CONTINENCE PROMOTION: Modern fundamentals for care givers

Video Script / November 7, 2013 / © 2013, Family Health Media


HOSTESS: Here’s the bathroom, George. Look for the sign.

GEORGE: Oh, okay. Don’t leave me.

HOSTESS: As care givers, one our most important duties is to help our elderly patients and residents keep or regain as much normal bladder function as they can. In years past, we thought (we used to think) incontinence was normal with age, that we couldn’t do much about it. George probably would have just relieved himself in adult briefs. Well, times have changed. Now we know, urinary incontinence is almost always manageable, (sometimes even curable ??). Today, federal compliance regulations require that every (incontinent) nursing home resident be assessed by clinical staff and given the opportunity for improved bladder control. Most can be measurably (noticeably) drier, Including residents with dementia, like George. And frail patients, like Ruth. And by reducing wet episodes and increasing dry hours, we have fewer of the serious health and comfort issues so common with mismanaged incontinence, …

Such as falls and injuries from trying to scurry to the toilet,

The unpleasant odor of urine,

Social isolation,

Sleep disruption

The need for restraints,

Urinary tract infections,

And skin breakdowns and dangerous pressure ulcers.

This program is about the continence promotion process, with a focus on our role, the direct care giver, and the knowledge and attitudes we need to give quality care. Whether you’re a nursing assistant, An LPN or a family member, providing care in a nursing home, a hospital or a home setting, the principles we’ll cover still apply. Who better than direct care givers to be champions for managing (reducing??) urinary incontinence? After all, we spend more time with our patients and residents and understand them better than anyone. We owe it to them to be knowledgeable and supportive about improving their bladder function.

“CONTINENCE PROMOTION - Modern fundamentals for care givers”

HOSTESS: Incontinence is any unintentional loss of urine. It’s never normal, not for any adult, at any age. There are several types, and care givers need to know what they are. Often we’re the first ones (it’s up to us) to notice new or undiagnosed incontinence, since some embarrassed patients and residents try to keep it their hidden secret, and early detection can mean easier management and better outcomes.

Stress incontinence is urine leakage from the physical strain of sneezing, or laughing, or standing up. It affects women and men. Normally the pelvic muscles are strong enough to support the bladder and pinch the urethra shut to stop or start urine flow. If the muscles become weak (with age), urine can leak out during a physical strain.

The second type is urge incontinence. Without warning, there can be a sudden urge to urinate, or void, that’s so strong, it’s almost impossible to make it to the bathroom in time. Urge is the most common type, and it can affect women and men. With age, the bladder muscles can weaken, and the nerves going to the bladder can become less dependable. The bladder can become sensitive, unstable and easy-to-irritate. An unstable bladder has a bad habit of contracting on its own without warning.

Functional incontinence, the third type, is when a physical or a mental barrier keeps the individual from getting to the toilet or from using the toilet properly. Common toileting barriers include difficulty in walking, A dark, cluttered or lengthy path to the toilet. Restraints ( or bed rails ??). Or clothing that’s difficult for arthritic hands to remove. A frequent mental barrier to proper toileting is dementia. Such individuals may (have an otherwise healthy urinary system, but still) forget where the bathroom is or what it’s used for.

Fifty to seventy percent of our nursing home residents and elderly patients in the hospital have incontinence. Often it’s the last straw leading to nursing home admission. Incontinence is a medical condition we no longer ignore. There are many management options, but some are better than others. For example, long-term use of indwelling catheters is discouraged nbecause of the high risk of urinary tract infections. And although medications can help, they’re usually not a first choice, since side effects can be a problem. A more common response to the problem is urine containment in absorbent briefs and pads, with a “check and change” routine.

Like Ruth, a new admission … to the facility. Her care givers check her absorbent undergarment

CNA: Is your brief dry, Ruth?

RUTH: No, it needs to be changed.

