Want to know more

URINARY INCONTINENCE
Nursing Standard of Practice Protocol: Urinary Incontinence (UI) in Older Adults Admitted to Acute Care

Annmarie Dowling-Castronovo, RN, MA-GNP, Christine Bradway, PhD, CRNP

Evidence-Based Content - Updated January 2008

 

The information in this "Want to know more" section is organized according to the following major components of the NURSING PROCESS:

 

Goal

A. Nursing staff will utilize comprehensive assessments and implement evidence-based management strategies for patients identified with UI.

B. Nursing staff will collaborate with interdisciplinary team members to identify and document type of UI.

C. Patients with UI will not have UI-associated complications.

 
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Overview

UI affects approximately 17 million Americans. 1, 2, 3 More than 35% of older adults admitted to the hospital develop UI. 4 In addition to medications, constipation/fecal impaction, low fluid intake, environmental barriers, diabetes mellitus, and stroke, 1, 5, 6, 7 immobility, impaired cognition, malnutrition, and depression are factors specific to identifying older adults at risk for UI in the hospital setting.4 Complications of UI include falls, skin irritation leading to pressure ulcers, social isolation, and depression. 1, 8, 9, 10 Nurses play a key role in the assessment and management of UI.

 
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Background

A. Definitions
UI is the involuntary loss of urine sufficient to be a problem. 1 UI may be transient (acute) or established (chronic). Types of established UI include:

1. Stress UI: defined as an involuntary loss of urine associated with activities that increase intra-abdominal pressure. 1, 11, 12.

2. Urge UI: characterized by an involuntary urine loss associated with a strong desire to void (urgency). 1, 11 An individual with an overactive bladder (OAB) may complain of urinary urgency, with or without UI. 11

3. Mixed UI: usually defined as a combination of Stress UI and Urge UI.

4. Overflow UI: an involuntary loss of urine associated with over-distention of the bladder and may be caused by an under-active detrusor muscle or outlet obstruction leading to over-distention of the bladder and overflow of urine. 1, 11, 13

5. Functional UI: caused by nongenitourinary factors, such as cognitive or physical impairments that result in an inability for the individual to be independent in voiding. 1

B. Epidemiology
UI affects approximately 17 million Americans. 1, 2, 3 UI studies specific to the hospital setting demonstrate that UI is present in 10% to 42% of older adults.1, 14, 16, 17 New-onset UI was identified in 35% of one patient sample.4 Therefore, it is essential to assess for UI and implement a protocol that offers evidence-based management strategies.

 
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Parameters of Assessment

A. Document the presence/absence of UI for all patients on admission. 18

B. Document the presence/absence of an indwelling urinary catheter.

1. Determine appropriate indwelling catheter use: severely ill patients, patient with Stage III–IV pressure ulcers of the trunk, urinary retention unresolved by other interventions. 19

C. For patients with presence of UI: The nurse collaborates with interdisciplinary team members to:

1. Determine whether the UI is transient, established (Stress/Urge/Mixed/Overflow/Functional), or both and document. 1, 18, 20, 21

2. Identify and document the possible etiologies of the UI. 1, 18

 
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Nursing Care Strategies

A. General principles that apply to prevention and management of all forms of UI:

1. Identify and treat causes of transient UI. 18

2. Identify and continue successful prehospital management strategies for established UI.

3. Develop an individualized plan of care using data obtained from the history and physical examination and in collaboration with other team members.

4. Avoid medications that may contribute to UI. 22

5. Avoid indwelling urinary catheters whenever possible to avoid risk for UTI. 15, 22, 23, 24, 25, 26

6. Monitor fluid intake and maintain an appropriate hydration schedule.

7. Limit dietary bladder irritants. 27

8. Consider adding weight loss as a long-term goal in discharge planning for those with a (basal metabolic rate (BMI) greater than 27, 28

9. Modify the environment to facilitate continence. 1, 29, 30

10. Provide patients with usual undergarments in expectation of continence, if possible.

11. Prevent skin breakdown by providing immediate cleansing after an incontinent episode and utilizing barrier ointments. 20

12. Pilot test absorbent products to best meet patient, staff, and institutional preferences, 44 bearing in mind that diapers have been associated with UTIs. 25

B. Strategies for specific problems:

Stress UI:

1. Teach pelvic floor muscle exercises (PFMEs). 18, 31, 32

2. Provide toileting assistance and bladder training PRN. 18

3. Consider referral to other team members if pharmacological or surgical therapies are warranted.

Urge UI:

1. Implement bladder training (retraining). 18, 33

2. If patient is cognitively intact and is motivated, provide information on urge inhibition. 34, 35

3. Teach PFMEs to be used in conjunction with #1. 36

4. Collaborate with prescribing team members if pharmacologic therapy is warranted.

5. Initiate referrals for those patients who do not respond to the previous steps.

Overflow UI:

1. Allow sufficient time for voiding.

2. Discuss with interdisciplinary team the need for determining a post-void residual (PVR). 18, 37, 38 See Figure 13.1 in protocol book.

