Restorative Nursing Programs

Transcription

1 Bladder and Bowel Master Series Independent Study Monograph III Restorative Nursing Programs by Diane K. Newman, DNP, ANP-BC, FAAN This Monograph was supported through an unrestricted educational grant made available by SCA Personal Care Copyright 2012 Diane K. Newman 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 III Page 1 of 63

2 Bladder and Bowel Master Series PURPOSE Restorative Nursing Programs is Independent Study Monograph III 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, 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 have 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 III, Restorative Nursing Program, is a practical guide for understanding bladder and bowel restorative nursing programs. It provides valuable information on dietary modifications, toileting programs, bladder training, pelvic floor muscle exercises and bowel management. I wish success for you, your staff, and your residents! Diane K. Newman 2012 Diane K. Newman Monograph III Page 2 of 63

3 Bladder and Bowel Master Series 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 1.25 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 III Page 3 of 63

4 Bladder and Bowel Master Series TABLE OF CONTENTS Learning Objectives ,,,,.4 Introduction ,,,,..5 Bladder and Bowel Behavioral Management...6 CMS RAI Version 3.0 Manual-Section H: Bladder and Bowel...8 Bladder Management & Restorative Programs...11 Techniques to Facilitate Voiding and Bladder Emptying Fluid and Dietary Management......,...13 Toileting Programs...,,..15 Scheduled Voiding/Habit Training/Timed Voiding....,.,..16 Prompted Voiding Bladder Training......,...19 Pelvic Floor Muscle Training.....,,, Use of Toileting Devices...,,,,23 Drug Therapy for Urinary Incontinence and Overactive Bladder.,,,,25 Commonly Prescribed OAB Drugs....,., 26 Estrogen Hormone Drug Therapy...,,,28 Bowel Management & Restorative Program Implementing a Bowel Regimen....,..31 Appendix I References Appendix II Glossary Appendix III Care Plans 1. Urgency Urinary Incontinence Related to Bladder Overactivity 2. Stress Urinary Incontinence Related to Weak Urinary Sphincter and/or Pelvic Muscle 3. Bowel Incontinence Related to Weak Rectal Tone 4. Constipation Related to Inadequate Dietary Fiber, Fluid Intake and Exercise 5. Constipation Related to Bowel Impaction 6. Diarrhea Related to Laxative and Medication Use or Infection Appendix IV Post Test Appendix V Independent Study Evaluation Form Sample A: 3-day Bladder and Bowel Record Sample B: Bladder and Bowel Record 2012 Diane K. Newman Monograph III Page 4 of 63

5 Bladder and Bowel Master Series LEARNING OBJECTIVES At the end of this Independent Study Monograph, the participant will be able to: 1. Review behavioral interventions including components of dietary and fluid modification, toileting programs, bladder training and pelvic floor muscle training. 2. Define the techniques used to facilitate voiding and bladder emptying. 3. Detail the specifics of bladder toileting programs that can be implemented in nursing homes. 4. List the components of prompted voiding for nursing home residents with incontinence. 5. Identify those residents who can be most successful with retraining programs. 6. Classify drug therapy for overactive bladder and urgency incontinence and the role of topical estrogen in women with bladder symptoms. 7. Review the components of a bowel regimen for restoration of normal bowel function. NOTE: A Reference list, Glossary of commonly used terms and Care Plans are found in Appendix I, II and III Diane K. Newman Monograph III Page 5 of 63

