PROMOTING CONTINENCE USING
OVERVIEW OF RNAO BEST PRACTICE GUIDELINE
Long Term Care Best Practice
– Northwest Ontario
• Understand incontinence.
• Understand recommendations
from the RNAO Best Practice
Guideline Promoting Continence
Using Prompted Voiding
• Understand prompted voiding
as an intervention for
What is Incontinence?
Defined by the International
Continence Society as:
“a condition where involuntary loss
of urine is a social or hygienic
Why is Incontinence Important?
• One of the most common reasons for admission to
Long Term Care.
• Negatively affects a person’s dignity.
• Causes embarrassment, depression and social
• Complications cause falls, urinary tract infections,
skin and wound problems.
Incontinence Myths and Truths
• Incontinence is a normal aging process.
• Little can be done for incontinent residents.
• Toileting residents every 2 hours prevents
• Restricting fluids reduces incontinence.
• Prompted voiding is an effective method to
use with incontinent patients.
Types of Urinary Incontinence
• Physical :
– Stress: cough
– Urge: need to go Now……
– Overflow: leaks out
– Need help
– Short term problem
• Loss of urine with a sudden increase in intraabdominal
(e.g. coughing, sneezing, exercise)
• Most common in women
• Can also happen to men
after prostate surgery.
Urge Incontinence (overactive bladder)
• Loss of urine with a strong
unstoppable urge to urinate
• Usually associated with
frequent urination during the
day and night
• Common in women & men
• Sometimes called an
• Bladder is full at all times and
leaks at any time, day or night
• Usual symptoms are a slow
stream and difficulty urinating
• More common in men as a result of
• Associated with decreased cognitive
capabilities or physical abilities
(e.g. Alzheimer’s Disease, Stroke)
• Resident is unable to go to the
toilet in time without help.
A short term
• DIAPPERS (mnemonic)
– Delirium, depression
– Atrophic Vaginitis
– Psychological, pain, polyuria
– Excess fluid, environmental
– Restricted mobility
– Stool impaction or constipation
1.0 Obtain a history of the client's incontinence.
2.0 Gather information on:
– The amount, type and time of daily fluid intake,
paying particular attention to the intake amount of
caffeine and alcohol.
– The frequency, nature and consistency of bowel
– Any relevant medical or surgical history which may be
related to the incontinence problem, such as but not
limited to diabetes, stroke, Parkinson's disease, heart
failure, recurrent urinary tract infections or previous
Assessment - Contributing Factors
• Current Medical Problems
ie Cognitive Impairment
• Low Fluid Intake
• Caffeine / Alcohol Intake
• Past Medical or Surgical
History ie Childbirth
• Aging- Loss of pelvic muscle
tone & atrophic Changes
• Decreased Mobility
• Environmental Factors
•Urinary Tract Infections
Assessment - Past Medical & Surgical History
• Parkinson’s Disease
• Multiple Sclerosis
• Spinal Cord injury
Gastro-Intestinal (GI) Problems
• Chronic constipation
• Diverticular disease
• Previous colon surgery
• Irritable bowel syndrome
Genito-Urinary (GU) Problems
• Recurrent Urinary Tract Infections
• Previous G/U Surgery or Injury
• Prostate Problems
• Heart Problems
Assessment - Medications
3.0 Review the client's medications to identify those
which may have an impact on the incontinence.
• Certain medications can make the
bladder too active or not active
• Some herbal preparations that can
effect the bladder
• Certain prescription medications that
can lessen urge incontinence
Assessment: Functional Ability
4.0 Identify the client's functional and cognitive ability.
• Any problem that lessens a
resident’s ability to get a toilet
in time can cause functional
• Access to bathroom
• Ambulation (needs assistance)
• Transfer aids
Assessment- Attitudes & Environment
• 5.0 Identify attitudinal and environmental
barriers to successful toileting.
• Barriers include:
– Proximity and availability of the nearest bathroom;
– Accessibility of commode;
– Satisfactory lighting;
– Use of restraints;
– Staff expectation that incontinence is an inevitable
consequence of aging; and
– Staff belief that few interventions exist to promote
Assessment – Urinary Tract Infections
6.0 Check urine to determine if infection is present
• Burning feeling or pain when voiding
• Voiding frequently and urgently
• Bacteria irritates the bladder and makes it
contract more often
• Vaginitis is itching, redness +soreness in and
around the vagina. Discharge from the vagina can
lead to UTI.