3. Instruct patients in double voiding and Crede’s maneuver.38

4. Sterile intermittent is preferred over indwelling catheterization PRN. 39, 40, 41

5. Initiate referrals to other team members for those patients requiring pharmacological or surgical intervention. Functional UI:

1. Provide individualized, scheduled toileting or prompted voiding. 29, 42, 43

2. Provide adequate fluid intake.

3. Refer for physical and occupational therapy PRN.

4. Modify environment to maximize independence with continence. 1, 29, 30

 

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Evaluation of Expected Outcomes

A. Patients:

1. Will have fewer or no episodes of UI or complications associated with UI.

B. Nurses:

1. Will document assessment of continence status at admission and throughout hospital stay. If UI is identified, document and determine type of UI.

2. Will use interdisciplinary expertise and interventions to assess and manage UI during hospitalization.

3. Will include UI in discharge planning needs and refer PRN.

C. Institution:

1. Incidence and prevalence of transient UI will decrease.

2. Hospital policies will require assessment and documentation of continence status.

3. Will provide access to AHRQ Guidelines for Managing Acute and Chronic UI.

4. Staff will receive administrative support and ongoing education regarding assessment and management of UI.

 
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Follow-up Monitoring of Condition

A. Provide patient/caregiver discharge teaching regarding outpatient referral and management.

B. Incorporate continuous quality improvement (CQI) criteria into existing program.

C. Identify areas for improvement and enlist multidisciplinary assistance in devising strategies for improvement

 

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Relevant Practice Guidelines

A. National Guideline Clearinghouse Guideline Synthesis. (updated 2007). Evaluation and management of Urinary Incontinence. http://www.guideline.gov/Compare/comparison.aspx?file=INCONTINENCE1.inc

 

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For Definition of Levels of Quantitative Evidence Click Here 

Reprinted with permission from Springer Publishing Company. Dowling-Castronovo, A. (2008).Urinary Incontinence (UI) in Older Adults Admitted to Acute CareSubstance abuse in older adults. In E. Capezuti, D. Zwicker, M. Mezey, & T. Fulmer (Eds.) Evidence-based geriatric nursing protocols for best practice. (3rd ed.) (pp. 649-672). New York: Springer Publishing Company, Inc.

References

For definition of Levels of Quantitative Evidence click here.

1. Fantl, A., Newman, D. K., Colling, J., DeLancey, J. O. L., Keeys, C., & Loughery, R. (1996). Urinary incontinence in adults: Acute and chronic management. Agency for Health Care Policy and Research, Publication No. 92-0047: Rockville, MD. Evidence Level I: CPCG Based on Systematic Review.

2. National Association for Continence (December 4, 1998). Release of findings from consumer survey on urinary incontinence: Dissatisfaction with treatment continues to rise. Spartansburg, SC: Author. Evidence Level IV: Nonexperimental Study.

3. Resnick, N. M., & Ouslander, J. G. (1990). Urinary incontinence: Where do we stand and where do we go from here. Journal of the American Geriatrics Society, 38, 264–265. Evidence Level VI: Journal Article.

4. Kresevic, D. M. (1997). New-onset urinary incontinence among hospitalized elders. Doctoral dissertation, Case Western Reserve University, 1997, UMI No. 9810934. Evidence Level IV: Nonexperimental Study.

5. Holroyd-Leduc, J., M., & Straus, S. E. (2004). Management of urinary incontinence in women. Journal of the American Medical Association: Scientific Review, 291(8), 986–995. Evidence Level I: Systematic Review.

6. Meijer, R., Ihnenfeldt, D. S., de Groot, I. J. M., van Limbeek, J., Vermeulen, M., & de Haan, R. J. (2003). Prognostic factors for ambulation and activities of daily living in the subacute phase after stroke. A systematic review of the literature. Clinical Rehabilitation, 17, 119–129. Evidence Level I: Systematic Review.

7. Thomas, L. H., Barrett, J., Cross, S., French, B., Leathley, M., Sutton, C., et al. (2005). Prevention and treatment of urinary incontinence after stroke in adults. The Cochrane Database of Systematic Reviews, Issue 3. Art. No.: CD004462.pub2. DOI: 10.1002/14651858.CD004462.pub2. Evidence Level I: Systematic Review.

8. Bogner, H. R., Gallo, J. J., Sammel, M. D., Ford, D. E., Armenian, H. K., & Eaton, W. W. (2002). Urinary incontinence and psychological distress in community-dwelling older adults. Journal of the American Geriatrics Society, 50, 489–495. Evidence Level IV: Nonexperimental Study.

