Barbara K. Haight, RNC, DrPH; Katherine F. Jeter, EdD, ET, CETN; Thelma J. Wells, RN, PhD, FAAN, FRCN
Researchers have successfully assessed, diagnosed, and categorized types of incontinence. Once the type of incontinence is established, there are tested methods for management. For example, gerontological nurses routinely advise older women with stress incontinence to practice pelvic floor muscle exercises as a way of strengthening themselves and combating stress incontinence. Other gerontological nurses use behavioral methods to manage incontinence. The use of habit training and timed voiding is effective and involves not only training the incontinent person, but also training the caregivers responsible for that person.
Although we seem to be winning the war against incontinence, we continue to lose many of the battles. Incontinence is still a major contributor to institutionalization. In some nursing homes, more than 50% of the residents continue to be incontinent. Thus, many of us in gerontological nursing practice ask, "What more can nurses do?"
To answer this question, "Clinical Outlook" contacted two clinicians nationally known for their work in incontinence: one a researcher, the other a practitioner. We asked them what additional information they could provide to help nurses in practice manage incontinence. Katherine F. Jeter, EdD, ET, CETN, founder of Help for Incontinent People, sees counseling and teaching as primary to the management of incontinence, particularly with people at home who spend more energy hiding the problem than caring for it. Thelma J. WeUs, RN, PhD, FAAN, FRCN, known for her research in incontinence, stresses commodes, communication, classification, and products. Each of these experts shares her insights in the hope that one more piece of information may be the catalyst for helping one more person to be continent.
Barbara K. Haight, RNC, DrPH
Help Wanted: Continence Advisers
Incontinence is one of the hottest health topics of the 1990s. This new awareness of an old problem is the result of many efforts: the media blitz surrounding the Consensus Development Conference on Urinary Incontinence in Adults in October 1988; the grass-roots work of patient advocacy organizations, such as Help for Incontinent People (HIP) and The Simon Foundation; and the public relations and advertising activities of absorbent product manufacturers, pharmaceutical companies, and urologie device manufacturers.
Unfortunately, there continues to be a chasm between incontinent people who need and desire care and the few, qualified professionals who are able to furnish it. This chasm is as vast as it was 2 decades ago. This was clearly demonstrated in September 1990 when more than 40,000 people wrote to HIP for information after "Dear Abby" advised her readers that HTP could offer help for their incontinence. Again, in July 1991, when bladder retraining was mentioned by Reader's Digest and HTP was listed as the source of information, 12,000 telephone calls and 20,000 letters were received in the first 4 weeks after the magazine's publication. The book Staying Dry is now in its fifth printing with more than 55,000 orders as a result of a mention in Ann Landers' column (Burgio, 1989).
BLADDER HEALTH QUESTIONS
Incontinence is a nursing issue because it is a human condition that is difficult to communicate. Many treatments for incontinence can be initiated and monitored by nurses. This became perfectly clear in the preparation of Nursing pr Continence (Jeter, 1990). Unfortunately, the economics of the American health-care system probably will not allow the development of continence adviser nurses as they exist in the United Kingdom and Australia. That does not mean that nurses should not be continence advisers; no extra credentials are required for the following important patient care services.
Help Minimize Social Stigma
Nurses should begin talking about bladder function and hygiene. The more you talk about it, the more incontinence will be de-stigmatized. School health officials should be encouraged to include information about excretory function in their health education curricula in an effort to teach young children how to maintain good bowel and bladder habits and to discourage attitudes of shame and secrecy associated with elimination.
Discuss reasonable toilet training practices with your daughters, their friends, young nurses, the granddaughters of your patients, and co-workers. Help them view the achievement of continence as a maturational milestone rather than an indication of superior intellect or social adroitness. Help your older patients and clients become familiar with lower urinary tract function and dysfunction and elicit secreted symptoms.
Re-Teach Before Referring
The medical model prevails in the approach to the treatment of urinary incontinence and insufficient attention is given to simple solutions. Simple handouts can enable patients to check the questions they wish answered. Figure 1 presents a sample check list for your patients.
Take a Thorough History
Getting an accurate history from a 65-year-old woman about her incontinence symptoms is often time-consuming and exasperating. Many patients cannot remember when their leakage began, and estimations of quantity of urine loss are usually inaccurate. Ask the patients or their caregivers to complete a "Uro-Log" for 1 full week (Figure 2). Provide a means of measuring urine output. Some patients may be able to use a jar or a measuring cup; others will need to have a pan that fits between the commode and the lid.
