eln otnneMngmn rga 2018 Super User Guide Medline Continence Management Program
Incontinence Solutions
Continence Management
VOLUME 1 Program Dear Valued Customer, Thank you for your dedication and commitment to Medline; we greatly value your partnership. As you know, the healthcare industry is in a state of anxiety with continued reductions in funding, and yet there is constant pressure to promote high-quality, resident-centered care.
Due to changes in reimbursement, many competitors have reduced product performance to decrease the cost of absorbent disposable products. This strategy is meant to appeal to customers trying to manage cost in the wake of these reimbursement challenges. Although this strategy may appear to be effective at first glance, it fails to promote cost-effective, resident-centered care.
As a leading provider of disposable incontinence supplies to the healthcare industry, Medline has continued to explore opportunities to better support you and your most pressing needs and objectives. Based on continued feedback from care providers, we have learned that management of continence can create many difficult challenges—like escalating costs and increased labor—while drastically impacting the quality of life for residents. We have also found that traditional adult disposable briefs were not designed to properly accommodate the contours of the body, leading to leakage, misuse of sizing, and poor outcomes. Medline was inspired to develop a new, innovative approach by improving and upgrading several features in our current product line. Our goal is to offer better dryness, exceptional containment, superior fit and comfort, while promoting cost-effective, individualized care and patient dignity. Today, we are proud to offer these exceptional products to you and your residents.
2 MEDLINE Table of Contents What Is Incontinence? ...... 4–5 Medline Continence Management Program ...... 6–7 Prepare for Change ...... 8–9 Get Everyone on Board...... 10–13 Assemble a Team ...... 14–20 Designate a Champion...... 21 Select a Team Captain ...... 22–23 Educate the Staff...... 24–53 Educate the Family ...... 54–55 Assessment...... 56–68 Care Plans ...... 69 Create an I.D. System ...... 70–71 Maintain and Sustain ...... 72–73 References...... 74–76
1-800-MEDLINE (633-5463) | medline.com 3 What Is Incontinence? A Widespread Issue Across Long-Term Care It’s probably no surprise that incontinence is one of the Culture Change most costly and labor-intensive issues in nursing homes First, it is important to recognize the necessity for and long-term care facilities. What’s more, despite years of improvement in both care quality and work-life quality in research and clinical efforts to improve it, the prevalence of long-term care. Acknowledge that the vital role of CNAs incontinence remains high. In fact, according to one recent in providing high-quality care, and the importance of study, upwards of 75% of residents are incontinent of urine, empowering them to improve the quality of their work feces or both.1 experience—including the effectiveness of their work—is critical. Finally, you must identify organizational culture as Another disheartening statistic is that 90% of residents a significant and necessary focus of change. become incontinent within 3 months of admission to a long-term care facility.2 A whole host of other concerns Culture change in long-term care has flourished, but accompany incontinence as well, including increased transferring culture change from programs to new risk for skin problems, a higher rate of falls, dignity and practices has been more difficult than anticipated. Many social interaction issues for residents, a greater burden organizations involved in culture-change initiatives, even on caregivers and increased costs, especially when homes with the best intentions and considerable resources, incontinence is poorly managed.3 struggle to achieve and/or sustain significant improvement in either care quality or work-life quality.
Strategies for Success An important challenge to culture-change initiatives is staff turnover. In a facility with high turnover rates, As caregivers, we always want to provide the highest information is easily lost. CNAs with important, valuable quality of care possible for our residents. However, despite information may be gone when attempting to evaluate our efforts, quality issues continue to plague long-term the efforts taken toward change. To address some of the care. When we take a closer look, most of us can usually above challenges, consider: find areas for improvement. » What is it about our current continence We know that a successful implementation of a continence management protocol that allows or management program is much more likely when it is encourages these problems to continue? understood and supported across the organization. If » How can we implement a program that you have been contemplating the implementation of an supports new initiatives and integrates the organization-wide continence management program, you changes into work routines at all levels? have come to the right place. Medline knows a thing or two » How can we implement a program where on- about education and program implementation, and can help going education is built into the daily routine? you achieve your goals. Throughout the years, we have learned how important it is for CNAs to understand and feel some commitment to the desired outcomes, and to clearly understand the role they will play in achieving the outcome. This is actually much more difficult than it sounds. You have a lot of CNAs that come and go. CNAs work different shifts and are too busy to attend in-services on something they may not see as relevant to their own situation. That is why Medline has developed this comprehensive program.
