevents premature urine leakage by relaxing the bladder muscle and contracting the urethra and bladder neck. The brain is the message center; the spinal

cord is the pathway for nerve innervation and communication (see Figure 5). Stretch receptors in the bladder stimulate nerve endings which transmit signals to the cerebral cortex in the brain that the bladder is full and the urge to void reaches consciousness. Voiding occurs when the parasympathetic nervous system stimulates the detrusor (bladder muscle) to contract and inhibits further sympathetic action, causing the urethra and external (voluntary) sphincter muscle to relax. When the pelvic muscles and the sphincter relax, voiding occurs. The advantage of this system is that during the early stages of bladder filling, the person

remains unaware of the slowly accumulating fluid and is not required to keep the external sphincter consciously closed. This only becomes necessary when enough urine collects to relax the internal sphincter. An interruption of the nerve innervation to any aspect of this system, as the result of injury or disease, will cause neurogenic bladder dysfunction leading to either urinary incontinence or urinary retention (incomplete bladder emptying).

NOTE: Normal function of the bladder, urethra, sphincters, and pelvic floor muscles are keys

to normal voiding.

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As already discussed, the bladder's function is to fill, store, and then empty urine through the urethra. During the filling phase, the bladder muscle (detrusor) relaxes to accommodate increasing volumes. As the bladder reaches its capacity and becomes distended, the pressure inside (intravesical pressure) increases. The bladder increases to the size of a softball when full. Normally, it can hold about 12-16 ounces (360-450 mLs) of urine, which is called the functional capacity of the bladder. When empty, the bladder lies in folds.

The following are the steps in the Normal Voiding Cycle.

Step 3

Since voiding is voluntary, the individual makes a conscious decision to void or to delay voiding. If voiding occurs, the pressure in the bladder muscle increases, causing the bladder to contract and the urethral sphincter and pelvic floor muscle to relax

Step 2

Bladder fills to capacity and nerves send messages to the brain, causing the first

sensation of need to void (urge).

Step 4

Voiding occurs.

Step 1

The bladder muscle relaxes as it fills with urine. The pelvic floor muscle and urethral

sphincter muscle remain contracted to prevent release of urine.

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INCONTINENCE IS NOT A NORMAL PART OF AGING

While UI should not be considered a normal consequence of ageing, age-related changes within the urinary tract do predispose older people toward UI and other lower urinary tract symptoms. Therefore, when properly assessed and treated, it can be corrected in about 30% of nursing home residents and controlled and managed in the rest. Though there are physiological, psychological, and environmental changes that accompany aging, they do not directly cause UI, but they do predispose the elderly to an increased risk or incidence of UI. Since many losses accompany aging, an individual may use incontinence as a means of regaining control, getting attention, or showing anger. Aging changes in the urinary tract include:

There is a 30% to 40% loss of functional kidney cells (nephrons) and a decrease in the kidney‘s ability to filter blood and concentrate urine.

Changes in the circadian rhythm of water excretion leads to the largest amount of urine production occurring at rest, usually during the night (see Monograph IV). Also, during the night, there is a lower level of physical activity; the resident is lying flat, promoting the movement of body fluid from extracellular spaces to blood vessels, causing an increase in the amount of urine in the bladder. This is why the elderly have nocturia (awakening several times during the night). Because of this larger volume of urine in the bladder, urine loss can occur during sleep (called nocturnal enuresis or nighttime incontinence).

The sensory nerve tracts from the bladder through the spinal cord and to the brain often ―wear out,‖ creating breaks in the neural pathway. There is ―short-circuiting‖ of nerve firing, and messages may not completely reach the brain. In general, the nervous system takes longer to respond to sensory stimuli. This causes a delay in the urge sensation to void and a decreased interval between the time the urge to void is felt and actual voiding occurs. This shortened warning period is called urgency. Urgency, which in most persons is sudden and strong, causes the elderly to rush when attempting to toilet. Toileting programs strive to control the voiding process so that urine leakage is avoided.