If you discover from this "Uro-Log" that the patient's primary problem is urge incontinence, bladder training is the best place to start. If it is obvious that the patient's primary complaint is stress incontinence, teach Kegel exercises. If the patient has mixed stress and urge incontinence, you may tailor the intervention to the patient's particular needs.
Intermittent catheterization may be a boon for older men and women who are unable to empty their bladders because of diabetes, stroke, and other conditions that contribute to voiding dysfunction. Nurses need not fear teaching intermittent catheterization to their older patients. Many older people learn very quickly and find that intermittent catheterization is much more efficient than trying to stay on or in front of a toilet long enough to get their bladder completely emptied.
A coudé tip catheter is often helpful when women have an invaginated urethra. We use a long, clear plastic catheter with a funnel on the end for both men and women to help them keep that end directed toward the toilet or the receptacle while they are concentrating on inserting the catheter tip into the urethral meatus. In women, use a mirror only to demonstrate where the urethra is located in the perineum. Dependence on a mirror is cumbersome and frequently confusing. Make catheterization simple, not complicated. There is nothing to indicate that aseptic technique is better than clean technique.
When preparing handouts and instructional materials, remember:
* Keep them very simple;
* Use line drawings;
* Use large black or dark blue print on dull paper; and
* Keep your language at the fourth- to seventhgrade reading level.
Read, Disseminale, and Promulgate
Geriatricians, urologists, gynecologists, and behavioral scientists, as well as physical therapists, write about incontinence. Two excellent new books for the lay public are now in bookstores: Overcoming Bladder Disorders by Chalker and Whitmore (1990) and Staying Dry by Burgio, Pearce, and Lucco (1989). In addition, Palmer's book Urinary Incontinence (1989), which is now available from the National Gerontological Nursing Association, remains a gold standard for nurses who care for older patients. Nursing for Continence addresses incontinence across the life span and includes chapters on incontinence in older persons, neurogemc bladder dysfunction, and an appendix with a complete listing of products and devices (Jeter, 1990). Mosby has recently published a Yearbook edition, Urinary and Fecal Incontinence: Nursing Management (Doughty, 1991). Finally, HIP has a variety of printed and audiovisual materials that have been prepared to educate the public. Geriatric nurses' subscriptions and participation are always welcomed.
In the US, probably 50% of incontinent people have never seen a health professional. Geriatric nurses are at the right place, and this is the right time, to reach out to an underserved population. Even if you do not see yourself as initiating evaluation and treatment of incontinent people, you can do your part for diminishing the stigma associated with loss of bladder control and helping people who have not been evaluated to see a qualified health professional. One does not need to be a certified continence adviser nurse to be an effective continence adviser. Please do your part today.
"Clinical Outlook" is a bimonthly column featuring clinical tips or other information that will be useful to gerontological nurses in their everyday practice. The editors for the column are Barbara Haight, RNC, DrPH, as Section Editor and Virginia Burggraf, RN, C, MSN, as Assistant Section Editor. The Journal invites all readers to submit nursing practice suggestions or questions to: Clinical Outlook, Journal of Gerontological Nursing, 6900 Grove Road, Thorofare, NJ 08086.
Burgio, E., Pearce, L., Lucco, A. Staying dry. Baltimore: Johns Hopkins University Press, 1989.
Chalker, R., Whitmore, K. Overcoming bladder disorders. New York: Harper & Collins, 1990.
Doughty, D. (Ed.). Urinary and fecal incontinence: Nursing management. St. Louis: MosbyYear Book, Inc, 1991.
Jeter, K., Faller, N., Norton, C. Nursing for continence. Philadelphia: WB Saunders, 1990.
Palmer, M. Urinary incontinence. Sliver Spring, MD: National Gerontological Nursing Association, 1989.
For more information, contact HIP, Ine, PO Box 544, Union, SC 29379.
Katherine F. Jeter, EdD, ET, CETN, Director, Help for Incontinent People; Clinical Assistant Professor Urology, Medical University of South Carolina; Adjunct Professor, Mary Black School of Nursing, University of South Carolina; Staff Affiliate, Enterostomal Therapy, Spartanburg Regional Medical Center
Although urinary incontinence is not a consequence of the normal aging process, it is known that some age-related changes affect urine control. Changes in mobility create a significant interactive effect with the smaller bladder capacity and late bladder warning signal common to old age. Just when one could benefit from great physical ability to respond to an often demanding bladder, a variety of body impairments limit mobility. However, there is much that can be done to compensate; think basic and be positive.