HOSTESS: and change it when it’s wet, provide good skin care, watch carefully for signs of skin breakdown, all while being tactful and providing privacy, since bladder control problems are embarrassing. Patients like absorbent products for their security. Staff like them for their convenience. They’re especially helpful for routine use at night, while sleeping, Or to protect a healing pressure ulcer, For unresponsive individuals or end of life care, Or for people who simply prefer pads and briefs rather than other management interventions – a personal choice we always honor.

But it’s important to understand that containment, by itself, is not a treatment, or an intervention or a toileting program. It won’t help people become drier. For most people, absorbent products are a short-term coping strategy. What’s more, long term day and night dependence on absorbent products leads to more urinary tract infections and pressure ulcers. Remember, standard protocols (and best nursing practice) require that we help every incontinent resident keep or regain as much normal bladder function as possible, a requirement containment alone can’t satisfy. In fact, 24 hour reliance on absorbent products may even encourage incontinence, by sending out the message that there’s no need to routinely help Ruth to the toilet; that voiding in her undergarment is what she’s expected to do. (we expect her to do.)

Most patients and residents, and even some care givers, don’t know about (aren’t familiar with) the many natural and safe daytime management options, other than absorbent products, that help elders stay drier by keeping a step ahead of the bladder, by beating it to the punch.

Simple interventions, beside check and change, such as basic, no-frills Scheduled Toileting at standard times during the day, even when the patient hasn’t asked to use the toilet.

Habit training, which is scheduling toileting, but set up so that it matches the resident’s natural voiding habits observed in the bladder diary.

And prompted voiding, which is scheduled toileting plus two extra steps: Praising, …

CNA: Are you dry George?


CNA: Very good, George. Excellent!

HOSTESS VO: and prompting.

CNA: Would you like to use the toilet now?


HOSTESS: This method can be very effective for people with dementia.

Alert, cooperative elders can learn to do special exercises of the pelvic floor muscles, called Kegel exercises. These are the muscles we tighten on purpose to hold back gas or stop urine flow. Doing Kegels every day strengthens the pelvic floor muscles and can help reduce stress and urge UI.

And bladder training, in which motivated elders learn special techniques to resist the sudden urge to void, gradually training their disobedient bladder to wait longer between trips to the bathroom.

So many options for managing incontinence. And they work, too! It’s encouraging how many residents and patients, once informed of their management choices, do end up with improved bladder function. The key to successful continence promotion is matching the right intervention to the person most likely to benefit. That’s why we always do a clinical assessment on incontinent residents. Ruth’s assessment has started. Let’s watch.

First, care staff keep a bladder diary for 3 days, writing down all the liquids Ruth drinks, her urine output, and any wet episodes. Then a clinical nurse examines Ruth to determine her cognitive status,

NURSE: Ruth, can you point to the window for me?

HOSTESS: the amount of assistance she needs for walking, the type of incontinence, potential reversible causes, and Ruth’s preference for treatment.

RUTH: I thought my bladder problem was normal, what you expect when you get old. But yes, I’d like to try being drier.

HOSTESS: She may ask care givers or family members about Ruth’s voiding habits and preferences.

CNA: I know Ruth leaks when she coughs, but she doesn’t want to talk about it. She started using undergarments at home when she started waking up with a wet bed.

HOSTESS: Then, based on all she’s learned, she writes a continence care plan customized to Ruth’s situation and preferences, with instructions for care staff to follow, and continence goals to meet. This is Ruth’s plan.

NURSE: For Ruth’s mixed urge and functional incontinence, a program of scheduled toileting will be put in place with the goal of reducing wet episodes from 4 per day to two. Every three hours, starting at seven in the morning and continuing till bedtime, caregivers should offer Ruth toileting assistance. During the day, to set (reinforce) an expectation of continence, Ruth should wear her usual street clothes and underwear, with no absorbent undergarment. A pad can be kept on her bed and in her chair. At night while sleeping, Ruth can wear an absorbent brief. (Ruth can wear an “overnight brief” to help with sleep.)