4 MEDLINE What Does the Research Tell Us? » Success requires a systematic, organizational level of commitment
» Continence care that is not appropriately WHAT IS INCONTINENCE? managed is often not addressed—this is partially due to caregivers and family members believing that “its just the way it has to be” » Residents and families often have a negative Tips for Success! view of incontinence and how it is being » For each resident, establish managed by facilities and staff a history of incontinence and » There are numerous barriers preventing CNAs from identify the type of incontinence. participating in the resident care they will be delivering » Implement a voiding diary » Levels of resources across facilities, such as for at least 3 days and staffing, are associated with widely varying document findings. levels of care quality and staff turnover » Develop an individualized » CNAs; perception of work-life quality is highly related care plan to promote as much to the degree of collaboration between them and their normal bladder function as direct supervisors. We also know that CNAs routinely: possible by utilizing behavioral – Feel left out of decision-making and toileting programs. (HINT: – Do not feel as if they are listened to or that their checking and changing every observations about residents are taken seriously 2 hours does not qualify as a bladder and bowel program.) CNAs want to be part of the decision-making team. They » Select the correct absorbent want their knowledge, skills, observations and insights to product based on the resident’s be considered in the residents’ care. level of incontinence. » Select the correct product size. Medline’s CMP effectively addresses these above questions » Implement a distribution by providing: system to deliver products » On-going monitoring of CNA education to the residents’ rooms. » Tools to implement the program successfully » Evaluate outcomes and » Evolving education to keep up with constant change revise individual care plans as necessary. » Clinical support to work with your CNAs
Use of the Guide This guide is not a recipe for change. Any significant change must reflect the particular mission, goals, culture and internal relationships of individual organizations. As each organization has its own personality, history, commitments and challenges, this guide is intended to be used as a reference. You are encouraged to consider what it is you value in your organization and to consider how to maintain those things while engaging in change. Mostly, the guide is intended to stimulate discussions and engage a wide range of staff within your organization as you plan, implement and embrace the Medline Continence Management Program.
1-800-MEDLINE (633-5463) | medline.com 5 How the Medline Continence Management Program Can Help
When continence assessments are built into the admission Improved Comfort, process, and plans are developed for high-risk residents, Confidence and Compliance better outcomes will be achieved. For example, when residents are confident that they will be checked on a With a simple, comprehensive continence management regular basis and offered assistance with toileting, the rate program that produces nursing care plans Individualized to of falls may go down. Residents will no longer be tempted each resident’s needs, your facility can benefit in a number to go to the bathroom unattended if they are proactively of ways: asked if they have to use the bathroom. A successful » Preservation of residents’ dignity program built on education and evidence-based protocols » Improvement in residents’ continence status will translate to more satisfied residents and staff. » Reduction in overuse of disposable products It is clear that the impact of incontinence extends beyond » Consistency of care across the facility the resident; therefore, it is important that all staff are »Regulatory compliance knowledgeable of the signs, symptoms, assessment, treatment and management of incontinence.