6 Bladder and Bowel Master Series INTRODUCTION Restorative nursing programs in residents with bladder and bowel disorders include behavioral interventions that include fluid and diet modifications, toileting programs which are more staffdependent and bladder and pelvic muscle training programs which involve resident understanding and active involvement. Bowel disorders involve the use of multiple strategies that can aid in normal and regular defecation. As a result of a thorough history, physical examination, and treatment of any identified reversible conditions, the facilities restorative nurse, in collaboration with nursing assistant staff, the medical director and/or nurse practitioner, and with input from the Interdisciplinary Team, can determine the most appropriate behavioral treatment program. Toileting programs include scheduled voiding, habit training, timed voiding, and prompted voiding. They are the cornerstone of continence care in cognitively and mobility impaired residents. In the most current RAI manual, CMS reports on a Crosswalk sample of a toileting program. Twenty percent of the 3,258 residents in the sample were noted as having had a trial toileting program. Of these, 44% had no improvement; 35% had decreased wetness; 8% were completely dry; 19% were unable to determine response. Of those who reported a toileting trial, 71% were reported to still be on a toileting program (14% of the total sample). Facilities would expect to see an evolution in these patterns as MDS 3.0 prompts facilities about basing a toileting program on a systematic trial that charts resident response to the trial. The benefits of implementing a bladder and bowel training program and reducing the incidence of urinary and fecal incontinence in your facility will be felt by the facility, the nursing staff, ancillary personnel, and the residents and their families through: Cost-savings in personnel time in cleaning up after incontinence episodes, including laundry and supplies. Improved resident self-esteem and dignity; possible decrease in disruptive behavior and depression. Enhanced job satisfaction as nursing staff s perception of the value and quality of nursing care improves; they are continence trainers, not merely incontinence cleaners. Improved environmental aesthetics and facility image. Appreciation from families for the positive, progressive changes in resident s status. Some residents may improve enough to permit visits outside the facility or even return to their own family member s home. Marketing tool to advertise services to the public. This Monograph will provide a comprehensive review bladder and bowel restorative programs Diane K. Newman Monograph III Page 6 of 63

7 Bladder and Bowel Master Series BLADDER AND BOWEL BEHAVIORAL MANANGEMENT Behavioral management of bladder and bowel conditions is essential interventions in the LTC setting. These conservative treatments are indicated for residents with urgency, stress and mixed incontinence and in those residents who have overactive bladder (OAB) symptoms of urgency and frequency. Residents with overflow UI are not primary candidates for these interventions. Research indicates that the most success is when behavioral treatments are combined with drug therapy. Through behavioral interventions, ambulatory, cognitively intact nursing home residents can learn or can relearn to regulate bladder or bowel performance sufficiently to achieve and to maintain clinically significant, improved function. Those with cognitive impairment can decrease urinary symptoms through staff-dependent toileting programs. Behavioral methods target restoration or maintenance of bladder and bowel function with the goal of restoring as much function as possible. These interventions usually include adjusting the intake of fluids and eliminating bladder irritants, toileting programs, bladder training, and pelvic muscle training. When combined with drug therapy, residents will gain more control of bladder urgency and decrease voiding frequency. The goals are to restore bladder and bowel continence, or establish a plan for incontinence management that enables the resident to maintain or prevent deterioration of the upper urinary tract. Behavioral approaches must be tailored to the resident s underlying problem. Baseline history, exam, bladder and bowel records will help determine the resident s type and pattern, if any, of voiding and defecation. Once a pattern is identified, a trial of a toileting program should be conducted Role of the Nurse Nursing staff is integral to the success of these programs in nursing homes. Although all staff must be involved in the continence program, the help of a trainer or Continence Champion, a designated nursing assistant who takes responsibility and ownership of the program, will ensure long term program success. The role of the trainer is to coordinate and ensure quality control of the Bladder and Bowel Records and subsequent toileting or retraining programs on assigned nursing unit, floor, or in the facility. Incontinence patterns can be identified and adjustments made to toileting times, if appropriate. This data collection process may take one week or more to gather enough data to observe a pattern and prepare future plans of action. The Bladder and Bowel Record should be completed over a 3-day (consecutive) period and reviewed by the nurse and trainer. Incontinence patterns can be identified and adjustments made to toileting times if appropriate. This data collection process will identify the following: Voiding and bowel movements: time amount, continent or incontinent. Fluid intake: time, amount, type of fluid (e.g., use of caffeine beverages) Diane K. Newman Monograph III Page 7 of 63

8 Bladder and Bowel Master Series However, for any program to succeed, it must be an interdisciplinary effort from the level of the administrator to the nursing assistant staff. This would include an interdisciplinary team of nurses, nursing assistants, medical director, physical therapist, dietician, pharmacist, and social worker. The assistance of a consultant (e.g. nurse practitioner) who has expertise in the area of incontinence would be an added resource to the Continence team. CMS s RAI Version 3.0 Manual: Urinary Incontinence Management: 1. Has a trial of a toileting program (e.g. scheduled toileting, prompted voiding or bladder training) been attempted on admission or since urinary incontinence was noted in this facility? Staff must note the type of toileting program. 2. If yes, what was the resident s response to the trial program? 3. Is a toileting program currently being used to manage resident s incontinence? 2012 Diane K. Newman Monograph III Page 8 of 63

