Independent Study Monograph I. Assessment of Bladder and Bowel

Transcription

1 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 Diane K. Newman Monograph I Page 1 of 77

2 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! Diane K. Newman 2012 Diane K. Newman Monograph I Page 2 of 77

3 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 The expiration date of this activity is 05/24/2015. This continuing nursing education activity is made available at and from SCA Personal Care. Requirements for completion of the program can be found at the website - 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 (Fax) The participant can also take the Post-Test and complete the Evaluation Form online at A Certificate of Contact Hour Credit and corrected Post-Test will be mailed, faxed or ed 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 Diane K. Newman Monograph I Page 3 of 77

4 TABLE OF CONTENTS Learning Objectives Incontinence in the Nursing Home Long Term Care Regulations Understanding Bladder Function...16 Incontinence is Not A Normal Part of Aging Identifying Residents At-Risk Causes of Transient Urinary Incontinence Types of Chronic or Persistent Urinary Incontinence Bladder Assessment Clinical Pathway for Management of UI...40 Understanding Bowel Function Review of Common Bowel Disorders...44 Fecal Incontinence....,.,..44 Constipation Fecal Impaction....,.,..47 Diarrhea 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 Sample B: 3-day Consecutive Bladder and Bowel Record 2012 Diane K. Newman Monograph I Page 4 of 77

5 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: A Reference list, Glossary of commonly used terms and Care Plans are found in Appendix I, II and III Diane K. Newman Monograph I Page 5 of 77

6 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. 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 of prompted toileting, assisted toileting, or scheduled toileting. 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 Diane K. Newman Monograph I Page 6 of 77

7 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. UI is 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, 2012 Diane K. Newman Monograph I Page 7 of 77

8 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 Diane K. Newman Monograph I Page 8 of 77

9 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) Diane K. Newman Monograph I Page 9 of 77

10 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 Diane K. Newman Monograph I Page 10 of 77

11 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 Diane K. Newman Monograph I Page 11 of 77

12 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 ( This section emphasizes outcomes the resident s response to the trial toileting program. This is an example of Section H found in the CMS s RAI Version 3.0 Manual Diane K. Newman Monograph I Page 12 of 77

13 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: 2012 Diane K. Newman Monograph I Page 13 of 77

14 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. 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 Diane K. Newman Monograph I Page 14 of 77

15 Quality Indicators (QIs) According to CMS, the MDS Quality Measure/Indicator (QM/QI) is part of the Nursing Home Quality Initiative (NHQI) ( 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 The table on the following page lists the QM domains that relate specifically to bladder dysfunction Diane K. Newman Monograph I Page 15 of 77

16 Quality Measure Incontinence (Low Risk) Numerator Denominator Exclusions Covariates 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) NA 2012 Diane K. Newman Monograph I Page 16 of 77

17 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. Figure 1 Urinary Tract 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 2 Bladder and Urethra 2012 Diane K. Newman Monograph I Page 17 of 77

18 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. Figure 3 Side view of the male and female pelvis 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 4 Urinary Sphincters 2012 Diane K. Newman Monograph I Page 18 of 77

19 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. NOTE: Normal function of the bladder, urethra, sphincters, and pelvic floor muscles are keys to normal voiding. 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. Figure 5 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) Diane K. Newman Monograph I Page 19 of 77

20 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 ounces ( 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 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. Step 2 Bladder fills to capacity and nerves send messages to the brain, causing the first sensation of need to void (urge). 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 4 Voiding occurs Diane K. Newman Monograph I Page 20 of 77

21 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 (postvoid residual [PVR]) may become infected with bacteria, causing an increased incidence of urinary tract infections Diane K. Newman Monograph I Page 21 of 77

22 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 increased risk of developing lower urinary tract symptoms (LUTS) Diane K. Newman Monograph I Page 22 of 77

