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 July 2012

Reprinted with permission from Springer Publishing Company. Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th Edition, © Springer Publishing Company, LLC. The text is available here.

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 (Ref 1; 2; 3; Landfeld et al., 2008). 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 (Ref 1;5;6;7; Offermans, Du Moulin, Hamers, Dassen, & Halfens, 2009; Shamliyan, Wyman, Bliss, Kane, & Wilt, 2007), 1, 5, 6, 7 immobility, impaired cognition, malnutrition, and depression are additional 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 (Ref 1;8;9;10; Morris & Wagg, 2007). 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 (Jayasekara, 2009).

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 (Ref 1;11;13; Jayasekara, 2009). 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 (Ref1; Hodgkinson et al., 2008). 1

B. Epidemiology
UI affects approximately 17 million Americans (Ref1;2;3; Landefeld et al., 2008). 1, 2, 3 UI studies specific to the hospital setting demonstrate that UI is present in 10% to 42% of older adults (Ref1;4;14;16;17),1, 14, 16, 17 therefore, assessment and implementation of an evidence-based protocol is essential.

 
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Parameters of Assessment

A. Document the presence/absence of UI for all patients on admission (DuBeau et al., 2010).

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

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 (Ref1;21; DuBeau et al., 2010; Jayasekara, 2009). 1, 21

2. Identify and document the possible etiologies of the UI (DuBeau et al., 2010; Ref1). 1

 
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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 (DuBeau et al., 2010).

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. Implement toileting programs as needed (Ref 43; Rathnayake, 2009c).

4. Avoid medications that may contribute to UI (Newman & Wein, 2009).

5. Avoid indwelling urinary catheters whenever possible to avoid risk for UTI (Ref 14; 23; 25; Gould et al., 2009).  23, 25

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 body mass index (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 (Ref 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) (DuBeau et al, 2010; Hodgkinson et al., 2008).

2. Provide toileting assistance and bladder training PRN (whenever necessary) (DuBois et al., 2010). 

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

Urge UI
and OAB:

1. Implement bladder training (retraining) (Ref 33; DuBeau et al., 2010).  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 bladder training, and instruct in urge inhibition strategies (Ref 36; Rathnayake, 2009a; Ref 33) . 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) (Ref 37; Newman & Wein, 2009). 37 See Table 18.2 in protocol book.

3. Instruct patients in double voiding and Crede’s maneuver (Ref 13).

4. If catheterization is necessary, 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, timed voiding, or prompted voiding (Ref 29; 42; 43; Lee et al., 2009). 29, 42, 43

2. Provide adequate fluid intake.

3. Refer for physical and occupational therapy PRN.

4. Modify environment to maximize independence with continence (Ref 1; 29; 30; Jirovec et al., 1988). 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 ("Assessing Care," 2007; Fung et al., 2007).

3. Will provide access to evidence-based guidelines for evaluation and management of 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 ("Assessing Care," 2007; Fung et al., 2007).

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. http://www.guideline.gov/syntheses/index.aspx

 

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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. (2003). 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 I.

12. Hunter, K. F., Moore, K. N., Cody, D. J., & Glazener, M. A. (2004). 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.

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.

 

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.

 

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.

 

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.

 

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.

 

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. (2000). 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.

43. Ostaszkiewicz, J., Johnston, L., & Roe, B. (2004). 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.

 

Offermans, M.P., Du Moulin, M.F., Hamers, J.P., Dassen, T., & Halfens, R.J. (2009). Prevalence of urinary incontinence and associated risk factors in nursing home residents: A systematic review. Neurourology and Urodynamics, 28(4), 288-294. Evidence Level I.

Shamliyan, T., Wyman, J., Bliss, D.Z., Kane, R.L., & Wilt, T.J., (2007). Prevention of urinary and fecal incontinence in adults. Evidence Report/Technology Assessment (Full Rep), (161), 1-379. Evidence Level I.

Morris, V., & Wagg, A. (2007). Lower urinary tract symptoms, incontinence and falls in elderly people: Time for an intervention study. International Journal of Clinical practice, 61(2), 320-323. Evidence Level VI.

Jayasekara, R. (2009). Urinary incontinence: Evaluation. JBI Database Evid Summaries, Publication ES0610. Evidence Level I.

Hodgkinson, B., Synott, R., Josephs, K., Leira, E., & Hegney, D. (2008). A systematic review of the effect of educational interventions for urinary and fecal incontinence by health care staff/carers/clients in the aged care, on level knowledge, frequency of incontinence episodes and hours spent on the management of incontinence episodes. JBI Lib Syst Rev, Publication 318. Evidence Level I.

Landefeld, C.S., Bowers, B.J., Feld, A.D., Hartmann, K.E., Hoffman, E., Ingber, M.J.,...Trock, B.J. (2008). National Insititutes of Health state-of-the-science conference statement: Prevention of fecal and urinary incontinence in adults. Annals of Internal Medicine, 148(6), 449-458. Evidence Level I.

DuBeau, C.E., Kuchel, G.A., Johnson, T., II, Palmer, M.H., Wagg, A., & Fourth International Consultation on Incontinence. (2010). Incontinence in the frail elderly: Report from the 4th International Consultation on Incontinence. Neurourology and Urodynamics, 29(1), 165-178. Evidence Level I.

Rathnayake,T. (2009c). Urinary incontinence: Timed voiding. JBI Database of Evidence Summaries, Publication ES5330. Evidence Level I.

Newman, D.K., & Wein, A.J. (2009). Managing and treating urinary incontinence (2nd ed.). Baltimore, MD: Health Professions Press. Evidence Level VI.

Gould, C.V, Umscheid, C.A., Agarwal, R.K., Kuntz, G., Pegues, D.A., & the Healthcare Infection Control Practices Advisory Committee. (2009). Guideline for prevention of catheter-associated urinary tract infections. Retrieved from http://www.cdc.gov/hicpac/cauti/001_cauti.html. Evidence Level I.

Rathnayake, T. (2009a). Urinary incontinence: Bladder training. JBI Database of Evidence Summaries. Publication ES5237. Evidence Level I.

Lee, P.G., Cigolle, C., & Blaum, C. (2009). The co-occurence of chronic diseases and geriatric syndromes: The health and retirement study. Journal of the American Geriatrics Society, 57(3), 511-516. Evidence Level IV.

Jirovec, M.M., Brink, C.A., Wells, T.J. (1988). Nursing assessments in the inpatient geriatric population. The Nursing Clinics of North America, 23(1), 219-230. Evidence Level VI.

Assessing care of vulnerable elders-3 quality indicators. (2007). Journal of the American Geriatrics Society, 55(Suppl 2), S464-S487. Evidence Level V.

Fung, C.H., Spencer, B., Eslami, M., & Crandall, C. (2007). Quality indicators for the screening and care of urinary incontinence in vulnerable elders. Journal of the American Geriatrics Society, 55(Suppl 2), S443-S449. Evidence Level I.
 

Last updated - July 2012

 
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