HOSTESS: Let’s give Ruth and her care givers a few days (some time) to try out the new plan and see if it’s going to work. Meanwhile, here are five rules for continence promotion we can use every day to help our patients and residents.

Rule one: Encourage fluids. A lot of people think if they have incontinence, they should limit their fluids. Well that’s myth, one of many about incontience, and a harmful one, too. Drinking less than the recommended 8 glasses of water per day leads to concentrated urine, which irritates the bladder, and makes incontinence worse! Concentrated urine is dark and smelly, and a sign of not drinking enough fluids. Promote fluids by keeping water by the bed and chair. Use flexible straws. Add a lemon wedge. Keep water at room temp, if preferred. Avoid fluids that irritate the bladder, like carbonated sodas, wine and caffeinated coffee, and avoid fluids before bed.

Rule two: Avoid constiptation. Excess stool in the bowel from constipation or impaction can actually push on the bladder, crowd it, reduce its capacity, and cause urgency. Encouraging high-fiber foods and plenty of fluids helps keep the bowel clear.

Rule three: Avoid urinary tract infections. Incontinence and urinary tract infections are closely related – one can lead to the other. We can help women keep intestinal germs out of their urinary tract by making sure they wipe in one direction, from front to back, after urination or a bowel movement. Drinking fluids as recommended and voiding every few hours flushes the urethra and helps block bacteria from migrating up to the bladder. Cranberry juice can help prevent infections. And 24-7 use of absorbent undergarments can increase urinary tract infections, another reason to be supportive of prescribed continence promotion programs.

Rule four: Understand the tricks people on a bladder training program use to calm their urgent bladder. When the sudden urge hits, sitting down puts reassuring pressure on the pelvic floor. Remaining calm, Breathing slowly, Distracting the mind by counting backward from 100.

performing a few Kegel contractions, all can help quiet the bladder. It helps to remember, the unpredictable urge to void comes and goes in a wave. It builds to a peak, then fades away, even if the bladder isn’t emptied. Then, she can walk slowly to the bathroom, since rushing encourages urgency, or she can wait for her next scheduled toilet break.

And finally, The Golden Rule. To provide continence care to others the way we’d want to be treated ourselves.

CNA: I used to think my residents were supposed to just go to the bathroom in their brief, and I’d change it when I could. I thought that was the way things were supposed to be. Now we do assessments and toileting programs. Keeping ahead of one uncooperative bladder is a challenge. Usually I have several! But my people are drier, and happier and more comfortable. It’s a better way. It’s how I’d want to be treated if I were in their slippers.

HOSTESS: Ruth’s been on her scheduled toileting program for over a week (a month). Her wet episodes are down from 4 per day to one, sometimes none! Instead of 4 pads per day, she’s using only 1. Her (perineal?) skin looks and feels better, her room smells fresher, and walking back and forth to the toilet is helping her remain active and steadier on her feet. Her daughter says Ruth just seems happier now. Ruth and her family are eager to continue. This is what continence promotion success looks like.

Using the bathroom properly – it seems such a simple thing to us – we take it for granted. But anyone who’s lost it knows, toileting is a matter of dignity, a fundamental human right, that everyone values and deserves, including our frail or cognitivtley impaired elderly. Now, it’s true, not everyone can be drier, and check and change is still a choice for some. That’s why we do routine continence assessments, and test a toileting program to see if it works, before committing our time to it. And it’s also true that providing toileting assistance takes us longer, about 90 seconds, than it does to just change a wet undergarment. Well, it might be quicker or more convenient for us if our patients and residents are in absorbent products day and night, but isn’t that a deficiency in our care when many of them could be drier, or completely dry, with our assistance and encouragement? It all boils down to an attitude, a top-down, facility-wide culture, that says most elders who no longer toilet independently, can have improved bladder function, and all the comfort, social and health benefits that come from being dry more hours each day. That’s modern continence promotion.

RESIDENT: Yes, dear; I’m dry. Thank you. Thank you!