23 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 Angiotensin-converting enzyme inhibitors (ACE inhibitors) (captopril, lisinopril, enalapril) Alpha-adrenergic receptor antagonists (prazosin, terazosin, doxazocin) Alpha-adrenergic receptor agonists (pseudoephedrine and ephedrine, present in many cold and OTC preparations) Anticholinergics Antidepressants, tricyclic Effect Antihypertensives, with a common side effect of cough, which can worsen stress UI. Smooth muscle relaxation of the bladder neck and proximal urethral causing stress UI (mainly in women). Contraction of bladder neck and proximal urethra leading to increased urethral resistance, causing postvoid dribbling, straining, and hesitancy in urine flow. Urinary retention with symptoms of postvoid dribbling, straining, hesitancy in urine flow, overflow incontinence, and fecal impaction. Anticholinergic effect and alpha-adrenergic receptor antagonist effect causing postvoid dribbling, straining, 2012 Diane K. Newman Monograph I Page 23 of 77

24 and hesitancy in urine flow. Psychotropics (sedatives, hypnotics) Cholinesterase inhibitors Narcotic analgesics, opioids Beta-adrenergic receptor antagonists (propranolol, metoprolol, atenolol) Calcium channel blockers (verapamil, diltiazem, nifedipine) Diuretics (loop) (furosemide) Methylxanthines (theophylline) Neuroleptics (thioridazine, chlorpromazine) Cholinesterase inhibitors Nonsteroidal anti-inflammatory drugs (NSAIDs) (gabapentin) Other: caffeine, alcohol May decrease bladder contractility leading to urinary retention. Can accumulate in the elderly and cause sedation, confusion, and immobility, resulting in functional UI. Increase bladder contractility and may cause UI. Also, may interfere with antimuscarinic/oab medications Decrease bladder contractility. Depress the central nervous system, causing sedation, confusion, and immobility, leading to urinary retention and UI. Constipation is common side effect. Urinary retention (rare). Impair bladder contractility, causing urinary retention. Cause constipation, leading to fecal impaction. 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). Polyuria, bladder irritation. Anticholinergic effect, sedation. 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. Can cause edema, causing nocturnal polyuria and exacerbating nocturia; may impair detrusor contractility. Act as diuretics causing rapid diuresis, leading to urgency and frequency; alcohol induces sedation Diane K. Newman Monograph I Page 24 of 77

25 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 Diane K. Newman Monograph I Page 25 of 77

26 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 Diane K. Newman Monograph I Page 26 of 77

27 A I S E D 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). 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) 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. 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) 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 condition) and minimizing caffeinated food and beverages.. (see Monograph III) 2012 Diane K. Newman Monograph I Page 27 of 77

28 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. 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. 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 2012 Diane K. Newman Monograph I Page 28 of 77

29 Stress Mixed Overflow Pelvic floor muscle sphincter weakness A combination of bladder and urethral dysfunction, causing stress and urgency incontinence. Blocked urethra Weak bladder muscles (detrusor underactivity, nerve damage) Urine leakage occurs with physical activities or effort, coughing, sneezing. Drops to small amount of urine leakage Usually does not occur daily Combination of urgency and stress UI Palpable or percussable bladder Elevated PVR (> 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 2012 Diane K. Newman Monograph I Page 29 of 77

30 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. Signs and Symptoms 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 2012 Diane K. Newman Monograph I Page 30 of 77

31 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. Signs and Symptoms 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 2012 Diane K. Newman Monograph I Page 31 of 77

