Three types of related bladder disorders are commonly seen in individuals living in extended care settings (e.g., nursing homes). They are urinary incontinence (UI), urinary retention or incomplete bladder emptying, and urinary tract infections (UTIs). These conditions, especially in the extended care environment, can be chronic in nature and, in some cases, life-threatening. Staff may not be aware of the underlying causes of bladder dysfunction and in most cases believe they are a normal part of aging (Fanti et al., 1996). Causes of bladder dysfunction may be secondary to a medical problem (i.e., transient causes), such as a recent illness or from certain medications. In many cases, bladder disorders are interrelated. For example, a presenting sign of urinary retention may be UI. Transient causes of UI can be bowel disorders, such as fecal impaction, or bladder disorders, such as urinary retention or UTI (Fanti et al., 1996; Lekan-Rutledge & Colling, 2003; Newman, 2002). Therefore, understanding these conditions is essential for clinical practice in this environment
Clinical problems are common in nursing homes, with UI identified as a severe problem. UI is the second leading cause of institutionalizatìon of elderly individuals and is present in at least 55% of nursing home residents (American Medical Directors Association [AMDA], 2005; Gabrel & Jones, 2000). In 2000, more than one-third of nursing home residents experienced bladder (urinary) incontinence all or most of the time (Centers for Medicare and Medicaid Services [CMS], 2000). The prevalence of UI is considered a measure of the quality of nursing care in the extended care setting (Zimmerman et al., 1995). Individuals with UI tend to be elderly and have more numerous and severe functional impairments than individuals who are continent. It is a condition associated with medical problems such as falls, bone fractures, pressure ulcers, UTIs, and depression (Brown et al., 2000; Newman, 2002; Ouslander, Palmer, Rovner, & German, 1993), and is often the cause of social isolation, depression, and psychological problems. In the elderly population, the most common cause of UI is overactive bladder with urge incontinence, small frequent contractions that create urgency (i.e., abrupt urge to void) before the bladder is full (Newman, 2002). These bladder contractions, which the individual has no control over, cause urine leakage termed urge urinary incontinence (UUI). In certain instances, UI can increase the use of indwelling urethral catheters as staff attempts to manage UI (Newman, 2005a, b).
CMS has issued surveyor guidance for incontinence and urinary catheters (CMS, 2005). This new guidance collapses current Tags F315 and F316 into one Tag, which will be F315. The new guidance contains interpretive guidelines, a new investigative protocol, and compliance and severity guidance.
URINARY TRACT INFECTION
The second common bladderrelated clinical problem is UTI. The urinary tract is the most common source for nursing-home-acquired bacteremias and constitutes the single cause of facility-associated infections (Nicolle & SHEA Long-Term-Care Committee, 2001). Published rates of UTIs in the nursing home range from 12% to 30% (O'Donnell & Hofmann, 2002). UTIs occur when bacteria clings to the urethra (urethritis), multiplies, and travels to the bladder (cystitis), ureters (ureteritis), or kidneys (pyelonephritis). Infections are classified as lower tract UTIs when the urethra and bladder are involved, and as upper tract UTIs when the infectious process involves the ureters and kidneys. Bacteriuria is defined as the presence of bacteria in the urine. While most patients are asymptomatic, the prevalence rates of bacteriuria in nursing homes are 25% to 50% (Nicolle & SHEA Long-TermCare Committee, 2001). UTIs account for between 8% and 30% of all nursing home transfers to acute-care facilities (Nicolle & SHEA Long-Term-Care Committee, 2001). Symptomatic UTIs in residents without an indwelling catheter are based on criteria outlined in the Bladder Function Checklist under Urologie Testing (see page 35).
Infection of the bladder is particularly common in women, mainly because of the much shorter urethra, which provides less of a barrier to bacteria, and the proximity of the anus to the urinary meatus, which increases the risk of contamination from fecal material. Contributory factors in elderly women are loss of estrogen and slower bladder emptying with increased risk of urinary retention leading to urine stasis and infection. The number of bacteria used for laboratory confirmation of a symptomatic UTI has been defined in the CMS Tag F315 and is 1 0,000 CFU/mL or greater. Of all UTIs, 95% are caused by one bacterial agent. Of these, Eschericbia coli is the culprit in 80% of cases (Nicolle & SHEA Long-Term-Care Committee, 2001). The bacteria in the bladder can irritate bladder mucosa, causing overactive bladder symptoms of urgency and frequency, leading to UUI.