Medline’s Continence Management Program The program has several essential components, Beyond Briefs— including: a Comprehensive Program » Step-by-step support for implementing the Medline Continence Management Program The Medline Continence Management Program » Educational tools and Toolkit is a comprehensive package featuring a model for systematic clinical continence assessment, » Comprehensive assessment tools management and evaluation documentation. Designed » Product education, hints and tips for to provide direction and education in evidence- success in use of absorbent products based assessment of actual or potential continence » Urinary and fecal incontinence issues, our Continence Management Program can management and evaluation tools help you achieve the following objectives: » Description and directions for use of forms and tools » Identify issues contributing to altered continence function » Online educational courses that are relevant to » Facilitate delivery of effective continence continence management—both for RN/LPNs and CNAs management interventions based on appropriate assessment and current evidence » Evaluate and re-evaluate care using measurable data and evidence based outcomes of care » Achieve excellence in continence management
6 MEDLINE Implementing MANAGEMENT PROGRAM Your Continence CONTINENCEMEDLINE’S Management Program 1 Prepare For Change.
2 Get Everyone On Board.
3 Assemble a Continence Management Team.
4 Designate a Continence Care Champion.
5 Select a Continence Care Team Captain.
6 Educate the Nursing Staff at All Levels. A Solid Foundation for Change Medline University Type of Incontinence & Behavioral Programs Products Skin Care
7 Educate the Family.
8 Assess New Residents and Reevaluate Current Residents.
9 Implement Care Plans and Select Products.
10 Create an Incontinence Product Identification System.
11 Maintain and Sustain.
1-800-MEDLINE (633-5463) | medline.com 7 Prepare For Change. These are questions that leadership must think about Introducing the Continence carefully and be prepared to discuss with staff as the Management Program program is being implemented. Otherwise, organizational change will be seen as something “extra” to do—something As an initial step to implementing the continence that is added to, rather than integrated into, daily work. management program in your facility, it is important to When change is viewed by facility staff, especially direct create a general awareness about what the key philosophy care workers, as something that is “added on,” it has little is and why you have decided to embark on the changes. chance of being successfully implemented or sustained. When there is insufficient awareness about the program, staff may be left wondering what the new initiative is all about or, worse, not knowing about it at all. Being clear that Specific Strategies for there is a commitment from the top of the organization, and that the program is neither short-term nor confined to Introducing the Program isolated areas of the organization, it’s necessary for staff Have On-Going Discussions About the Need in the organization to take change seriously. Unless this is for Implementing the Continence Management done carefully, there is a risk that most staff will see the Program and Desired Outcomes. program as “someone else’s concern” or “just a phase.” Discussions must be held at multiple times and in multiple places to be effective. This means all shifts, all units and Anticipate Questions from Staff. departments, resident and family councils, and any formal Successful implementation will be dependent on the gatherings of staff, residents and family. It might also be success of creating a facility-wide belief that continence helpful to include medical directors, physicians and nurse care is everyone’s concern and that there are roles for practitioners that attend to the residents in your facility. everyone to play in its implementation. Promoting the Physicians and nurse practitioners can be an important belief that everyone has a role to play relies on a clear source of information regarding the impact of the program understanding of exactly what those roles are. It is crucial implementation on resident outcomes. They can also for leadership to have a clear understanding of those roles provide insight into the quality and comprehensiveness of and to be able to describe them in a way that staff can reports and documentation on resident conditions, which see themselves in the program. Questions from staff that should be positively influenced by the implementation of the leadership team can expect and must be prepared to the program. respond to include: » What exactly are we trying to achieve? Schedule Meetings to Discuss Changes » What is wrong with the way we are in Staff Responsibilities. currently managing incontinence? Such meetings could be used to make expectations clear, » Does this mean I will have additional responsibilities? while also allowing staff to ask questions and make suggestions about the evolution of their roles. » What are the systems that will be used to communicate as the program is implemented? » What exactly will be different for me? » Will this ultimately make the care we provide here better? If so, how? » Will this affect my relationships with coworkers? If so, how? » What if I don’t have the skills or knowledge to do this? » Will I relate differently to those above and below me in the organization? If so, in what ways? » Will I or others be held accountable? If so, how?