32 incontinence found in hospitals and nursing homes is functional in origin. Immobility, due to impairment of cognitive or physical functioning, psychological unwillingness, or environmental barriers to toilets are associated with the problem. Causes Common factors contributing to functional incontinence include: Impaired mobility or dexterity causing difficulty in getting to the bathroom and removing clothes. Inaccessible caregivers. Environmental barriers such as inconvenient bathroom or toilet equipment, stairs, lack of handrails and narrow doorways which don t accommodate wheelchairs or walkers. Mental and psychosocial disability causing a lack of awareness of the need to urinate, confusion over the location of the bathroom or individual toileting habits. Physical or chemical restraints. Sensory impairments including poor vision, hearing, and speech, which influence success in reaching and communicating the need to toilet. Incontinence as a display of anger and/or depression to gain attention or control. Signs and Symptoms Large volumes of urine leakage are seen, with total emptying of the bladder in inappropriate situations. Diagnosis Diagnosis is suggested by the history and physical examination. A urinalysis and PVR determination are required. Special attention should be paid to the resident s toileting behavior. Management according to CMS s RAI Version 3.0 Manual: Residents with functional incontinence caused by dementia or psychological disorders often respond to habit training or scheduled voiding. Treatment should focus on removing the physical or psychological barriers to continence. If the resident requires assistance to the toilet, prompt attention should be provided to the resident. Lowered dosages or changes in medications that contribute to confusion, drowsiness, or incontinence may solve the problem. Physical and painful disabilities should be treated with analgesics and physical therapy, if appropriate, to regain or maintain mobility and dexterity. Simple environmental modifications, such as a night-light to illuminate the path between the bed and toilet, eliminating clutter and unsafe throw rugs, can mean the difference between leaking and continence. The use of absorbent products or external collection devices may be the appropriate management device if the resident fails to respond to other treatment modalities. Toileting devices should be made available if toilets are inaccessible or if the resident is unable to reach one Diane K. Newman Monograph I Page 32 of 77

33 BLADDER ASSESSMENT 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 o Resident s self performance of toileting 2012 Diane K. Newman Monograph I Page 33 of 77

34 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. 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 Assess full? urine (Overflow stream for UI) 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) Diane K. Newman Monograph I Page 34 of 77

35 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 2012 Diane K. Newman Monograph I Page 35 of 77

36 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. Palpate each testis and epididymis between examiner s thumb and first two 2012 Diane K. Newman Monograph I Page 36 of 77

37 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: 2012 Diane K. Newman Monograph I Page 37 of 77

38 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 According to CMS RAI Manual Version 3.0: Voiding records should: 1. Help detect urinary patterns or intervals between incontinence episodes. 2. Facilitate providing care to avoid or reduce the frequency of incontinence episodes. 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 2012 Diane K. Newman Monograph I Page 38 of 77

39 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 10 3 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 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 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]) o PVR volume must be measured no more than 20 minutes after the resident voids Diane K. Newman Monograph I Page 39 of 77

40 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 o Ability of wheelchair bound or resident with a walker to propel their equipment to the toilet in a timely fashion. o Assure restraints (physical or chemical) are not preventing normal bladder function. Physical restraints include various straps and ties, as well as, geri-chairs. In addition, sedating drugs can act as chemical restraints. Environmental Barrier Assessment: o Distance from the bed to bathroom. o Access (e.g. distance, visibility) to toilet/bathroom is unimpeded. o Toileting facilities promote privacy. o Toilets at least 17 inches high with arms to aid in lowering or rising. o Call lights available and accessible. o Chairs designed for ease in rising. NOTE: In one study, toilet height for 45.2% of nursing home residents was higher than the optimal height (defined as 100% to 120% of the resident's lower leg length), which could consequently increase risk of falls and difficulty toileting Diane K. Newman Monograph I Page 40 of 77