UTIs are of major importance because of their effect on resident outcomes and treatment costs. Although many approaches have been used to minimize catheter-induced UTIs, elimination of instrumentation from catheter usage remains the best method because inserting a catheter may carry urethral and introitai organisms into the bladder (Warren, 2001).
The third common bladder disorder is urinary retention or incomplete bladder emptying. Urinary retention is defined as the inability or failure to empty the bladder completely with voiding. Usually, a resident may maintain some ability to void, but elevated post-void residual (PVRs) lead to an increased risk of acute urinary retention, urinary tract infection, or upper tract pathology, such as pyelonephritis, hydronephrosìs, or renal insufficiency (Gray, 200Oa). Chronic urinary retention is characterized by an ongoing inability to completely empty the bladder during voiding.
There are several causes of urinary retentioa The prevalence of urinary retention rises with increasing age, particularly among men because of prostate disorders (e.g., prostatitis, benign prostatic hypertrophy). Pelvic organ prolapse (e.g., cystocele) in women can cause a mechanical obstruction of the urethra at the bladder neck leading to urinary retentioa Neurogenic bladder is a general diagnosis commonly used and refers to altered bladder function resulting from interrupted nerve innervation caused by a lesion of the central or peripheral nervous system. However, in most cases, this diagnosis is inappropriately used in residents to justify use of an indwelling urinary catheter. Damage to nerve pathways at any point between the cortical center in the brain and the bladder can impair normal bladder function, leading to incomplete bladder emptying. The type of bladder dysfunction depends on the exact site and the extent of the lesion. Diffuse neurologic damage, such as from multiple sclerosis, Parkinson s disease, or spinal cord injury, can produce the inability to initiate or adequately complete voiding.
Urinary retention is determined by measuring the PVR urine volume (Colling, Owen, McCreedy, & Newman, 2003; Gray, 200Ob; Newman, 2002), or the amount of urine left in the bladder within 10 to 20 minutes after voiding. PVR parameters are listed in the Checklist under Urologie Testing. Urinary retention is the reason elderly individuals need to void often in small amounts (i.e., urinary frequency). Urine remaining in the bladder after the individual has voided can become colonized with bacteria, increasing incidence of UTI.
ASSESSMENT OF BLADDER FUNCTION
Bladder disorders are common among the elderly population, but they should not be accepted as a normal part of aging or of being in an institution (Fanti et al., 1996). Although physiological, psychological, and environmental changes accompanying aging do not directly cause the bladder to malfunction, they do predispose elderly individuals to an increased risk or incidence of disorders. Assessment of residents with UI or any bladder symptom is necessary to determine the pathophysiologic causes and associated factors that can be an impediment to bladder function (AMDA, 2005, CMS, 2005, Fanti et al., 1996). The Bladder Function Checklist can be used for assessing residents. The Resident Assessment Protocol (RAP) (CMS, 2002) is considered to reflect the critical components of problem solving, care plan development, and treatment decisions in the provision of comprehensive care and the improvement of residents' quality of life. When a resident is deemed incontinent or has an indwelling catheter, further assessment is required. The RAP addresses situational factors, medical conditions, bowel function, abnormal laboratory values, and presence of neurologic diseases. This emphasizes the need to evaluate transient causes that may cause UI, such as urinary retention, urinary tract infection, environmental factors, and certain medical conditions and medications.
In addition to the RAP, nursing homes will be surveyed based on the CMS interpretive guidance on Tag F3 1 5 (CMS, 2005; Newman, 2005c). The intent of this requirement is to ensure the following:
* Each resident who is incontinent of urine is identified, assessed, and provided appropriate treatment and services to achieve or maintain as much normal urinary function as possible.
* An indwelling catheter is not used unless valid medical justification exists, and, if not medically justified, it is discontinued as soon as clinically warranted.
* Services are provided to restore or improve normal bladder function to the extent possible after the removal of the catheter.
* A resident, with or without a catheter, receives the appropriate care and services to prevent infections to the extent possible.