Consider distance to the toilet or commode: can you relocate the bed/chair closer? Consider access: is the bed /chair height appropriate, ie, can the individual sit with feet flat on the floor and firm chair arms or can a bed attachment assist rising? Consider the toilet: does it need adaptation, such as an elevated seat or support rails? Consider the commode: does the design, ie, height, back, arms, meet this person's needs?
Spending some time learning about different commode models and how to use each to its best advantage is worthwhile. A variety of commodes should be available because patients have a variety of needs. All staff must know how to use these toilet substitutes. I remember visiting a unit where the staff were dissatisfied with a commode because the arm kept coming off, even though they tried to fix it with various straps. They had a commode with detachable arms, ideal for bed/chair transfer, but no one had shown them how to use it or which patient was appropriate or inappropriate for its use.
Modern products are not always the best, although they may be popular. This is true for commodes, which are usually lightweight mobile or fixed models for institutional care. In the recent past, commodes were heavyweight and usually fixed. It is rare to see such commodes in use today, yet the need exists for such large, stable structures. Obesity, a common American syndrome, plus paralysis or general weakness in a patient make lightweight commode use awkward and rather risky for accidents. Although it is worthwhile roaming storage areas for serviceable old-style commodes, new heavy models are available. Matching the best commode to a patient may not look like a dramatic action, but it will dramatically improve urine control.
Women mobile in wheelchairs may not need to toilet transfer to void if a funnel and tubing device is used. The patient wheels up facing the toilet and slides a cup-shaped funnel between her legs, and attached tubing drains the urine into the toilet. Although homemade devices can be tried, inexpensive commercial products are available (eg, Millie Tinkle Tube, Viscot Industries, Inc, PO Box 351, 32 West Street, East Hanover, NY 07936).
There are some modern products that bring technology to a useful and practical level. One is a washable bed or chair pad designed to pass urine through the surface into a holding layer with a protective draw sheet underneath (Kylie Bed Pad, Kylie Health Care Products, 200 Berwyn Park, Berwyn, PA 19312). With this product, absorbent diapers or external drainage systems can be removed at night for the urine incontinent, not toileted individual, yet the urine will be contained in the pad's inner layer and the bed surface will dry by body heat. This pad has received considered clinical research in several countries for more than 10 years (Brink, 1990).
Types of Incontinence
Among incontinent patients, it is extremely important to realize that there are different types of incontinence and correspondingly different treatments (Wells, 1989). Initially, all incontinence should be considered simple or transient. That is, a temporary condition caused by reversible factors such as a medication effect or infection. If incontinence remains after careful, systematic review and action along simple, pragmatic factors, then more complex causes need to be considered.
Nurse's aides sometimes characterize incontinence patients as "leakers," "callers," or "soakers," and these classifications do make sense.
* "Leakers" are those who either periodically leak urine on exertion, as in stress incontinence, or constantly leak, only more so on exertion, as in overflow incontinence. Stress incontinence is the most common type of complex urine loss in women, and is caused by structural alteration in the bladder and urethra due to muscular relaxation or neurological damage. Overflow incontinence is common in elderly men with obstruction due to prostatic enlargement, but it is also caused by neurologic damage as seen in individuals with an atonic bladder.
* "Callers" are characteristically individuals with urge incontinence. They have very short bladder emptying warning signals, tend to have small bladder capacities, and void often. They call for the bedpan or to toilet frequently and are often wet when assistance arrives. Associated with increasing age and neurological dysfunction, urge incontinence is common in long-term care.
* "Soakers" are usually individuals with functional incontinence, that is, they have normal urologic ability but, due to either mental or communication impairment or mobility problems, cannot respond to toilet needs. They wet large volumes in a fairly predictable pattern associated with fluid intake.
Of course, an individual may have more than one type of incontinence, although there is usually a dominant pattern.
Communicating With Aides
It is useful to explore patients' incontinence patterns with nurse's aides. Aides typically use incontinence classification to share padding or wetting management schemes, eg, soakers need more padding than leakers. The classification can be extended to include other strategies; eg, fixed toileting schedules will reduce the number of soakers, callers are frequently cured or greatly improved with low doses of anticholinergics, and leakers may be able to learn how to tighten pelvic muscles to prevent leakage as they get out of a bed or chair. Becoming aware of the terminology aides use and applying it in teaching more progressive care may be helpful.
Brink, C.A. Absorbent pads, garments, and management strategies. Journal of the American Geriatric Society 1990; 38:368-373.
Wells, T.J., Diokno, A.C. Urinary incontinence in the elderly. Semiti Neurol 1989; 9(1):60-67.
Thelma J. Wells, RN, PhD, FAAN, FRCN
University of Rochester
School of Nursing