41 Clinical Pathway for Management of UI 2012 Diane K. Newman Monograph I Page 41 of 77

42 UNDERSTANDING BOWEL FUNCTION Bowel regularity or irregularity has an impact on the bladder and its ability to empty. Bowel dysfunction is commonly seen in nursing home residents. Therefore, it is important for nursing home staff to assess the resident for any bowel disorder. Anatomy & Physiology of the Bowel The large intestine is a hollow muscular tube about five feet in length. The colon is subdivided into the ascending, transverse, descending, and sigmoid colon (see Figure 6). The sigmoid colon bends towards the left as it joins the rectum, which allows gravity to aid the flow of water from the rectum into the sigmoid colon. (This is the rationale for having the resident lie on the left side when administering an enema.) The last portion of the large intestine is the rectum, which extends from the sigmoid colon to the anus (about six inches). The last inch of the rectum is called the anal canal. It contains the internal and external sphincters which play an important role in regulating defecation. The anus is the outside opening of the anal canal. Figure 6 Large Intestine Muscle contractions in the colon push the stool toward the anus. By the time it reaches the rectum, it is solid because most of the water has been absorbed. The large intestine has many functions, all related to the final processing of intestinal contents. Very little, if any, digestion takes place in the large intestine whose most important function is the absorption of water and electrolytes. The left side of the colon and the rectum are the "storage tank" Figure 7 at the end of the large bowel. Normally, the rectum is relatively empty. Stool does not enter the rectum from the colon on a continuous basis, but as a result of peristalsis or mass movements, which happen from time to time, especially before the need to go to the toilet is experienced. These mass movements are major waves of pressure, which can move stool through the whole length of the colon, like toothpaste being squeezed along a tube (see Figure 7). Mass peristalsis moves the feces (stool) mass into the sigmoid colon where it is stored. It occurs two to three times per day, especially after breakfast. Total transit time through the colon does not change with aging and averages hours. Often, a large part of the contents of the colon arrives in the rectum at once. The lining of the bowel produces fluid called mucus (a bit like the saliva in your mouth) which lubricates the movement of stools along the colon Diane K. Newman Monograph I Page 42 of 77

43 These mass movements are often triggered by the so-called gastro-colic response or reflex. Food arriving in the stomach after eating a meal sets off a pressure wave in the colon some minutes later. This can lead to the need to empty the bowel, sometimes urgently, soon after eating. For many people the bowel is relatively quiet at night. The first meal of the day, together with the physical activity involved in getting out of bed and washing and dressing, stimulates contractions in the colon and mass movements. This leads to a call to stool, the feeling that the bowel needs emptying, shortly after breakfast. Food usually takes an average of 1 to 3 days to be processed between the mouth and the anus. Like the urinary tract, the nerve supply to the large intestine contains both parasympathetic and sympathetic nerves. In general, stimulation of the sympathetic fibers inhibits activity in the intestinal tract. It also excites the internal anal sphincter. Stimulation of the parasympathetic fibers causes an increase in bowel activity and in the defecation reflexes. The external anal sphincter is controlled by the pudendal nerve, the same nerve that controls the external urinary sphincter. Continence depends on functioning muscles and nerves in and around the rectum and anal canal. At the lower part of the bowels, the sigmoid colon helps to slow the passage of fecal material before it moves into the rectum. The rectum is more elastic than the rest of the bowel so it can stretch to store fecal material. It is surrounded by nerves that detect expansion of the rectum and signals a sensation of urgency, telling the person it is time to have a bowel movement. Below the rectum is the area known as the pelvic floor, which is made up of many different muscles. The muscles of the anus and anorectal junction that maintain bowel continence are the anal sphincters (internal and external) and the puborectal muscle (called the puborectalis muscle sling). All muscles of the pelvic floor, including the external anal sphincter, are under voluntary control, and can prevent expulsion of rectal contents, when coughing occurs or when fluid in the rectum threatens continence. The internal anal sphincter is an involuntary muscle that helps to prevent leakage from the rectum. The puborectalis muscle and the external anal sphincter are voluntarily contracted to prevent leakage of stool when fullness is felt in the rectum. Figure 8 Rectum, Anal Canal and Sphincters 2012 Diane K. Newman Monograph I Page 43 of 77