Assessment of incontinence is the key component of this new guidance, and emphasis is placed on identifying the transient and persistent causes of UI. Because assessment is an important component of this guidance, determining a PVR in certain residents with urinary incontinence will be required in residents at risk (e.g., neurologic disease, men with prostate disorders, previous history of retention, recurrent UTIs) (Newman, 2005c).
USE OF TECHNOLOGY
Nurses at the bedside can perform evaluation of the bladder as recommended in the RAP and Tag F315 with the use of the newest technology that does not involve invasive instrumentation (Colling, 1996, Ouslander et al., 1994). New technology in this area is a portable ultrasound instrument called the BladderScan® (Diagnostic Ultrasound Corporation, Bothell, Washington).
Theportable BladderScan instrument uses V-mode® ultrasound technology to create a three-dimensional image of the bladder and calculate volume based on this image. To create the three-dimensional image, the BladderScan measures ultrasonic reflections on multiple planes within the resident s body to differentiate the bladder from surrounding tissues. A microprocessor within the instrument automatically calculates and displays bladder volume; the operator applies ultrasound coupling medium (ultrasonic gel), aims the scanhead, and initiates the scaa Non-invasive bladder volume measurement via the V-mode BladderScan has been shown to be quick, easy, and very specific for determining elevated PVR. Portable ultrasounds have been found to have a specificity of 96.5% in detecting PVR 5= 100 mLs in ambulatory women (Goode, Locher, Bryant, Roth, & Burgio, 2000). Specific indications for use on residents in extended care include objective measurement of bladder volume, avoidance of prolonged urinary retention, prevention of unnecessary catheterizations with subsequent minimization of the risk of nosocomial UTI, and determination of bladder volume when attempting toileting or on prompted voiding programs (Newman, 2002; Woolridge, 2000).
The accuracy of portable ultrasound scanning has been documented in numerous studies. Coombes and Millard (1994) assessed the accuracy of two successive models of the portable bladder ultrasound device in determining PVRs in 100 patients. Ultrasound measurements were compared to post-scan bladder volumes obtained by catheterization and fluoroscopic screening in the same patients. The accuracy of the BladderScan (BVI 2500 model) was as good as catheter estimations of true residual volumes. The researchers recommend BladderScan use as an alternative to catheterization for the determination of PVR volume. Ouslander et al. (1994) used a portable ultrasound scanner (BladderScan BVI 2500) to determine the accuracy of PVR volumes in nursing home residents. Accuracy of the scanner ranged from 90% to 95% for volumes of 50 mLs to 100 mLs to a rate of 69% for volumes greater than 200 mLs.
Because the uterus may resemble the bladder ultrasonically, the BladderScan has a gender setting, which excludes the uterus from measurements. The operator selects the female setting when scanning a woman who has not had a hysterectomy and proceeds with the examination. The gender setting helps to ensure optimum accuracy of measurement.
Causes of inaccurate readings include:
* Morbid obesity.
* Moving the probe during the scan.
* Presence of an indwelling urethral catheter. However, such measurements still have clinical utility because they enable the detection of a blocked catheter.
* Scar tissue, incisions, sutures, and staples can affect ultrasound transmission and reflection; operators should use care when scanning residents who have had suprapubic or pelvic surgery.
* Improperly aiming the scanhead so the bladder is partially or wholly outside its field of vision. (BladderScan instruments display aiming icons on their LCD screens to guide operators to the best aim.)
* Inadequate ultrasound gel. (To ensure this problem does not occur, Diagnostic Ultrasound offers Sontac® ultrasound gel pads - small disposable discs of gel placed on the patient's abdomen before scanning.)
Two newer BladderScan models are currently available - the BladderScan BVI 3000 and the handheld BladderScan BVI 6400 (Figures 1 and 2). Accuracy specification for the BVI 3000 is O to 999 mL, ± 20% ± 20 mL; accuracy specification for the BVI 6400 is O to 999 mL, ± 15% ± 15 mL. Both are portable, noninvasive, easy to use, and rapidly determine bladder volume. The BVI 3000 is transported to the resident s bedside using a rolling cart and prints examination results instantly using a built-in printer. The handheld BladderScan BVI 6400 integrates with Diagnostic Ultrasound Corporation's ScanPoint® on-line imaging and calibration service so users can view ultrasound images, save and print examination results, and calibrate their handheld scanner on-line. This model will store up to 10 scans.