8 MEDLINE Request Regular Reporting from Leadership The successful implementation of a continence on How the Program is Going. management program, and transforming how your staff Success of the program implementation relies heavily on manages incontinence in your facility, will require everyone the accuracy of data about resident outcomes, effective use to work hard. of information about the program, and how well the staff is PREPARE FOR CHANGE able to use the data about resident care outcomes. The data Assessment work by the leadership team will include: should be made available and shared with staff members » Ease of staff access to tools and education participating in the program. Implications of the data should » Effectiveness of communication and be discussed with everyone involved as well. targeted information flow » Focus of performance evaluations Utilize Communication Systems. and link to desired behaviors Assess whether and how these systems will serve the » Link between staff development program implementation plan, and identify places where activities and care outcomes these systems need to be modified. In particular, this should » Work environment quality include discussions about what information is needed, by whom and when, so that systems are established. Points » Resident quality of life at which information flow is blocked or tends to be delayed should be identified and addressed. It is helpful to utilize Questions to Consider: the tools, checklists or information flow charts that are In addition to providing information to the nurses, how available as part of this program whenever long established are the CNAs in your facility participating in the resident communication systems are being examined or altered. care planning process? Do they feel as if they are true participants? How do you know? Create a System to Determine Whether Follow- Through on Each of the Above Areas Is Occurring. Communicate Effectively Across Shifts. There is often a significant difference between perception Cross-shift communication is a challenge in almost every and reality regarding how well goals are being achieved and healthcare environment. In long-term care settings, lack of how well staff are following through with the continence effective communication across shifts is a source of anxiety management program. and frustration for families and residents and undermines carefully designed clinical interventions. Families and Objective accountability systems that provide actual evidence residents frequently report that important information for degree of follow-through are extremely helpful to identify. about their loved one, as well as simple requests made to Can you identify clear and convincing evidence that what you staff, are not transferred from one shift to the next. perceive is occurring in your facility related to communication and follow-through is actually occurring? If you are able to do These simple things are often important quality-of-life this, the likelihood of successfully implementing the program issues for residents and family members. Vital information in your facility increases significantly. about clinical practice interventions frequently suffers the same fate, leading to interruptions and delays in care. Prior to Implementing Questions to Consider: What is being done to prevent such information from being the Program lost? If information related to a family member or resident request or related to clinical practice change were given to Implementing the program will require a facility-wide care someone on the staff and you tracked what happened to it assessment to be clear about your starting point and create for three days, what would you expect to find? a reference point for later comparison. A facility-wide assessment will yield crucial information about how your facility works and what structures and processes might need to be altered to reduce frustration during the program implementation, maximizing your chances of success.
1-800-MEDLINE (633-5463) | medline.com 9 Get Everyone On Board. Leadership Building Trust Between Administrators have sometimes had a difficult time figuring Leadership and CNAs out how to support program implementation efforts. Many administrators have seen their role as primarily providing During times of change, CNA trust is an essential ingredient the resources for frontline staff to improve their skills and for retention and for engaging them as partners in change alter some of the direct-care processes. efforts. Trust makes a difference. CNAs who feel as though leadership is credible, fair and respectful of them will Providing resources and verbally expressing support for often spend more energy working with management in the continence management program is important, but that a positive manner. alone is not sufficient for sustainability. » Demonstrate credibility »Show respect The administrator and other management staff must be »Be fair directly involved with the continence management program implementation if it is to succeed. Empower CNAs. “Empowering CNAs” can be a rather ambiguous phrase in Who Should be Involved? long-term care. Many leaders are unsure what constitutes Membership of the leadership team should include, empowering their CNAs. One way to empower them is to at a minimum: educate them on continence management through the » Facility administrator Medline Continence Management Program. » Director of nursing Assign the courses and allow CNAs to use the tools that » Department heads are a part of the program. The more they learn, the » Frontline care