44 Understanding Bowel Elimination (Defecation) The physiological process of defecation is similar to that of urination, except for the excretory structures involved. Stool consists of water, indigestible residue from food, and bacteria that aid in breakdown of food. Approximately 600 mls of water is absorbed daily from intestinal contents. The longer the fecal mass stays in the colon, the more water can be absorbed. The faster contents move through the colon, the less opportunity there is for this absorption, leading to loose stool. Defecation is a reflex involving the muscles of the anal canal and end of the rectum. Stool passes through the large intestine into the rectum by means of peristalsis or contractions of the bowel wall. Entry of the feces into the rectum distends the rectal walls and stimulates mass peristaltic movements of the bowel, which moves the feces toward the anus. Stretch receptors in the rectum stimulate the rectal defecation reflex which is normally under voluntary control. Simply stated, a message is sent to the brain that the rectum is full, and the urge to defecate is felt. As the stool nears the anus, the internal anal sphincter is inhibited, and if the external anal sphincter is relaxed (under voluntary control), defecation will occur. When it's time to have a bowel movement, all these muscles relax so the stool can pass through the anus. Rectal sensation warns of imminent defecation and helps the person discriminate between formed and unformed stool and gas. Impaired rectal sensation may deprive a person of this useful information and result in incontinence. The defecation reflex may be halted by voluntary contraction of the external anal sphincter. When this is done, the defecation reflex dies out after a few minutes and usually will not return for several hours. Water continues to be absorbed from the stool, causing it to become firmer so that subsequent defecation is more difficult. This may lead to constipation. Defecation may be made easier by an increase in intra-abdominal pressure brought about by simultaneous contraction of the chest muscles and abdominal muscles (called Valsalva's maneuver or straining). Age-Related Changes in the Bowel Little is known about age-related changes in bowel. The pelvis undergoes a loss of motor nerves, which is presumed due to nerve damage occurring in women during prolonged childbirth and in individuals who habitually strain at stool. Although this nerve loss increases with age, it does not occur universally, and therefore, is not a basic age change. There is, however, more universal nerve loss in the sensory nerve tracts from the bowel to the brain. As with the bladder, there are breaks in this neural pathway, and subsequently, messages may not completely reach the brain. The nervous system takes longer to respond to sensory stimuli. There is a decrease in the bowel s muscle tone and motility. Stool passes through the large intestine at a slower rate due to decreased peristaltic action. More water is absorbed, leaving the stool harder and difficult to pass. Simple constipation is the most common gastrointestinal complaint of the elderly Diane K. Newman Monograph I Page 44 of 77

45 REVIEW OF COMMON BOWEL DISORDERS The most common types of bowel dysfunction are: fecal or bowel incontinence, constipation, fecal impaction, and diarrhea. These conditions can occur alone or together. For example, severe constipation can contribute to fecal incontinence and fecal impaction. A presenting symptom of fecal impaction may be incontinence, in which liquid stool can trickle around the impaction and leak out. Chronic and intractable constipation, especially in frail older patients, may lead to fecal impaction. This section provides a short over view of these conditions. Fecal Incontinence Fecal incontinence (FI), also called bowel incontinence, is defined as the unwanted loss of solid or liquid stool or gas from the anus at inappropriate times. Bowel incontinence affects an estimated 2.2% to 5% of the population in general, and two nursing home studies have identified a 45.0% to 47.0% prevalence of FI among residents. Studies suggest that FI contributes to the decision to institutionalize elderly patients. It is not as prevalent as UI, but it can lead to social isolation, depression, and loneliness. FI affects patients physical and psychological well-being, and is responsible for considerable morbidity and mortality in older patients. This results in significant healthcare costs. According to CMS RAI Manual Version 3.0 (H0400 Importance) Bowel incontinence leads to many of the same risks as urinary incontinence: Interferes with participation in activities Is socially embarrassing and can lead to increased feelings of dependency Increases risk of long-term institutionalization Increases risk of skin rashes and breakdown Increases the risk of falls and injuries resulting from attempts to reach a toilet unassisted One of the leading causes of FI is severe constipation, which often leads to fecal impaction, laxative abuse, diarrhea, cognitive impairment, senescence, and neuromuscular disorders including autonomic neuropathy. Fecal seepage or soling is an underappreciated condition that is frequently misdiagnosed as FI. Residents often have a history of constipation with the sensation of poor rectal evacuation with frequent, incomplete bowel movements and excessive wiping. They commonly present with anal pruritus and fecal staining of their undergarments. The anti-diarrheals often prescribed for presumed FI tend to exacerbate the situation. There are 4 factors that maintain control over bowel function, and impairment in any one of them can result in bowel incontinence. The 4 factors are: rectal sensation, rectal storage capacity, sphincter pressure, and the established bowel habits of the individual. Impairment of the anal sphincter is the most common cause of fecal incontinence. Risk factors for fecal incontinence include frailty in older individuals, female sex, impaired mobility, and cognitive impairment Diane K. Newman Monograph I Page 45 of 77