Due to an incomplete nerve pathway or cortical brain damage that causes impaired bladder inhibition, there is an increase in bladder contractions (referred to as overactive bladder) that create the urge to void before the bladder is full. The resident will have no control over these contractions, which cause urine leakage usually on the way to the bathroom (urge urinary

incontinence).

Detrusor muscle is less able to expand as muscle fibers stiffen and atrophy. This can cause bladder capacity to decrease and prevent the bladder from emptying completely (called

urinary retention). This is the reason why the resident needs to void more frequently in

small amounts. The urine that remains in the bladder after the individual has voided (post-void residual [PVR]) may become infected with bacteria, causing an increased incidence of

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Estrogen receptors are found in squamous epithelium of the urethra, vagina and bladder trigone in women. The pelvic floor muscle is also estrogen sensitive. After menopause, the tissue lining of the vagina and urethra become thin and less vascularized leading to urogenital atrophy/atrophic vaginitis and urinary symptoms, such as urgency and frequency. Also, estrogen reduction in the genitourinary tract increases UTI risk by depletion of vaginal colonization of Lactobacilli. These changes can appear immediately following or several years postmenopausal.

The prostate gland in men enlarges with aging and can cause ―bladder outlet obstruction‖ leading to urinary symptoms, especially urgency and frequency.

NOTE: Normal age-related changes that occur in the urinary system also place the resident at

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IDENTIFYING RESIDENTS “AT-RISK”

The first steps toward assuring that a resident receives appropriate treatment and services to restore as much bladder function as possible, or to treat and manage the incontinence, is to identify the resident already experiencing some level of incontinence or at risk of developing UI and to complete an accurate, thorough assessment of factors that may predispose the resident to having urinary incontinence. As information is collected regarding the resident‘s medical history, and as the physical examination progresses, the nurse should be alert to identification of these risk factors.

Risk factors associated with incontinence include:

Immobility Impaired cognition Smoking

Obesity Diuretics Low fluid intake/dehydration

Fecal impaction Delirium Pregnancy/childbirth

Diabetes Physical activity or exercises Childhood nocturnal enuresis

Stroke Estrogen depletion Pelvic floor muscle weakness

Environmental barriers Polypharmacy

Medication is a significant and frequently overlooked risk factor for incontinence. Various medications can interfere with continence at various steps in the voiding process and Table 1 is a list of medications that effect lower (bladder, urethra and prostate in men) urinary tract function.

Table 1. Medications that affect bladder function

Medication Effect

Angiotensin-converting enzyme inhibitors (ACE inhibitors) (captopril, lisinopril, enalapril)

Antihypertensives, with a common side effect of cough, which can worsen stress UI.

Alpha-adrenergic receptor antagonists (prazosin, terazosin, doxazocin)

Smooth muscle relaxation of the bladder neck and proximal urethral causing stress UI (mainly in women).

Alpha-adrenergic receptor agonists (pseudoephedrine and ephedrine, present in many cold and OTC preparations)

Contraction of bladder neck and proximal urethra leading to increased urethral resistance, causing postvoid

dribbling, straining, and hesitancy in urine flow.

Anticholinergics Urinary retention with symptoms of postvoid dribbling,

straining, hesitancy in urine flow, overflow incontinence, and fecal impaction.

Antidepressants, tricyclic Anticholinergic effect and alpha-adrenergic receptor

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and hesitancy in urine flow. Psychotropics (sedatives,

hypnotics)

May decrease bladder contractility leading to urinary retention. Can accumulate in the elderly and cause sedation, confusion, and immobility, resulting in functional UI.

Cholinesterase inhibitors Increase bladder contractility and may cause UI. Also,

may interfere with antimuscarinic/OAB medications

Narcotic analgesics, opioids Decrease bladder contractility. Depress the central

nervous system, causing sedation, confusion, and immobility, leading to urinary retention and UI. Constipation is common side effect.

Beta-adrenergic receptor antagonists (propranolol, metoprolol, atenolol)

Urinary retention (rare).

Calcium channel blockers

(verapamil, diltiazem, nifedipine)

Impair bladder contractility, causing urinary retention. Cause constipation, leading to fecal impaction.