workers (CNAs, activity aides, etc.) more empowered they will feel. When implementing the » Mid-level managers and supervisors program, it is important that the CNAs: »Unit nurses » Understand changes and the reasoning behind them » Have numerous opportunities to increase their knowledge The makeup of the leadership team is purposeful and important. The team should include employees with » Understand how to actively implement what they learn authority to access and distribute resources and who have knowledge about the organization, direct care practices, Provide Support. and the work environment. Leaders can sometimes become distanced from actual change implementation. This distancing can be detrimental Mission: to the success of the program and can deeply impact The leadership team will: employee perception of support. » Set the strategic direction for the » Listen—create clear mechanisms for soliciting implementation of the program ideas, input and requests for resources, then consider all requests and input » Be a strong resource for staff » Provide resources » Define a uniform stance on how they – Staff training or education in primary areas of concern envision the Continence Management – Technology and products to help the Program taking shape at the facility CNAs do their jobs efficiently » Assure clear communication of the program implementation vision, tasks and progress to all staff in the facility » Listen to staff comments and concerns, taking time to consider all feedback and respond » Perform routine assessments and gather necessary data related to continence management » Set organization-wide benchmarks for meeting change goals
10 MEDLINE Make Communication a Priority. Hold Regular Meetings. Clear, constant communication at all levels will help with the Many underestimate the importance of regular meetings. implementation. Consider having a team examine current Leadership team members are seen as the primary staff
information flow in the facility and pull together a new resource for all change information, as well as role models. EVERYONE ON BOARD GET communication plan that encompasses communication at Having consistent, frequent meetings will ensure that the multiple levels. Look at an accurate organizational chart for leadership team has current information at their fingertips your facility and consider all the places information flows and energy is sustained. Frequent meetings will help keep within and outside of the organizational chart: the ball rolling. You will want to set up meetings well in » All units and staff advance to avoid scheduling conflicts. Decide early in the process how you will support attendance via backup staff » Residents or possibly a reward system. » Families If one person is absent, consider passing on careful notes. Encourage Input and Feedback. If multiple people are absent, decide how to update other Ever say to yourself “I wish CNAs would bring up continence members of the leadership team about change activities management issues and discuss solutions more often”? in each department over the recent time period and any Getting CNAs to give constructive feedback or raise pressing issues that need to be dealt with immediately. issues can be challenging. It may take trial and error to have workable systems in place. There are a few ways to The following are some areas that deserve scrutiny: approach this, and you may develop ideas of your own. 1. Is culture-change participation included Some suggestions: in annual performance evaluations? » Provide a clear venue for all CNAs to share 2. Is the staff committed to carrying out their positive and negative feedback the program implementation plan? » Consider systems that can safely solicit concerns 3. Has turnover affected outcomes of previous program implementations? A facility leadership team could address several common 4. Are staff nurses able to participate in the program? barriers or challenges to implementing the continence 5. Do department heads and charge nurses management program: integrate continence care plans into their » Insufficient awareness across the decision-making about their areas? facility about the program 6. Are staff throughout the organization supported » Uncertainty about their roles in the operation to attend continence care team meetings and and implementation of new practices other meetings related to culture change? » Inconsistent implementation across 7. Is necessary information shared easily? units and departments 8. Are problems addressed quickly? » Difficulty in creating and sustaining change 9. Do staff feel appreciated? 10. Does each level of the organization have a clear view » Lack of accountability of what the level just above and just below is doing? » Challenges related to team implementation ideas 11. Is staff development clearly related to » Communication and information flow that is inconsistent the work and what the staff need? with the needs of CNAs, families and residents Conduct Effective Meetings. The leadership team will have a lead role in preparing Many common program implementation challenges are an assessment of the facility and identifying things surrounded by meetings. Some examples include: to be done to ready the organization for the changes being implemented. » Invited team members did not respond or attend » Team members attended meetings but didn’t participate much in the meeting discussions » Team members attended and participated in meetings, but follow-through on meeting decisions or work plans varied significantly
These challenges can lead to team ineffectiveness.