9 Bladder and Bowel Master Series CMS RAI VERSION 3.0 MANUAL: SECTION H: BLADDER AND BOWEL Research has shown that one quarter to one third of residents will have a decrease or resolution of incontinence in response to a toileting program. According to the CMS s RAI Version 3.0 Manual coding tips for H0200A-C; toileting (or trial toileting) programs refer to a specific approach that is organized, planned, documented, monitored, and evaluated that is consistent with the nursing home's policies and procedures and current standards of practice. A toileting program does not refer to: Simply tracking continence status. Changing pads or wet garments. Random assistance with toileting or hygiene. Section H of MDS 3.0 places an emphasis on the accurate assessment of Urinary and Bowel Continence and the interventions used to manage Incontinence. It centers on outcomes the resident s response to the trial toileting program. The look back period for the trial is to the most recent admission/readmission assessment, the most recent prior assessment, or to when incontinence was first noted. Care planning (found in Monograph I) should include interventions that are consistent with the resident's goals and minimize complications associated with appliance use. The following detail the specifics about Section H of the CMS RAI Version 3.0 Manual. Steps for Assessment: H0200B, Response to Trial Toileting Program 1. Review the resident s responses as recorded during the toileting trial, noting any change in the number of incontinence episodes or degree of wetness the resident experiences. Steps for Assessment: H0200C, Current Toileting Program or Trial 1. Review the medical record for evidence of a toileting program being used to manage incontinence during the 7-day look-back period. Note the number of days during the lookback period that the toileting program was implemented or carried out. 2. Look for documentation in the medical record showing that the following three requirements have been met: implementation of an individualized, resident-specific toileting program that was based on an assessment of the resident s unique voiding pattern evidence that the individualized program was communicated to staff and the resident (as appropriate) verbally and through a care plan, flow records, and a written report notations of the resident s response to the toileting program and subsequent evaluations, as needed 3. Guidance for developing a toileting program may be obtained from sources found in Appendix C. Coding Instructions H0200A, Toileting Program Trial Code 0, no: if for any reason the resident did not undergo a toileting trial. This includes residents who are continent of urine with or without toileting assistance, or who use a 2012 Diane K. Newman Monograph III Page 9 of 63

10 Bladder and Bowel Master Series permanent catheter or ostomy, as well as residents who prefer not to participate in a trial. Skip to Urinary Continence item (H0300). Code 1, yes: for residents who underwent a trial of an individualized, resident-centered toileting program at least once since admission/readmission, prior assessment, or when urinary incontinence was first noted. Code 9, unable to determine: if records cannot be obtained to determine if a trial toileting program has been attempted. If code 9, skip H0200B and go to H0200C, Current Toileting Program or Trial. Coding Instructions H0200B, Toileting Program Trial Response Code 0, no improvement: if the frequency of resident s urinary incontinence did not decrease during the toileting trial. Code 1, decreased wetness: if the resident s urinary incontinence frequency decreased, but the resident remained incontinent. There is no quantitative definition of improvement. However, the improvement should be clinically meaningful for example, having at least one less incontinent void per day than before the toileting program was implemented. Code 2, completely dry (continent): if the resident becomes completely continent of urine, with no episodes of urinary incontinence during the toileting trial. (For residents who have undergone more than one toileting program trial during their stay, use the most recent trial to complete this item.) Code 9, unable to determine or trial in progress: if the response to the toileting trial cannot be determined because information cannot be found or because the trial is still in progress. Coding Instructions H0200C, Current Toileting Program Code 0, no: if an individualized resident-centered toileting program (i.e., prompted voiding, scheduled toileting, or bladder training) is used less than 4 days of the 7-day look-back period to manage the resident s urinary continence. Code 1, yes: for residents who are being managed, during 4 or more days of the 7-day look-back period, with some type of systematic toileting program (i.e., bladder rehabilitation/bladder retraining, prompted voiding, habit training/scheduled voiding). Some residents prefer to not be awakened to toilet. If that resident, however, is on a toileting program during the day, code yes. Coding Tips for H0200A-C Toileting (or trial toileting) programs refer to a specific approach that is organized, planned, documented, monitored, and evaluated that is consistent with the nursing home s policies and procedures and current standards of practice. A toileting program does not refer to simply tracking continence status, changing pads or wet garments, and random assistance with toileting or hygiene. For a resident currently undergoing a trial of a toileting program, o H0200A would be coded 1, yes, a trial toileting program is attempted, o H0200B would be coded 9, unable to determine or trial in progress, and o H0200C would be coded 1, current toileting program Diane K. Newman Monograph III Page 10 of 63