Diuretics (loop) (furosemide) Rapid-acting or loop diuretics overwhelm the bladder with

rapidly produced urine, resulting in frequency and urgency for up to 6 hours after ingestion.

If clinically possible, discontinue or change therapy. Dosage reduction or modification can be used (e.g., flexible scheduling of rapid-acting diuretics, such as administration of a late afternoon dose, to allow accommodation to sudden increase in urine volume).

Methylxanthines (theophylline) Polyuria, bladder irritation.

Neuroleptics (thioridazine, chlorpromazine)

Anticholinergic effect, sedation.

Cholinesterase inhibitors Cholinesterase inhibitors may cause OAB and UI by

increasing acetylcholine levels in the bladder.

Acetylcholine is a neurotransmitter that causes the bladder to contract and is released at the time of voiding.

Nonsteroidal anti-inflammatory drugs (NSAIDs) (gabapentin)

Can cause edema, causing nocturnal polyuria and exacerbating nocturia; may impair detrusor contractility.

Other: caffeine, alcohol Act as diuretics causing rapid diuresis, leading to urgency

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CAUSES OF TRANSIENT URINARY INCONTINENCE

To restore bladder function to the highest level possible in each resident, the nursing staff will need to understand the underlying causes of UI, be able to differentiate between transient and chronic persistent UI, and identify those residents at risk.

Urinary incontinence can be sudden, and is sometimes referred to as transient incontinence, because it may appear unexpectedly, during an acute illness or exacerbation of a chronic medical problem or disease. For many residents, incontinence can be resolved or minimized by

identifying and treating the underlying potentially reversible causes, including medication side effects, urinary tract infection, constipation and fecal impaction, and immobility (especially among those with the new or recent onset of incontinence); eliminating environmental physical barriers to accessing toilets.

Once identified, reversible conditions should be treated, and the resident reassessed at the end of the course of treatment to determine if the incontinence is resolved. It is important to distinguish between them because the onset of incontinence may be an early manifestation of a potentially serious, but reversible, disorder. Table 1 on the next two pages, reviews transient causes of UI by using the acronym PRAISED.

NOTE:

Urinary incontinence can be classified into transient (acute) or persistent (chronic) causes. All residents need a determination of the underlying causes. Once the causes of acute UI have been identified and they have been treated or eliminated, many residents will become continent and restore to normal or a greater level of bladder function. Some may require intervention and monitoring to prevent the acute UI problem from becoming persistent.

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Table 1. Medical Problems that can Cause Transient Urinary Incontinence

P

Polypharmacy as medications can either trigger new onset UI or unmask urine leakage. Nursing staff should consult with the

facility pharmacist and medical director to determine if discontinuing a specific drug, changing to another drug, or altering dosage and/or administration time are options, since they may alleviate the problem.

Psychiatric disorders, such as depression and schizophrenia, impair motivation contributing to self-neglect that reduces the

impetus for maintaining bladder control. Residents who have schizophrenia more frequently demonstrate these ―negative‖ disease symptoms of apathy and lack of motivation. These residents withdraw from social activity which further dampens the drive to maintain personal hygiene. Improving depression, other psychiatric disorders, and attention to personal care are essential to treating UI in these residents.

R

Retention of urine or incomplete bladder emptying can present as urinary urgency, frequency, or overflow UI. The resident may

perceive bladder fullness, but cannot completely empty the bladder (PVR >200 mLs), or may have no sensation of fullness or ability to initiate voiding. This condition can be due to a urethral obstruction (e.g., from an enlarged prostate or stricture) or from certain medications that contain anticholinergic properties. Urinary retention is also seen in residents admitted to the facility after a recent hospitalization or recent indwelling catheter removal. Neurologic condition such a stroke, diabetes, etc., can also cause the bladder to incompletely empty. Treatment depends upon the cause of the retention and the severity of the medical conditions, but initially will include intermittent catheterization until the bladder resumes normal emptying. An indwelling (Foley) catheter is not the long term treatment of choice.