1-800-MEDLINE (633-5463) | medline.com 11 Assess Team Member Skills. This would include an inability to describe trends, over time, It is important that management and teams make the on their unit in functional ability, continence, weight gain effort to assess the capacity of their team and team or participation in activities. It is important to appreciate members, and that they quickly identify which skills are the distinction between understanding an individual missing, and which are present but may need further resident and understanding the resident population on development. It is important that this assessment be a unit. What happens to an individual resident can always done early and repeatedly. This assessment can be used be explained by particular circumstances, idiosyncrasies to inform the selection of new team members and to of the resident, or staffing problems that occur during a determine where team development needs to be done. particular time. When confronted with data indicating a This clearly has implications for staff development activities poor outcome for a particular resident, staff often see this at the individual and alliance levels. Given the level of staff situation as “unusual.” They will often say that the situation turnover in most long-term care settings, it is important to has been corrected or that it is so unusual as not to merit have some idea what skills your frontline staff possesses. any corrective action. Not seeing the proverbial forest leads That is, it would be unwise for only one team member to to inaction, while allowing the staff to maintain the belief be skilled in any particular area. Many of these skills can be that nothing needs to be done. For this reason, it is vital to developed over time: provide staff with data about how their local environment » Knowledge about accessing, interpreting (unit/shift/department) is doing and how the residents and using multiple types of data receiving care in that local area are faring. It is quite difficult to dismiss data that shows trends over time, that defies » Familiarity with the work routines of multiple groups, departments, units and shifts what may appear to be the case—and that cannot be explained away by unusual circumstances or residents. » An understanding of information flow, lines of authority and decision-making processes in the organization Questions to Consider: » An understanding of the quality-improvement Can staff on a selected unit tell you what trends have systems in the organization been over the last month? Last year? What about trends in » Familiarity with staff-development continence management for low-risk residents? What about and orientation programs high-risk residents? What about other care outcomes? Can » An understanding of employee they tell you how they compare to other units? performance-evaluation processes » Familiarity with the usual problem-solving Develop Unit Nurses’ Supervisory Skills. mechanisms used throughout the organization Over the years, we have learned that the supervisory skills of » An ability to assess organizational aspects of, or unit nurses can effect the work-life quality for CNAs. Despite contributions to, events or incidents that occur learning this, there has been little attention paid to this. » The ability to develop a detailed plan with a timeline » The ability to collaborate While some nursing homes have attended to the development » The ability to participate in and run of supervisory skills in their RNs, most facilities have neither effective, efficient meetings assessed nor promoted this area of skill development. This may be one reason for frontline staff turnover. » The ability to hear, appreciate and consider multiple perspectives Questions to Consider: » The ability to generate multiple approaches What training have nurses in your facility had on to each problem identified, anticipate the likely outcomes of each approach and make supervision, delegation, collaboration and leadership? decisions based on such an assessment How important do nurses think these skills are in the work-life quality of CNAs? Do nurses in your facility enjoy » The ability to identify resources needed supervising? Are they comfortable with it? Are they » The ability to identify learning needs of evaluated, in part, on their effectiveness as supervisors? self and other committee members Do they have mentors to help them develop these skills? » The ability to work with others to develop the above skills in new team members
Share Outcomes Data with Your Staff. Staff are quite good at describing what has happened to a particular resident in a particular care area. However, most staff would not be able to say how their unit is doing overall or over time in any of several care areas.
12 MEDLINE Link Staff Development to Actual Work. or follow-through, the solution to this is often focused on Frontline staff have identified their lack of preparation in fixing a particular problem for a particular resident. This several areas as a source of frustration and work stress. results in very little transfer of learning to new situations.