11 Bladder and Bowel Master Series Documentation Staff must have clear and concise documentation to support reevaluation of a toileting program whenever there is a change in cognition, physical ability, or urinary tract function. Staff must use clinical judgment to determine when it is appropriate to reevaluate a resident's ability to participate in a toileting trial or, if the toileting trial was unsuccessful, the need for a trial of a different toileting program. According to the CMS s RAI Version 3.0, documentation in the medical record must show that the following three requirements have been met: 1. Implementation of an individualized, resident-specific toileting program that was based on an assessment of the resident s unique voiding pattern 2. Evidence that the individualized program was communicated to staff and the resident (as appropriate) verbally and through a care plan, flow records, and a written report 3. Notations of the resident s response to the toileting program and subsequent evaluations, as needed Documentation: No point in describing voiding pattern if resident is not prompted or assisted. Describe result of 2-day trial: frequency of continent and incontinent voids. Have a plan for nighttime issues 2012 Diane K. Newman Monograph III Page 11 of 63

12 Bladder and Bowel Master Series BLADDER MANAGEMENT AND RESTORATIVE PROGRAMS Behavioral interventions can be categorized as resident-independent or resident-dependent and caregiver-dependent therapies: Resident-independent or training programs necessitate adequate function, learning capability, and motivation of the individual. Resident-dependent therapies include scheduled toileting assistance regimens, which have been the mainstay of treatment for managing UI and symptoms of OAB. Caregiver-dependent interventions, scheduled toileting, prompted voiding, are useful in residents with functional disabilities. The success of these interventions is largely dependent on caregiver knowledge and motivation, rather than on the resident s physical function and mental status. Prior to developing a restorative bladder care plan for an individual resident, convene a team that includes all disciplines involved in a bladder program including physical therapy, occupational therapy, restorative nurse, and nursing staff assigned to the resident. The following bladder restorative interventions are reviewed in this Monograph: Fluid and Dietary Management Techniques to Facilitate Voiding and Bladder Emptying Toileting Programs o Scheduled voiding/habit training/timed voiding o Prompted Voiding Bladder Training Pelvic Floor Muscle Training Use of Toileting Devices Drug Therapy 2012 Diane K. Newman Monograph III Page 12 of 63

13 Bladder and Bowel Master Series Definition: TECHNIQUES TO FACILITATE VOIDING AND BLADDER EMPTYING Manual techniques used by the resident who has urinary retention, incomplete bladder emptying or overflow urinary incontinence to increase bladder emptying and/or to improve voiding. Objective: Techniques: To teach the resident how to manually empty the bladder completely. To prevent urinary incontinence, urinary tract infection, and urinary retention. Program of double voiding may be effective in cases of mild to moderate urinary retention or incomplete bladder emptying. The resident is taught to void twice during each trip to the bathroom to attempt to make sure the bladder is empty. The resident is instructed to void, to remain on the toilet, and to void again after a rest period of two to five to ten minutes. Another method of double voiding is to have the resident void, then stand up and sit back down and attempt to void again. Residents without a spinal cord injury may find a "trigger" to initiate a bladder contraction. One common method is called "suprapubic tapping," which involves drumming the abdomen overlying the bladder. Other trigger mechanisms include pulling pubic hairs, stroking the abdomen or inner thigh, digital anal stimulation, running water at the sink, placing hands in a basin of warm water, drinking warm fluids, and pouring warm water on the perineal area. Crede maneuver is the use of direct manual compression to empty the bladder. The resident presses firmly with one hand (or both hands) directly into the lower abdomen over the bladder. This technique should be used with caution, especially in residents with detrusor-sphincter-dyssynergia. Staff in nursing homes may want to have residents experiment to discover which technique works best and is easiest Diane K. Newman Monograph III Page 13 of 63