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A

Atrophic vaginitis or urethritis is a thinning in the skin around the urethra and in the vagina from a decrease in the hormone estrogen. Women may have symptoms of vaginal dryness, burning, and vaginal bleeding and urinary symptoms such as UTIs,

frequency, urgency, and incontinence. This condition is frequently missed in frail older women, especially those living in LTC facilities. Transvaginal estrogen can improve these changes (see Monograph III).

I

Infection – symptomatic urinary tract infection, commonly seen in women residing in nursing homes can be due to incomplete

bladder emptying. Residual urine (urine remaining in the bladder following voiding) can irritate the bladder wall, creating bladder spasms, urgency and frequency, leading to urinary incontinence. The following conditions are seen in these residents:

see Monograph II &III

Immobility or functional changes in mobility due to surgery, illness, or physical restraints can interfere with or limit a resident‘s

mobility, preventing ability to toilet in time. Environmental considerations, such as providing a bedside commode or urinal and toileting the restrained resident can help avoid incontinence episodes. (see Monograph III& IV)

S

Stool impaction and chronic constipation create increased pressure on an already weakened bladder causing urinary frequency,

urgency and incontinence. A chronically full rectum interferes with normal bladder distension and increases bladder irritability.

E

Endocrine disorders such as high blood sugar and hypercalcemia can cause increased urine output (polyuria) and a delay or

lowered state of awareness of the urge sensation to void, contributing to UI. Cardiovascular disorders (e.g. CHF, venous

insufficiency) can cause excessive urine output (nocturnal polyuria), excessive fluid intake, and pedal edema. (see Monograph IV)

D

Delirium or acute confusion caused by an acute illness, such as myocardial infarction (MI), stroke, sepsis or infection can dull an

individual‘s awareness of the urge sensation and lead to the inability or unwillingness to reach a toilet.

Dehydration causes the urine to become concentrated, which, in turn, irritates the bladder wall precipitating UI, urgency and

frequency. Fluid consumption by residents‘ averages 1,200 to 1,500 ml (40 to 50 ounces) per day and it has been estimated that dehydration is present in 33% of residents. Use of a fluid management program should include giving enough fluids to meet each resident‘s fluid needs (approximately 30ml/kg/day with a 1,500 mL/day minimum or as indicated based on their medical

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TYPES OF CHRONIC or PERSISTENT URINARY INCONTINENCE

After transient causes of UI have been explored and UI persists, it is probably a chronic or persistent type of incontinence. Residents who continue with UI and bowel disorders should be considered for restorative nursing programs such as scheduled toileting, prompted voiding, bladder retraining, and pelvic floor muscle exercises, all discussed in Monograph III. For

residents whose incontinence does not have a reversible cause and who do not respond to bladder training, prompted voiding, or scheduled toileting, the interdisciplinary team should establish a plan to maintain skin dryness and minimize exposure to urine discussed in Monograph II. Chronic or long standing UI occurs because of persistent abnormalities of the structure or function of the lower urinary tract, including:

Bladder overactivity; the bladder contracts when it should not.

Bladder underactivity; the bladder fails to contract when, or as well as it should. The bladder stays full and some ―overflow‖ of urine may occur.

Urethral obstruction due to an enlarged prostate or stricture (narrowing of the urethra). Urethral incompetence where the sphincter and pelvic floor muscles are weak and cannot

prevent urine leakage upon exertion.

There are four types of chronic persistent UI: urgency UI, stress UI, overflow UI, and functional UI. In the elderly, symptoms may be seen in combination and referred to as ―mixed‖

incontinence. It is important to determine the type of UI in order to select the best method of management. Table 2 summarizes the types of UI followed by a more comprehensive review.

Table 2: Common Causes of Persistent and Chronic Urinary Incontinence

Types Causes Symptoms

Urgency UI with overactive bladder (OAB) Bladder overactivity. Neurologic conditions called neurogenic detrusor overactivity.

