This month’s Clinical Capsule will be the last in a series of nursing newsletters covering urinary incontinence and the new CMS guidelines under F315. During the past month, the Council sponsored seminars presented by Mary H. Palmer, PhD, RNC, FAAN. Dr. Palmer co-edits the column, "Bladder Matters," in the American Journal of Nursing and has given permission to share the following information on behavioral interventions for incontinence.

As mentioned in previous newsletters, the bladder diary is one of the most important parts of the assessment process. A three to five day diary of the resident’s voiding patterns is essential on admission and with a change of condition. All staff must be diligent about the process in order to get a true picture of the resident. The assessor then interprets these diaries by looking for the following:

Patterns –Incontinence upon arising, before lunch, etc.

Frequency – How often does the resident void?

Volume – Are the amounts large or small?

Bowel movements – Frequency

Fluids – Timing in relation to voiding

Location of incontinent episode – Accessibility of toilet

The bladder diary will help you answer the question, "Which type of intervention is appropriate for the resident?" There are three types of behavior interventions and each requires skills on the part of the resident. In order to be successful with a behavioral program the resident must have the following skills:

Ability to comprehend and follow education and instructions

Identify urinary urge sensation

Learn to inhibit or control urge to void

The goal of bladder rehabilitation is to achieve a normal voiding pattern or achieve the longest possible interval. Voiding is delayed to increase capacity and to inhibit detrusor muscle contractions. These residents should be able to hold their urine until reaching the toilet. Optimum voiding intervals are usually between 2-4 hours. Residents in this group should also be able to manage their fluid intake. Only residents with the following characteristics will be successful at bladder retraining:

Be able to resist or inhibit the urge to void

Void according to a timetable

Be independent in activities of daily living

Experience occasional incontinent episodes

Be aware of need to void

Usually assessed to have urge incontinence or overactive bladder

The proposed mechanism of action for habit training is regular emptying of the bladder before capacity is reached, usually every two hours. The goal is to prevent incontinence from occurring. The facility is providing access to the toilet based on the resident’s voiding pattern. Habit training requires scheduled toileting, at regular intervals, on a planned basis, that matches the resident’s voiding habits. The facility works with the resident on a daily schedule that allows the resident to meet his/her voiding schedule. The most common time frame is two hours, however, studies have shown that some residents have better success with a three or four hour schedule.

Prompted voiding is very labor-intensive and is not for someone who is very incontinent. There are three components to prompted voiding:

Regular monitoring with encouragement

Taking the resident to the toilet on a scheduled basis and prompting them to void

Praise and positive feedback when the resident is continent and attempts to toilet

The following predictors of responsiveness may help the assessor decide if this is the right program for the resident:

Resident’s response to three day therapeutic trial of prompted voiding – If the resident is very incontinent, PV will not work

Normal bladder capacity (>200 and <700cc)

Recognizes need to void

Baseline incontinence of less than 4 times in 12 hours

Maximum voided volume >150cc

Post-void residual <100cc

Able to void successfully when given toileting assistance

Usually residents placed on a prompted voiding program have been assessed for urge incontinence but cannot toilet themselves. They usually have a cognitive impairment and are dependent on facility staff for assistance. They should be able to say their name or reliably point to one of two objects and will require a great deal of training, motivation and effort from the staff.

The goal of all behavioral interventions is to avoid incontinent episodes. If you cannot prevent incontinence after trying interventions then it may be appropriate to place the resident on a check and change program. The goals of a check and change program are to keep the resident as dry as possible and to prevent complications.

Although nursing cannot do a complete physical examination, Dr. Palmer suggests that nursing look for any external problems that may be affecting continence. If the resident will let you, examine the external genitalia for prolapse, redness, inflammation or discharge. Do not use a speculum, but explain to the resident that you are only looking for external signs that may need to be reported to the physician. This exam should be done quietly and quickly only after resident consent has been given.

Bladder health is a people issue, not just an elderly people issue. It affects men as well as women. The education in this area should be addressed to staff, residents and families because they are all at risk for developing incontinence some time in their lifetime.

In addition to this month’s Clinical Capsule, the following issues of Council newsletters complete the Council’s coverage of this important topic: This Week Number 1069; Clinical Capsule Volume 10, Numbers 6, 7, and 8 and Vital Signs Volume 10, Numbers 6 and 7.

The Web is an excellent resource for staff, and family education. Check out the National Association for Continence, http://www.nafc.org for daily voiding diaries, and the Collaboration to Support Urinary Incontinences and Women’s Health, http://StressUI.org for wonderful clinical tools (differential diagnosis sheets, physical exam tip-sheets, and bladder diaries).