9. Brown, J. S., Vittinghoff, E.,Wyman, J. F., Stone, K. L., Nevitt, M. C., Ensrud, K. E., et al. (2000a). Urinary incontinence: Does it increase risk for falls and fractures? Journal of the American Geriatrics Society, 48, 721–725. Evidence Level IV: Nonexperimental Study.

10. Johnson, T. M., Kincade, J. E., Shulamit, L., Busby-Whitehead, J., Hertz-Picciotto, I., & DeFriese, G. H. (1998). The association of urinary incontinence with poor self-related health. Journal of the American Geriatrics Society, 46, 693–699. Evidence Level IV: Nonexperimental Study.

11. Abrams, P., Cardozo, L., Fall, M., Griffiths, D., Rosier, P., Ulmsten, U., et al. (2002). The standardization of terminology of lower urinary tract function: Report from the standardization subcommittee of the International Continence Society. Urology, 61, 37–49. Evidence Level V: Narrative Literature Review.

12. Hunter, K. F., Moore, K. N., Cody, D. J., & Glazener, M. A. (2005). Conservative management for postprostatectomy urinary incontinence. The Cochrane Database of Systematic Reviews, Issue 2. No.: CD001843.pub2. DOI: 10.1002/14651858.CD001843.pub2. Evidence Level I: Systematic Review.

13. Doughty, D. B. (2000). Retention with overflow. In D. B. Doughty (Ed.), Urinary & Fecal Incontinence Nursing Management (2nd ed., pp. 159–180). St. Louis, MO: Mosby. Evidence Level VI: Expert Opinion.

14. Dowd, T. T., & Campbell, J. M. (1995). Urinary incontinence in an acute-care setting. Urologic Nursing, 15, 82–85. Evidence Level IV: Nonexperimental Study.

15. Dowd, T. (1991). Discovering older women’s experience of urinary incontinence. Research in Nursing and Health, 14, 179–186. Level Evidence IV: Nonexperimental Study.

16. Palmer, M. H., Bone, L. R., Fahey, M., Mamom, J., & Steinwachs, D. (1992). Detecting urinary incontinence in older adults during hospitalization. Applied Nursing Research, 5, 174–180. Evidence Level IV: Nonexperimental Study.

17. Schultz, A., Dickey, G., & Skoner, M. (1997). Self-report of incontinence in acute care. Urologic Nursing, 17(1), 23–28. Evidence Level IV: Nonexperimental Study.

18. International Consultation on Incontinence (ICI) (2000). Assessment and treatment of urinary incontinence. Lancet, 355, 2153–2158. Evidence Level VI: Respected Experts.

19. Wound Ostomy Continence Nurse’s Society (1996). Indwelling Catheter Fact Sheet. Retrieved February 6, 2007, from http://www.wocn.org/publications/facts/pdf/C_INDCAT.pdf. Evidence Level VI: Respected Experts.

20. Ersser, S. J., Getliffe, K., Voegeli, D., & Regan, S. (2005). A critical review of the inter-relationship between skin vulnerability and urinary incontinence and related nursing intervention. International Journal of Nursing Studies, 42, 823–835. Evidence Level I: Systematic Review.

21. Johnson, M., Bulechek, G., McCloskey-Dochterman, J., Maas, M., & Moorhead, S. (2001). Nursing Diagnoses, Outcomes, and Interventions: NANDA, NOC, and NIC Linkages. St. Louis, MO: Mosby. Evidence Level VI: Expert Opinion.

22. Kane, R., Ouslander, J., & Abrass, I. (2004). Essentials of Clinical Geriatrics (5th Ed.). New York: McGraw-Hill. Evidence Level VI: Expert Opinion.

23. Bouza, E., San Juan, R., Munoz, P., Voss, A., Kluytmans, J., & Cooperative Group of the European Study Group on Nosocomial Infections (2001). A European perspective on nosocomial urinary tract infections II: Report on incidence, clinical characteristics and outcome (ESGNI-004 study). Clinical Microbiology & Infection, 7(10), 532–542. Evidence Level IV: Nonexperimental Study.

24. Madigan, E., & Neff, F. F. (2003). Care of patients with long-term indwelling urinary catheters. Online Journal of Issues in Nursing, 8(3). Retrieved February 6, 2007, from http://www.nursingworld.org/ojin/hirsh/topic2/tpc2_1.htm. Evidence Level I: Systematic Review.

25. Zimakoff, J., Stickler, D. J., Pontoppidan, B., & Larsen, S. O. (1996). Bladder management and urinary tract infections in Danish hospitals, nursing homes, and home care: A national prevalence study. Infection Control and Hospital Epidemiology, 17, 215–221. Evidence Level IV: Nonexperimental Study.