 Sudden and strong urge to pass urine

 Little warning time so unable to delay voiding after sensation of bladder fullness (urge) is perceived  Moderate to large amounts of leakage

 Urine loss on way to bathroom  Timing of urine loss is unpredictable

 Associated with other symptoms such as frequency, nocturia

 Usually occurs several times daily CMS‘s RAI Version 3.0 Manual contains numerous resources for training and preparation. Appendix C, Care Area Assessment (CAA) Resources, section six on Urinary Incontinence and Indwelling Catheter(s), contains a review of the causes of incontinence, the types of incontinence, and the factors that impact the level of incontinence. This reference should assist the facility‘s care team in establishing the resident‘s unique plan and documenting its outcomes.

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Stress Pelvic floor muscle

sphincter weakness

 Urine leakage occurs with physical activities or effort, coughing, sneezing.

 Drops to small amount of urine leakage  Usually does not occur daily

Mixed A combination of bladder

and urethral dysfunction, causing stress and urgency incontinence.

Combination of urgency and stress UI

Overflow Blocked urethra

Weak bladder muscles (detrusor underactivity, nerve damage)

 Palpable or percussable bladder  Elevated PVR (>150-200 mLs)

 Interrupted urinary flow (start and stop voiding)  Post-void dribbling

 Continual leakage of small amounts of urine

Urgency Urinary Incontinence (UUI)

The most common type of UI seen in the nursing home resident is urgency urinary incontinence; the involuntary urine loss that is usually preceded by urgency. In addition, these residents usually have OAB symptoms of urgency (sudden and strong desire to void) and frequency, both day and night (going to the bathroom more than 8 times in a 24 hour period). UUI is provoked by involuntary or overactive bladder contractions which overcome the urethral sphincter, or the bladder pressure exceeds urethral pressure sufficiently enough to cause urine loss.

Causes

Urgency incontinence is caused by an overactive bladder or poor bladder compliance. In many residents, urgency UI is caused by a neurologic disorder associated with the brain or central nervous system lesions or disorders that cause nerve changes to the bladder and sphincter. This is called ―neurogenic detrusor overactivity‖ (NDO) but most clinicians know this as ―reflex incontinence‖ or ―neurogenic bladder.‖ There are many common neurologic disorders associated with NDO including stroke, Parkinson‘s disease, dementia and with metabolic

disorders such as hypoxemia and encephalopathy. Peripheral nervous system impairment is seen in persons with diabetes and often these residents will have a combination of OAB, urgency UI, and incomplete bladder emptying.

A number of frail, elderly incontinent residents will have involuntary bladder contractions, but not empty their bladder completely. This can cause chronic urinary retention, which is one reason why the MDS 3.0 and CMS guidance requires bladder assessment of all residents with UI. In residents with suprasacral (above the sacral spinal cord) spinal cord lesions and multiple sclerosis, NDO is commonly accompanied by detrusor sphincter dyssynergia (DSD),

inappropriate contraction of the external sphincter with detrusor contraction. This can result in the development of urinary retention, vesicoureteral reflux (reflux of urine back up into the ureters and kidneys), and subsequent renal damage. Another urodynamic diagnosis associated with the symptom of urgency UI in frail, elderly residents is detrusor hyperactivity with impaired

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bladder contractility (DHIC). Residents with DHIC have involuntary bladder contractions, yet

must strain to empty their bladders either incompletely or completely. Clinically, residents with DHIC generally have symptoms of urgency UI and an elevated PVR, but they may also have symptoms of obstruction, stress UI, or overflow UI. DHIC must be distinguished from other types of UI because it can mimic them, resulting in inappropriate diagnosis and treatment.

Signs and Symptoms

The following symptoms are usually seen in combination:

 Urgency – sudden, intense urge to void, which does not allow enough time for a resident to reach a toilet or obtain a bedpan or urinal.

 Moderate to large quantities (can measure several hundred milliliters) of unwanted urine leakage. The timing of incontinence is usually unpredictable and can occur in any position and at any time, day or night. Although an urge usually precedes the incident, in some cases, no warning occurs at all.

 Frequency – going to the bathroom more than 8 times in a day and night.

 Nocturia - sleep interrupted by the need to urinate, usually occurring twice or more nightly.  Poor or low bladder capacity.