46 Other causes of bowel incontinence include: Previous anorectal surgery, pelvic radiation, or trauma that caused external anal sphincter damage. Bowel incontinence commonly occurs several times daily. Cognitive impairment or dementia where one is unable to suppress the process of defecation. The incontinence presents with a formed stool once or twice a day. Colorectal disease (e.g., diverticulitis, colitis, colon or rectal carcinoma) and diabetic neuropathy may present with diarrhea and bowel incontinence. The stool may be bloodstained or contain mucus, depending on the underlying pathology. Chronic and/or excessive use of laxatives and enemas. Among older people the most common cause of fecal incontinence is neither loss of mobility or dementia, but simply the natural effects of aging on the body. Muscles and tissues weaken, lose their elasticity, and become lax. Changes in muscle strength, muscle mass, and muscle and nerve reflexes affect the anorectal area just as they affect our arms and legs. Thus, some older people can t retain gas or stool, especially liquid stool, as well as or for as long as they once could. Also, the older person may not be able to reflexively close the anal sphincter quickly enough to avoid a fecal incontinent accident. Compared to continent people, incontinent elderly people have less rectal sensation and less sphincter strength. When FI is associated with diarrhea, it is important to treat underlying disorders, such as lactose malabsorption (or intolerance), bile salt malabsorption, and inflammatory bowel disease. Antidiarrheal medications, such as loperamide, and diphenoxylate, or bile acid binders such as cholestyramine may help. In a study of institutionalized elderly patients, the use of a single osmotic agent, with a rectal stimulant and weekly enemas to achieve complete rectal emptying, reduced the frequency of FI by 35% and the incidence of soiling by 42%. Gradually increasing the intake of dietary fiber can relieve constipation. However, in the presence of impaired sphincter function and decreased rectal sensation, the fluidity of the stool induced by the use of laxatives and stool softeners administered to prevent constipation and impaction. may in fact predispose the nursing home residents to FI. Constipation Most epidemiologic studies demonstrate a higher prevalence of constipation and laxative use in the elderly, particularly in the institutionalized. Prevalence of constipation can be as high as 50%, with up to 74% of nursing home residents using daily laxatives. The high prevalence of constipation in nursing home residents could be explained because of the higher use of medications and other comorbidities. Many people have misconceptions concerning normal bowel habits. Having a bowel movement every other day or three times a week may be normal as bowel patterns vary. Constipation is a decrease in the normal frequency of bowel movements and is often associated with increased difficulty in defecation. One definition of constipation is having a bowel movement less than three times per week. Constipation plays an integral role in the development of bowel impaction 2012 Diane K. Newman Monograph I Page 46 of 77