14 Bladder and Bowel Master Series Definition: FLUID AND DIETARY MANAGMENT The amount of fluid ingested and ingredients in certain beverage and foods may be contributing to a resident s incontinence and overactive bladder symptoms of urgency and frequency. Therefore, increasing fluid intake in resident s who are drinking too little and elimination of caffeinated beverages and foods can have a positive impact on bladder symptoms. Objective: To identify bladder irritants in the diet and work with the resident to decrease or eliminate them. To maintain a hydration program 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). Dietary Modification Strategies: Many residents who have bladder control problems reduce the amount of liquids they drink in the hope that they will urinate less often. While drinking less liquid does result in less urine in the bladder, the smaller amount of urine may be more concentrated and thus irritate the bladder muscle. Highly concentrated urine (dark yellow, strong smelling) urine may cause urgency and frequency, and encourage bacteria to grow, which may lead to infection. Fluid intake should be regulated to 6 to 8 ounce glasses (1200cc to 1600cc) or 30cc/kg body weight per day with a 1,500 ml/day minimum at designated times unless contraindicated by a medical condition (e.g. CHF). Also, consider water-based foods (e.g. jello) and other fluids. Consider developing a fluid management program that may involve a fluid cart that is placed in a central location so residents who are ambulatory can easily access beverages throughout the day. Assign a staff member each shift to roll the cart to those residents whose mobility prevents them from accessing the cart independently. It is helpful for residents to consume small amounts of fluids between meals so fluid intake is spread evenly throughout the daytime. All fluids and foods should be caffeine-free because caffeine contributes to increased urgency. Caffeine is a bladder muscle irritant, acts as a diuretic, and is a central nervous system irritant. Caffeine is found in tea, coffee, colas, and other drinks. Foods that contain chocolate also contain caffeine. It is recommended that residents drink no more than 2 cups of caffeinated drinks per day or switch to caffeine-free products. Nutritional supplements, puddings and cakes that contain cocoa, which contains caffeine, are favorite foods and daily staples in nursing homes. Residents who have nocturia (awakens at night to void) more than twice a night, or who experience nocturnal enuresis (bed wetting) may benefit from fluid restriction in the evening (e.g., stop at 7 p.m. or at least 2 to 3 hours before bedtime). These residents 2012 Diane K. Newman Monograph III Page 14 of 63

15 Bladder and Bowel Master Series maintain adequate fluid intake by drinking the bulk of their liquids during the day hours. They may also benefit from elimination of caffeine in the evening. Residents who develop edema of the lower extremities should be advised to elevate their legs on a stool or recliner during the day (e.g., early afternoon) to stimulate natural diuresis and limit the amount of urine production and voiding during the night. In residents with bacteriuria or frequent UTIs, consider the addition of a daily glass of cranberry juice or cranberry tablets (2 tablets) or oral Vitamin C (Ascorbic acid 1000 mg). Cranberry juice contains a high concentration of ascorbic acid, which is felt to bind with Escherichia coli (E. coli) in the bladder, preventing adherence of this bacteria to the bladder mucosa Diane K. Newman Monograph III Page 15 of 63