26. Wong, E. S. (1981). Guidelines for preventing catheter-associated urinary tract infections. Centers for Disease Control. Retrieved February 6, 2007, from http://www.cdc.gov/ncidod/dhqp/gl_catheter_assoc.html. Evidence Level VI: Expert Opinion.

27. Gray, M. L., & Haas, J. (2000). Assessment of the patient with urinary incontinence. In D. B. Dougherty (Ed.), “Urinary and fecal incontinence.” Nursing Management (2nd ed.). St. Louis, MO: Mosby. Evidence Level VI: Expert Opinion.

28. Subak, L. L., Whitcomb, E., Hui, S., Saxton, J., Vittinghoff, E., & Brown, J. S. (2005). Weight loss: A novel and effective treatment for urinary incontinence. The Journal of Urology, 174, 190–195. Evidence Level II: RCT.

29. Jirovec, M. M. (2000). Functional incontinence. In D. B. Dougherty (Ed.), "Urinary & fecal incontinence nursing management (2nd ed., pp. 145–157). St. Louis: Mosby. Evidence Level VI: Expert Opinion.

30. Palmer, M. H. (1996). Urinary continence: Assessment and promotion. Gaithersburg, MD: Aspen. Evidence Level VI: Expert Opinion.

31. Bo, K., Talseth, T., & Holme, I. (1999). Single-blind, randomized controlled trial of pelvic floor exercises, electrical stimulation, vaginal cones, and no treatment in management of genuine stress incontinence. British Medical Journal, 318, 487–493. Evidence Level II: RCT Experimental Study.

32. Hay-Smith, E. J. C., & Dumoulin, C. (2006). Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. The Cochrane Database of Systematic Reviews, Issue 1. Art. No.: CD005654. DOI: 10.1002/14651858.CD005654. Level Evidence I: Systematic Review.

33. Teunissen, T. A. M., deJonge, A., van Weel, C., & Lagro-Janssen, A. L. M. (2004). Treating urinary incontinence in the elderly: Conservative measures that work: a systematic review. The Journal of Family Practice, 53(1), 25–32. Evidence Level I: Systematic Review.

34. Gray, M. (2005). Assessment and management of urinary incontinence. The Nurse Practitioner, 30(7), 32–41. Evidence Level VI: Journal Article.

35. Smith, D. A. (2000). Urge incontinence. In D. B. Dougherty (Ed.), Urinary & Fecal Incontinence Nursing Management (2nd ed., pp. 91–104). Mosby, MO: St. Louis. Evidence Level VI: Expert Opinion.

36. Flynn, L., Cell, P., & Luisi, E. (1994). Effectiveness of pelvic muscle exercises in reducing urge incontinence among community-residing elders. Journal of Gerontological Nursing, 20(5), 23–27. Evidence Level IV: Nonexperimental Study.

37. Shinopulos, N. (2000). Bedside urodynamic studies: Simple testing for urinary incontinence. Nurse Practitioner, 25(6), 19–25. Level Evidence VI: Expert Opinion.

38. Weiss, B. D. (1998). Diagnostic evaluation of urinary incontinence in geriatric patients. American Family Physician, 57(11). Retrieved February 6, 2007, from http://www.aafp.org/afp/980600ap/weiss.html. Evidence Level VI: Journal Article.

39. Saint, S., Kaufman, S. R., Rogers, M. A. M., Baker, P. D., Ossenkop, K., & Lipsky, B. A. (2006). Condom versus indwelling urinary catheters: A randomized trial. Journal of the American Geriatrics Society, 54, 1055–1061. Evidence Level II: RCT Experimental Study.

40. Terpenning, M. S., Allada, R., & Kauffaman, C. A. (1989). Intermittent urethral catheterization in the elderly. Journal of the American Geriatrics Society, 37, 411–416. Evidence Level IV: Nonexperimental Study.

41. Warren, J. W. (1997). Catheter-associated urinary tract infections. Infectious Disease Clinics of North America, 11(3), 609–622. Level VI: Journal Article.

42. Eustice, S., Roe, B., & Paterson, J. (2005). Prompted voiding for the management of urinary incontinence in adults. The Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD002113. DOI: 10.1002/14651858.DC002113. Evidence Level I: Systematic Review.

43. Ostaszkiewicz, J., Johnston, L., & Roe, B. (2005). Timed voiding for the management of urinary incontinence in adults. The Cochrane Database of Systematic Reviews (Protocol), Issue Art. No.: CD002802. DOI: 10.1002/14651858. CD002802.pub2. Evidence Level I: Systematic Review.

44. Dunn, S., Kowanko, I., Patersonk, J., & Pretty, L. (2002). Systematic review of the effectiveness of urinary continence products. Journal of WOCN, 29(3), 129–142. Evidence Level I: Systematic Review.

 

Last updated - February 2008

 
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