47 and FI in the nursing home resident. It is often associated with UI and will respond to many of the same treatment modalities used for UI. However, constipation is a series of complaints which are expressed differently depending on the individual. The most common are: Difficulty and straining to defecate. Not going as often as the person would like. Changes in the stool, whether too hard, too small or too large. CMS 3.0 Definition: Constipation: If the resident has two or fewer bowel movements during the 7-day look-back period or if for most bowel movements their stool is hard and difficult for them to pass (no matter what the frequency of bowel movements). Constipation may present as a change in bowel habit or as overflow FI. The constipation can lead to a large amount of stool in the rectum, a condition called impaction. The impaction interferes with the normal ability to control bowel movements. A liquid stool eventually trickles around the impaction and leaks out. Chronic constipation is a result of prolonged transit time of the bowel contents or a decrease in peristalsis that accompanies aging. Food usually takes one to three days to travel through the body; most of this time is spent in the colon. High fat meals take longer to travel through the colon than high fiber meals. When other factors are present that frequently occur in the elderly, such as a decrease in fluid intake, a decrease in physical activity and mobility, a decrease in the intake of high-fiber foods, and an overall decrease in functional ability, the individual is at risk for developing chronic constipation. Other factors which can predispose a resident to constipation and the following are the 10 D s of constipation: Drugs (side effects from anticholinergics, analgesics, iron and some sleeping pills, these may also cause confusion. Defecatory dysfunction. Degenerative disease, such as Parkinson s, diabetes, or stroke. Decreased dietary intake as changes in eating habits, because of diminished sense of taste or poor dentition, can lead to the inability or unwillingness to consume fiber-rich foods. Dementia. Decreased mobility/activity. Dependence on others for assistance which may alter time for elimination and/or change in environment. Decreased privacy when attempting to have a bowel movement. Dehydration. Depression Diane K. Newman Monograph I Page 47 of 77

48 Stool softeners, saline laxatives, stimulant laxatives, and single-agent osmotic products are frequently administered as prophylactic treatment against constipation and impaction. According to CMS RAI Manual Version 3.0 (H0600 Importance) Severe constipation can cause: Abdominal pain Anorexia Vomiting Bowel incontinence Delirium Constipation can lead to fecal impaction if unaddressed. Fecal impaction is constipation. Fecal impaction Fecal or bowel impaction is when dry, hard lumps of stool collect in the rectum, making it difficult to expel this material. It is a common cause of diarrhea and FI in the nursing home resident and can be the cause of at least 20% of FI seen. The stool proximal to the obstructing bowel mass becomes liquefied and oozes around the mass. Often with impaction, the lining of the bowel can be irritated and mucus may be formed which can move past the mass and leak from the bowel. Usually the person is unable to pass this large amount of stool, may pass small amounts of watery stool around the impacted stool. This leakage may be misdiagnosed as FI, leading to inappropriate treatments that worsen the constipation and impaction. This condition, sometimes called bowel oozing or bowel staining, commonly presents with semi-solid bowel soiling many times daily. The resident with fecal impaction may experience severe stomach pain, discomfort, and bloating, loss of appetite, may become confused and develop a fever. If a large impaction is present, it may need to be broken up manually. If fecal impaction is not relieved by laxatives and better toileting, a regimen should be implemented using manual disimpaction, tap water enemas two or three times weekly, and possible use of rectal suppositories. CMS 3.0 Definition: Fecal Impaction: A large mass of dry, hard stool that can develop in the rectum due to chronic constipation. This mass may be so hard that the resident is unable to move it from the rectum. Watery stool from higher in the bowel or irritation from the impaction may move around the mass and leak out, causing soiling, often a sign of a fecal impaction Diane K. Newman Monograph I Page 48 of 77

49 Diarrhea Diarrhea is a major and often underrecognized problem in long-term care. It is a major cause of morbidity (especially weight loss, dehydration, and delirium) and mortality. Diarrhea is a significant cause of increased expenditures in the nursing home because of nursing time and laundry expenses. Diarrhea can be caused by an infectious process and raises particular concern in the nursing home where an infection may spread among the residents. Chronic diarrhea in the nursing home needs to be carefully evaluated for underlying treatable causes. Table 3. Commonly Used Drugs That Can Cause Diarrhea Cardiovascular medications Antiarrhythmics: quinidine, procainamide, digoxin Antihypertensives: hydralazine, nifedipine, furosemide, ethacrynic acids, spironolactone, angiotensin converting enzyme inhibitors, beta blockers, acetazolamide, methyldopa, guinethidine Gastrointestinal medications Magnesium containing antacids, lactulose, mannitol, polyethylene glycol, misoprostol, ursodeoxycholic acid, chenodeoxycholic acid Pulmonary medications Lipid lowering medications Nervous system medications Medications for infectious diseases Antiprotozoal agents Antiarthritic medications Miscellaneous Theophylline Gemfibrozil, lovastatin Levodopa, lithium, alprazolam, meprobamate, selective serotoninreuptake inhibitors, carbamazepine Antibiotics: quinolones, macrolides, tetracyclines, penicillin derivatives, cephalosporins Antivirals: nelfinavir, interferon pentamidine, atovaquone Nonsteroidal inflammatory agents, colchicine Calcitonin, acarbose, biguanides, thyroid hormones, octreotide, olsalazine, gold salts, ticlopidine, biphosphonates, riluzole, artificial sweeteners 2012 Diane K. Newman Monograph I Page 49 of 77