16 Bladder and Bowel Master Series TOILETING PROGRAMS Toileting programs are the cornerstone of continence care in cognitively impaired and mobility impaired residents. They include scheduled/timed voiding, habit training and prompted voiding. Residents who have urgency or mixed UI, overactive bladder symptoms of urgency and frequency and incomplete bladder emptying are candidates for toileting programs. They are the cornerstone of continence care in cognitively impaired and mobility impaired residents. According to MDS 3.0, an individualized, resident-centered toileting program [that] may decrease or prevent urinary incontinence, minimizing or avoiding the negative consequences of incontinence. MDS 3.0 defines these programs as follows: Habit Training or Scheduled/Timed Voiding - A behavior technique that calls for scheduled toileting at regular intervals on a planned basis to match the resident s voiding habits or needs. Timed voiding is probably the most frequently used behavioral technique employed in nursing homes. Prompted Voiding - Prompted voiding includes (1) regular monitoring with encouragement to report continence status, (2) using a schedule and prompting the resident to toilet, and (3) praise and positive feedback when the resident is continent and attempts to toilet. NOTE: Excluded from these programs are residents with mobility impairment necessitating a mechanical or multiple person transfer, those terminally ill, comatose, or severely behaviorally disturbed residents are excluded from a prompted voiding trial. Check and Change - Involves checking the resident s dry/wet status at regular intervals and using incontinence devices and products. Rehabilitation/Bladder Training - A behavioral technique that requires the resident to resist or inhibit the sensation of urgency (the strong desire to urinate), to postpone or delay voiding, and to urinate according to a timetable rather than to the urge to void. Documentation for the Urinary Toileting Program is completed on this section of the MDS Diane K. Newman Monograph III Page 16 of 63

17 Bladder and Bowel Master Series Scheduled Voiding/Habit Training/Timed Voiding Definition: A behavioral technique that calls for scheduled toileting at regular intervals on a planned basis to match the resident s voiding habits or needs (new definition per MDS 3.0). NOTE: In habit training and timed voiding, no rehabilitation of the bladder is involved. The resident is a passive participant; there are no attempts to assist the resident in delaying voiding or resisting the urge to void. The goal is to pre-empt an incontinent episode. Objective: The goal is for the staff to intervene and toilet the resident prior to incontinence, thus keeping the resident dry, but not modifying bladder function. Regular voiding prevents chronic bladder distension and its sequelae (e.g., compromised bladder due to overstretching of the muscle fibers), UTI (due to urine stasis and urinary retention), and urine leakage with activity (overactive bladder). Procedure: Obtain a Bladder and Bowel record for 72 hours to ascertain voiding and incontinence pattern. Based on the observed pattern, a toileting interval is established, usually every 2 to 3 hours. In general, a typical toileting schedule for each nursing shift is as follows: o Day Shift: Toilet after breakfast and after lunch o Evening Shift: Toilet after dinner and before bedtime o Night Shift: Toilet on last resident care rounds or upon resident awakening In establishing the interval between voiding, one could negotiate the interval with a caregiver or cognitively intact resident to increase compliance. Encourage the resident to void in the toilet, commode, or bedpan/urinal, whichever is most suitable, even when incontinence episodes occur, to assure complete bladder emptying. Combining OAB drug therapy (antimuscarinics/anticholinergics) with scheduled toileting may provide the best outcome in decreasing UI. Staff should document on the resident s medical record the toileting assistance needed, the frequency, and the resident s responsiveness to toileting program. According to MDS 3.0: Toileting program does not refer to: Simply tracking continence status Changing pads or wet garments Random assistance with toileting or hygiene 2012 Diane K. Newman Monograph III Page 17 of 63

18 Bladder and Bowel Master Series Prompted Voiding Definition: Prompted voiding (PV) is a toileting program that involves an active dialogue between the staff member and resident about toileting needs. PV has been shown to reduce UI episodes by up to 33% in nursing home residents with urinary incontinence regardless of the type or cognitive deficit. PV has 3 components: 1) regular monitoring with encouragement to report continence status, 2) prompting of resident to toilet on a scheduled basis, and 3) praise with positive feedback when the resident is continent and tries to toilet. For PV to be effective, the individual must be able to delay voiding and cooperate with toileting, or have an awareness of when there is a need to void or know when they are wet. But PV has also been shown to be effective in residents with cognitive impairment. NOTE: A successful PV program requires a staff trained in its: 1) implementation, 2) adherence to the designated schedule, 3) documentation and monitoring of toileting, and 4) follow-up. Objective: To assist the resident in discriminating continence status, the need to urinate and to encourage requests for toileting assistance from nursing staff. Procedure: Prior to implementing a PV program with an individual resident, a 3-day trial should be done to see if the resident is appropriate for this type of toileting program. Predictors of a good response include those residents who: o Respond to prompts when toileting o Void an adequate volume of urine (at least 150 to 200 mls or 5 to 7 ounces) o Have appropriate number of voids (voids at least 50% of the time into a toileting receptacle) o Have incontinence frequencies < 4 episodes in 12 hours (baseline incontinence rate) o Have normal PVR urine volume (< 150mLs to 200mLs or 5 to 7 ounces) Follow these specific steps for PV: o Focus the resident s attention on the bladder by asking whether he or she is wet or dry. o Check the resident s clothing or incontinence pad to confirm wetness or dryness and provide verbal feedback to the resident on the accuracy of his or her response. o If resident is dry, provide praise (positive feedback) for maintaining continence. If resident is wet, provide corrective verbal feedback (disappointment) and change resident without further comment. o Prompt resident to request toileting assistance and provide assistance with toileting. Ensure appropriate toileting environment by providing privacy during toileting, placing toilet tissue and call signal within easy reach Diane K. Newman Monograph III Page 18 of 63