Stress Urinary Incontinence (SUI)

SUI is the loss of urine associated with sneezing, coughing, laughing, lifting, walking, or other forms of physical exertion that increase intra-abdominal pressure. These activities increase pressure on the bladder causing urine leakage. Urine leakage occurs simultaneously with exertion, because intra-abdominal pressure exceeds urethral resistance. Typically, more women than men experience stress UI; 6 out of 7 people with this problem are women.

Causes

The most common cause of SUI in women is sphincter dysfunction, due to relaxation and weakness of the pelvic floor muscles and a decrease in urethral closure. Abnormal urethral movement, called ―hypermobility,‖ can occur during physical activity or exertion (changing from sitting to standing). The urethra can‘t prevent the flow of urine and urine will leak from the urethra. A damaged or weakened sphincter muscle might also be the source of leakage. As women age, many develop intrinsic urethral sphincter dysfunction (called ISD). Childbearing stretches and relaxes a woman‘s pelvic floor, and may damage nerves in the pelvic area and tissue in the bladder‘s neck. Prolapse of the pelvic organs can be a cause of SUI. The position of the uterus, bladder, and bladder neck within the pelvis has a direct effect on the control of urine. SUI in men can be caused by prostate surgery, especially for cancer which can cause damage to the urethral sphincter muscle. Obesity and smoking, with chronic coughing, can contribute to stress UI.

SUI usually produces only small amounts or ―drops‖ of urine leakage. However, the amount of leakage may change, depending on the specific activities that cause the urine loss and the underlying cause of the SUI. Severe SUI can even occur during minimal activity, such as changing positions in bed, or the leakage may not be related to any activity. SUI usually occurs

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during the daytime. Usually women with SUI will start a pattern of urinary frequency, because they believe an incontinence accident is more apt to happen with a full bladder.

Mixed Urinary Incontinence

Most nursing home residents will have both urge and stress UI, which is termed ―mixed‖ UI. Female residents most often have mixed UI. Men will have urgency and overflow UI. In residents with mixed UI, a combination of behavior interventions, dietary changes, bladder retraining and pelvic floor muscle exercises can be successful. Addition of drug therapy in those residents on toileting or bladder retaining programs is most appropriate. Most residents will need to use incontinence products.

Overflow Urinary Incontinence

Overflow incontinence is urine loss associated with an over distended bladder due to an obstruction or blockage in the urethra causing the bladder not to empty completely.

Because the bladder never completely empties, the muscle gradually stretches and stretches until it can‘t empty completely (called hypotonic bladder). If overflow UI goes untreated, the urine that stays in the bladder can become infected, leading to infection in the entire lower and upper urinary tract. In severe cases, the urine can reflux into the kidneys, causing hydronephrosis.

Causes

A hypotonic bladder caused from neurologic dysfunction and a bladder that does not contract (acontractile) due to diabetes or spinal cord injury can lead to chronic urinary retention. Bladder outlet or urethral obstruction due to enlarged prostate in men, pelvic organ prolapse in women, urethral stricture or bowel impaction in men and women can lead to urinary retention. The chronic use of certain drugs such as analgesics and any drug that causes anticholinergic side effects may increase the capacity of the bladder, but they dull the sensation of the need to urinate and many reduce the ability of the muscle to contract normally. All can present as overflow UI.

Leakage of small amounts of urine, either periodically or continuously, will be evident in the Bladder and Bowel Record. Complaints or observations of the resident‘s difficulty starting urination may be present and once voiding is started, the urine stream may be weak (residents may report that the urine ―stops and starts). Signs may include a palpable or percussable bladder, suprapubic tenderness, and a hesitant, interrupted urine flow or post void dribbling. The resident may need to strain to void and feel a sense of incomplete emptying or bladder fullness.

Prolonged, untreated high volume urinary retention can cause reflux of urine into the ureters, which over time will cause kidney damage (hydronephrosis) due to very high bladder pressures

Functional Urinary Incontinence

Functional incontinence occurs when a normally continent individual is either unable or unwilling to toilet appropriately. Bladder and urethral function are essentially normal, and factors outside the urinary tract may be the cause of this type of UI. It is felt that over 25% of