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PROMOTING CONTINENCE USING

PROMPTED VOIDING

OVERVIEW OF RNAO BEST PRACTICE GUIDELINE

Heather Woodbeck

Long Term Care Best Practice

Coordinator

– Northwest Ontario


Objectives

• Understand incontinence.

• Understand recommendations

from the RNAO Best Practice

Guideline Promoting Continence

Using Prompted Voiding

• Understand prompted voiding

as an intervention for

incontinence


What is Incontinence?

Defined by the International

Continence Society as:

“a condition where involuntary loss

of urine is a social or hygienic

problem”

(ICS, 1987)


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

isolation.

• 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

incontinence.

• 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

• Functional:

– Need help

• Transient

– Short term problem


Stress Incontinence

• Loss of urine with a sudden increase in intraabdominal

pressure

(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

overactive bladder


Overflow Incontinence

• 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

prostate problems


Functional Incontinence

• 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.


Transient Incontinence

A short term

decline in

continence

usually with

sudden or

recent onset

caused by:

• DIAPPERS (mnemonic)

– Delirium, depression

– Infection

– Atrophic Vaginitis

– Pharmaceuticals

– Psychological, pain, polyuria

– Excess fluid, environmental

barriers

– Restricted mobility

– Stool impaction or constipation


Promoting

Continence Using

Prompted Voiding

Summary of

Recommendations

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Recommendations: Assessment

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

movements.

– 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

bladder surgery.


Assessment - Contributing Factors

• Current Medical Problems

ie Cognitive Impairment

• Low Fluid Intake

• Caffeine / Alcohol Intake

• Past Medical or Surgical

History ie Childbirth

damage

• Overweight

• Aging- Loss of pelvic muscle

tone & atrophic Changes

• Constipation

• Decreased Mobility

• Environmental Factors

•Urinary Tract Infections

•Medications


Assessment - Past Medical & Surgical History

Neurological Conditions

• Stroke/CVA

• Parkinson’s Disease

• Multiple Sclerosis

• Spinal Cord injury

Gastro-Intestinal (GI) Problems

• Chronic constipation

• Diverticular disease

• Hemorrhoids/fissures

• Previous colon surgery

• Irritable bowel syndrome

Immobility Issues

• Arthritis

Genito-Urinary (GU) Problems

• Recurrent Urinary Tract Infections

• Previous G/U Surgery or Injury

• Prostate Problems

Medical Conditions

• Diabetes

• Hypertension

• Hypothyroidism

• Heart Problems

Cognitive Problems

• Dementia


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

enough

• 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

incontinence.

• Access to bathroom

• Ambulation (needs assistance)

• Wheelchair

• Transfer aids

• Adaptive

clothing/environment


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

continence.


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

addressed.

• 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

incontinence

• “Smearing” or “staining” of stool,

may be caused by constipation or

possible rectocele.


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

voiding schedule.

• Time and amount of:

– Fluid intake

– Urine voided

– Incontinence

• Done for 3 - 7 days


Assessment Tool – Voiding Record

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

prompted voiding

intervention.

24


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

response.

Caregiver prevents undesired

urine loss from occurring before

the resident would be

incontinent.


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

sessions.

• 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

time.

• Try out the intervention for one week with your

resident, carefully track results, then reassess

effectiveness.

• Discontinue, if client is not responding.


Prompted Voiding - Monitoring

Effectiveness

• 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

plan


The Best Practices Toolkit

http://ltctoolkit.rnao.ca

• Resources in the Long-Term Care Toolkit are designed to

assist homes with the implementation of Best Practice

Guidelines.

• 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.

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Resources

• 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

Practice Guideline.

• Anna and Harry Borun Center for Gerontological Research. Incontinence Management

Training Module.

http://www.geronet.med.ucla.edu/centers/borun/modules/Incontinence_managemen

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.


Contact

Heather Woodbeck, RN, HBScN, MHSA

Long Term Care Best Practice Coordinator

– Northwest Ontario

807-707-0466

hwoodbeck@rnao.org

32


THANKS for listening, sharing and

caring about improving continence

in LTC residents

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