19 Bladder and Bowel Master Series o Assist the resident in relaxing by offering a magazine to read, since relaxation is important to elimination. o Do not rush the resident. Allow them to sit on the toilet, commode, or bedpan for about 15 minutes. A shorter time is too rushed and more time defeats the purpose, which is, getting the resident to void at expanding intervals when toileted. o Praise resident if voiding occurs as the positive feedback will encourage dryness and appropriate toileting. Special attention from the staff, such as engaging in conversation unrelated to toileting behavior, offering fluids, or assisting with personal grooming, may encourage the resident to continue using the PV program. o Remind resident of time when toileting will occur again. PV program is only attempted when the resident is awake to minimize sleep disruption. Also, residents tend to respond better to daytime PV than nighttime PV. Residents who toilet successfully 66% of the time prompted (number of total number of continent and incontinent voids divided by the total number of voids in the toilet) should be placed on an ongoing toileting program. Designating a staff member to monitor documentation during the trial period will save time and prevent the need to duplicate the trial due to lack of data. Posting individual resident s toileting schedules in convenient locations and using staff meetings to discuss resident response to PV can help the nursing home maintain high levels of bladder function for residents for extended periods of time. Staff must document condition of the resident (wet or dry), what resident does during transfer to toilet and behavior exhibited during the toileting episode. NOTE: Nursing home staff must use clinical judgment to determine when it is appropriate to reevaluate a resident s ability to participate in a toileting trial or, if the toileting trial was unsuccessful or, the need for a trial of a different toileting program Diane K. Newman Monograph III Page 19 of 63

20 Bladder and Bowel Master Series Definition: BLADDER TRAINING Bladder training or retraining helps to restore normal bladder function by gradually increasing the intervals between voiding in an attempt to correct urinary frequency and eventually diminish urgency. The resident is taught urge-suppression techniques to transiently suppress urgency episodes and prevent leakage. Objective: To restore bladder function by teaching the resident techniques that will relax the bladder, lessen urgency, allowing more time for the resident to get to a toilet. Unlike habit training, in which the voiding schedule is adjusted to the needs of the resident, bladder retraining encourages the resident to adopt an expanded voiding interval. Indications: Residents who are assessed with urgency, frequency, stress, urge or mixed UI and are cognitively intact and motivated to learn about this intervention. Procedure: Determine resident s voiding pattern from a 3-day Bladder and Bowel Record (see Samples A and B). When usual voiding times have been established, progressively lengthen the times or intervals between voids. Usually, bladder training starts at hourly intervals and gradually lengthens to every 2 to 3 hours. As the bladder capacity increases, voiding intervals increase and urgency decreases. Teach the resident that urgency is the sudden need to void immediately that may result in urine leakage. Urgency follows a wave pattern; it starts, grows in intensity until it peaks, and then subsides and stops until the next wave begins (see Figure 1). Teach the resident that the key to controlling the urinary urge is not to respond by rushing to the bathroom. Rushing causes movement, which jiggles the bladder, and in turn increases the urge sensation. The resident should wait until the urgency subsides, then walk slowly to the bathroom. Teach the resident that they can Squeeze pelvic muscle quickly (x5) Sit & be still The Urge Grows Grows Distract Yourself Peaks Urgency Wave Figure 1 Wait a few minutes Subsides Subsides Then walk slowly to toilet Stops 2012 Diane K. Newman Monograph III Page 20 of 63