Figure 2. BladderScan® Bladder Volume Instrument 6400.
Figure 1 . BladderScan® Bladder Volume Instrument with scan head.
CLINICAL APPLICATION OF BLADDER ASSESSMENT TECHNOLOGY
CRISTA Senior Community, a 176-bed long-term care facility located in north Seattle, has been successful in using a portable bladder ultrasound scanner, specifically the BVI 3000. CRISTA offers a full spectrum of care, including a special care unit for dementia. After the BVI 3000 was purchased, staff developed usage guidelines and a plan for ensuring that staff understood indications for use and how to perform a scan. To ensure staff compliance and effective use of bladder scanning, a case manager was assigned to identify residents who would benefit. All staff (RNs, LPNs, and CNAs) were trained in the use of the bladder scanner with emphasis on continuing education with return demonstrations. At CRISTA, it took time for staff to incorporate new technology into their daily practice and plan of care.
The staff member performing the scan assessed the resident for voiding prior to scan, the inability to void, and the presence of urinary incontinence to ensure accurate PVRs. To minimize time and maximize efficiency, residents were scanned in bed or in a chair depending on where the resident was at any given time. Staff found that application of a generous amount of ultrasonic gel (at least 2 tablespoons) generated more accurate readings. The facility developed a policy and procedure for specific resident criteria for use of the scanner, which also included physician orders. As part of this policy and procedure, the following criteria for scanning were developed at CRISTA:
* To properly diagnose a resident's bladder fonction to determine incomplete bladder emptying through the measurement of the bladder volume and PVR.
* To determine actual bladder volume in residents who have incomplete bladder emptying and who are on scheduled urinary catheterization times to drain the bladder. The staff felt performing intermittent catheterizations based on actual volume instead of a specific schedule may avoid unnecessary catheterizations and reduce risk of infection.
* To prevent the onset of urinary retention following Foley catheter removal post-hospitalization and to assist with bladder retraining by determining the need to void based on bladder volume.
* To determine urinary retention or incomplete bladder emptying and the need for catheterization in those residents with risk factors for developing urinary retention (e.g., diabetes or other neurologic diseases, spinal cord injury, men with prostate disorders, suprapubic tenderness or distension, taking anticholinergics or other medications that interfere with bladder emptying).
* To assist staff in implementing a toileting program by determining the amount of urine in the bladder when attempting to toilet a resident.
As first sensation of bladder fullness occurs at 250 mLs, staff were told to encourage the resident to void if scanned volumes were 200 mLs or greater. Knowledge about bladder volume at any given time may help eliminate unnecessary toileting and allows for accurate assessment of the resident's hydration state (Newman 2002; Woolridge, 2000). This may be a helpiul tool in the resident who has an obsession with frequent toileting.
Initially, a pre-scan assessment was performed on all residents identified as at risk, which included primary diagnosis (with ICD 9 Code), physical assessment, medications used, history, and physician's orders (Form available at www.seekwellness.com/incontinence/ Christa_formsl.pdf). This assessment was developed to closely follow RAP guidelines for assessment of residents with new onset or worsening incontinence and reviews possible causes of transient incontinence. To determine medical necessity, a protocol for scanning residents was developed which included indications, scanning procedure and parameters, and specific documentation (see the Form above). The protocol included the need for a physician's order for scanning and criteria for medical necessity. The physician order noted indications, medical necessity (e.g., urinary retention), frequency (e.g., three times per day), and duration of scans (e.g., scan for 2 weeks) prior to performing the scan. Scan results were reviewed on a daily basis to provide ongoing assessment of findings, medical necessity, and treatment care planning update and review. After scanning, a post-scan assessment of the resident was completed, which included follow-up notes, diagnosis, nursing assessment, and the effect on the resident's quality of life (Form available at www.seekwellness.com/incontinence/Christa_forms2.pdf). This report was signed by the physician and placed in the resident's medical record. After scans were performed, the results of the scan were affixed to a paper, copied, and placed in the laboratory reports section of the resident's medical record.