50 BOWEL ASSESSMENT Evaluation should begin with consideration of the underlying cause. Although examination of the rectum may show decreased sphincter tone, there is generally a poor correlation between digital exam of rectal tone (ask resident to squeeze the examiner s finger) and measurement. Careful assessment and identification of the cause(s) of constipation and FI are the first steps for appropriate and successful treatment. Assessing a resident s previous bowel pattern before developing an individualized program for bowel training will maximize the potential for success. Bowel incontinence is often associated with UI and may respond to many of the treatment modalities. The primary objective of a bowel management program is to prevent incontinent episodes by establishing a regular bowel/defecation pattern. Defecation should occur in a desired location at planned, scheduled intervals. Short-term goals, based on the nursing diagnosis and cause of incontinence are to: Assess residents for constipation and bowel incontinence by using accurate Bladder and Bowel Records (found at the end of this Monograph). Implement an appropriate bowel rehabilitation program. Prevent embarrassing episodes of incontinence. Prevent bowel impaction. Some examples of long-term goals are to: Eliminate the misuse of multiple laxatives and enemas. Eliminate abdominal discomfort. Prevent bowel obstruction. Avoid hemorrhoids, straining during defecation and bleeding. The benefits of implementing a bowel rehabilitation program are many and include: Decrease in medication use (laxatives, cathartics, suppositories and enemas) and associated side effects. Increase staff and resident morale. Reduction in obsessive bowel behavior. Decrease in disruptive behavior around toileting. Improve resident s quality of life. The assessment for identifying the problem or risk for problems should include a detailed history, physical examination and functional component. Each resident with bowel incontinence should be evaluated by the nurse for possible inclusion in a Bowel Restorative Program (see Monograph III). Other disciplines, besides nursing, including dietary and social services, can be of assistance with gathering this data. The Nursing Care Plans related to bowel dysfunction are found in Appendix III Diane K. Newman Monograph I Page 50 of 77

51 This assessment includes: History Diagnosis, primary and secondary. Previous bowel pattern and habits (laxative and enema use) Stool consistency, size, and shape(hard, soft, loose, watery) Onset, type, and pattern of bowel incontinence or constipation. Symptoms (e.g., constipation, diarrhea, bowel impaction, bowel incontinence and/or prolonged straining before defecation) Associated symptoms (abdominal bloating, nausea, cramping pain, rectal bleeding and urinary symptoms) Exacerbating or relieving factors (mechanical strategies, such as digital disimpaction or vaginal splitting) Diet/fluid intake: o Presence of dehydration. o Daily diet including fiber-rich foods. Medications: o Use of herbal agents, laxatives, stool softeners, suppositories, and enemas. o Side effects of currently prescribed medications that may be causing constipation and diarrhea. Physical Examination Abdominal examination o Assess bowel distension, sounds and tenderness. External genitalia/perianal o To determine skin condition o Evidence of fecal soiling o Presence of hemorrhoids Rectal (digital) examination o To determine resting tone of the sphincter and ability to voluntarily contract sphincter o Presence of feces and impaction. Stool culture for occult blood, if indicated Diane K. Newman Monograph I Page 51 of 77