• Can be caused by failure to wash and wipe
perineum from ‘front to back’.
• Discuss with physician . May treat with antibiotic
Assessment – Client’s Perception
• 7.0 Determine how the client perceives their
urinary incontinence and if they will benefit
from prompted voiding. Before initiating
prompted voiding, identify the client's pattern
of incontinence using a 3-day voiding record.
Intervention - Constipation
8.0 Ensure that constipation and fecal impaction are
• Pushing too hard and too often durng
a bowel movement can weaken
pelvic floor muscles
• Stool “impaction” (hard, “stuck” feces
in the rectum) adds to urinary
• “Smearing” or “staining” of stool,
may be caused by constipation or
Intervention - Poor Fluid Intake
9.0 Ensure an adequate level of fluid intake (1500 - 2000
ml per day), and minimize the use of caffeinated and
alcoholic beverages where possible.
• The less residents drink the more concentrated
their urine becomes and the more irritating.
• They urinate just as often only
smaller amounts & may feel urge
to urinate more frequently.
Assessment - Voiding Record
11.0 Initiate a 3-day voiding record, a minimum of 3
weeks and a maximum of 8 weeks, after the prompted
• Time and amount of:
– Fluid intake
– Urine voided
• Done for 3 - 7 days
Assessment Tool – Voiding Record
A 3-day, hourly fluid
intake and urine
output record useful
for determining when a
resident voids in
relation to intake for a
Intervention: Prompted Voiding
10.0 Initiate an individualized prompted voiding
schedule based on the client's toileting needs, and as
determined by a 3-day voiding record.
• Changes caregiver’s response to
urine loss rather than resident’s
• Caregiver prevents undesired
urine loss from occurring before
the resident would be
Prompted Voiding Intervention
Three main interventions:
• Monitoring - Ask the resident at regular intervals if
he/she needs to use the toilet.
• Prompting - Remind the resident to use the toilet
and try not to void between prompted voiding
• Praising - Give positive feedback to resident to
reinforce dryness and appropriate toileting
Prompted Voiding - Trial Run
• Collect baseline information about your resident for
at least 3 days.
• Review data. Assess responsiveness of your resident
to prompted voiding.
• Start slowly, with only one or two residents at one
• Try out the intervention for one week with your
resident, carefully track results, then reassess
• Discontinue, if client is not responding.
Prompted Voiding - Monitoring
• Decreased # of incontinent episodes per day
and increased the # of continent voids.
• Resident will be continent during waking hours
• Bladder irrigation will be discontinued
• Full continence will be achieved
• Resident will have an individualized toileting
The Best Practices Toolkit
• Resources in the Long-Term Care Toolkit are designed to
assist homes with the implementation of Best Practice
• Documents are evidence-based, but are not program plans.
Resources are to use at your discretion.
• Some resources have copyright notations. It is
recommended that LTC homes obtain permission from the
primary author prior to implementing them.
• The Toolkit is a dynamic resource, and is being updated and
revised on a regular basis.
• RNAO Promoting Continence Using Prompted Voiding: A PDA Guide.
http://www.rnao.org/pda/void - Condensed version of the Continence BPG. Excellent
summary in English and French.
• RNAO BPG – Promoting Continence Using Prompted Voiding.
http://www.rnao.org/Page.asp?PageID=1212&SiteNodeID=155&BL_ExpandID = Best
• Anna and Harry Borun Center for Gerontological Research. Incontinence Management
t/about.htm . A clearly written, self-learning package that breaks the process into
steps-assessment, responsiveness, maintenance and audits. Includes voiding records,
monitoring forms, MDS subscales, etc. Highly recommended.
• Ouslander JG, Schnelle JF, Uman G, Fingold S, Nigam JG, Tuico E, & Bates-Jensen B.
Predictors of successful prompted voiding among incontinent nursing home residents. J
Am Med Assoc, 1995b; 273(17):1366-1370. Good discussion of factors to consider if a
resident will benefit from prompted voiding.
Heather Woodbeck, RN, HBScN, MHSA
Long Term Care Best Practice Coordinator
– Northwest Ontario
THANKS for listening, sharing and
caring about improving continence
in LTC residents