The following are case studies of CRISTA residents whose bladder disorders were resolved through the appropriate use of the BladderScan.
Case Study 1
A male resident had a history of urinary frequency, UTIs, and falls secondary to self-toileting needs. Bladder scanning revealed urinary retention with PVRs ranging from 53 mLs to 446 mLs. Average scan volume was 330 mLs. A total of 40 scans were completed. The resident was referred to a local urologist who diagnosed benign prostatic hypertrophy and severe prostatitis. The enlarged prostate was causing urethral obstruction leading to incomplete bladder emptying with overflow incontinence. His urologist prescribed terazosin, an alpha adrenoreceptor blocking agent that shrinks the size of the prostate. Urinary incontinence decreased, and the resident's comfort increased. Quality of life increased with the addition of a 6-week course of antibiotic treatment for the prostatitis. Nursing staff felt that urinary retention would have gone unnoticed and UI accepted as unchangeable had it not been for 2-week analysis of bladder volume measurements.
Case Study 2
A female resident had a history of chronic urinary retention of approximately 3,000 mLs necessitating the insertion of a Foley catheter. The resident had an extensive history of mental illness with episodic delusions and paranoia. Assessment indicated that the resident would not tolerate invasive measuring of PVR with intermittent catheterizations. An indwelling catheter remained in place for approximately 1 year. With the ability to perform non-invasive PVRs with the bladder scanner, the indwelling catheter was discontinued and routine bladder scanning was started. Scan results revealed incomplete bladder emptying with PVRs ranging from 277 mLs to 360 mLs in the first several days, but normal bladder function returned by the end of 2 weeks (PVRs from 53 mLs to 198 mLs). The resident tolerated bladder scanning well. She was less restless and more comfortable without the indwelling catheter. More important, the resident's quality of life improved.
Case Study 3
A female resident had a 10-year history of intermittent self-catheterization secondary to urinary retention following bladder surgery and urinary incontinence. Bladder scanning started to frequently measure PVRs for 2 weeks to establish current bladder functioa Scanning revealed PVRs within normal limits. The resident was also initially prescribed anticholinergic medication for overactive bladder (oxybutynìn), which was later changed to tolterodine, and urinary incontinence decreased. The resident no longer needs to selfcatheterize, improving her quality of life. Without the bladder scanner, this resident could have feasibly continued with self-catheterization indefinitely.
Case Study 4
An 89-year-old woman with a diagnosis of an anxiety disorder was identified as a candidate for a nursing rehabilitation toileting program. During the assessment process, a CNA reported, "You don't need to do that, she's in the bathroom every 5 minutes." The care manager assessed the resident as being appropriate for bladder scanning to measure PVRs. Scans revealed urinary retention with PVRs of 218 mLs to 956 mLs. Medications were evaluated and changes were made in an attempt to lower PVRs. Scanning continued, but nurses found the readings continued to be elevated (averaged 981 mLs to 998 mLs). The resident was prescribed 25 mg of hydroxyzine three times daily for her anxiety. Medication was discontinued and a Foley catheter was inserted. It was noted that elevated PVRs and the placement of an indwelling catheter only exacerbated the resident's existing anxiety disorder. After 2 weeks and a tapering of oxycontin and the addition of neurontin, the catheter was discontinued. Bladder scanning was initiated again for 3 days to measure PVRs. PVRs were found to be within normal limits. Quality of life was greatly improved. Bladder scanning allowed non-invasive diagnosis and resolution of urinary retention, which significantly decreased resident's anxiety and increased comfort and psychosocial well-bang.
The most widely accepted methods of determining PVR are urethral catheterization and transabdominal bladder ultrasound. However, catheterization carries the risk of infection and trauma. Transabdominal ultrasound involves transporting the resident to a facility that performs radiology. Portable ultrasound scanners are accurate and very specific for elevated PVR determinatioa This instrument is being used as the standard of care in the acute and rehabilitative care settings to properly diagnose, treat, and manage bladder disorders (Lewis, 1995; Resnick, 1995; Wagner & Schmid, 1997). Adopting this technology in the extended care setting provides the highest level of medical care for each resident while preserving the resident's dignity and respect The scanner should be part of assessment of residents in the extended care setting.
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