While in-service programs are often interesting and EVERYONE ON BOARD GET sometimes helpful, frontline staff often find little or no The specific (and common) problems in long-term care link between what they are learning and what they need settings that change has had a positive effect on include: to know to do their work. Sometimes this is as simple as » Frontline workers’ beliefs that they are not making the link more explicit. Many times, it also involves respected by the managers of the organization assisting the frontline worker to develop new care » CNAs’ beliefs that they are not approaches that would allow them to integrate the new respected by the unit nurses learning. Changing approaches to care would, necessarily, » Nurses’ and department heads’ lack of interest or lack involve others who also care for the same resident. Only of skill in supervising and mentoring frontline workers with collaborative decision-making, and a change in the way » CNAs’ inability to participate in work schedules, work the group approaches care, can new skills and knowledge design, care planning and evaluation for residents be put to use. CNAs have identified the inability to use new » Lack of advancement opportunity for staff at many levels skills and knowledge as a negative aspect of their work. » Inability of staff to use what they Questions to Consider: learn in educational programs What happens on each unit or each department when a Provide Educational Materials for frontline worker, or other worker, returns from an in-service Addressing Clinical Knowledge. program? What, if anything, is done beyond information There are tools available as part of this program that may sharing? Are the implications for care delivery routinely be useful for addressing clinical areas of: discussed? What is done to promote the integration of new learnings into care? How successful has this been? »Sizing »Skin problems Follow Up—Suggested Questions for Specific »Leakage Care Problem: High Levels of Incontinence. »Laundry If incontinence levels are high, what do staff say about the »Falls incidence of incontinence on their unit? » Incontinence » Do staff think that anything should be changed to address the issue? » Is there any leadership addressing the issue? » Is there a unit plan in place to assess and address the plan, or is it just focused on individual residents? » Do staff have adequate knowledge about what the plan is and why it was developed? » Can staff tell you how well they have been following the plan? » If there are barriers to implementation, have they been addressed effectively? » If the plan was abandoned, what were the precipitating events and how do staff feel about it? » Do staff have suggestions for what might be tried next? » Have staff assessed the situation or have they just seized the first idea to come along? » Should the in-service educator or other staff be involved in resolving the problem? » Do current documentation systems need to be developed? » Does the unit nurse know of follow-through on the plans: Worker-to-worker? Shift-to-shift? Across departments?
One of the common challenges you can anticipate facing is that staff generally focus on solving clinical problems for individual residents. When there is inadequate assessment
1-800-MEDLINE (633-5463) | medline.com 13 Assemble a Continence Management Team. If you have eight units and would like a manager and CNAs Continence Care from each to participate, you can justify a larger group. Team Development Integrate Members from Across the Organization Success Is in the Mix. and Ensure Management Participation. It is essential to engage in understanding continence It is valuable to include perspectives from across the management issues faced by staff and to help them solve organization, across shifts and at multiple levels. A common problems during the program implementation. When pitfall when creating teams is to put only managers implementation activities hit a stumbling block, it’s useful on teams that deal with management decisions. This to assemble a team of involved individuals, guide them effectively isolates managers from important conversations through the issues and help them to problem-solve. with staff as they consider alternatives, discuss how the Remember to use each stumbling block as a learning change will affect their work, and design their approach. opportunity and evaluate the solution. Having managers on teams at all levels also increases the access that teams have to information that is relevant Changes in continence care practice will generally affect to their work. At the same time, it may become clear to the work routines of many caregivers. A common mistake managers and staff on the team what new information they when implementing change is overlooking the effects of will need to continue their work and to develop ways to these changes on the people that are directly involved. gain ongoing access to that information. Remember that your caregivers are often affected by change in many ways. Make Management Recommendations to the Team: Mission, Goals, Timelines. It is always best to include all affected units and caregivers While a team’s mission will largely be dictated by as the changes are implemented. Creating teams to help management’s charge, there might be room for the team to plan out and implement change and communicate those help further shape the mission. Team input can be valuable plans and changes to their co-workers is an effective way and essential to the team’s commitment to success. to improve the chances of success. Goals may also be partially shaped by management, but this can be a collaborative process. Management may have a Forming Continence Care Teams few concrete goals that must be accomplished as part of a facility-wide project. However, the team will certainly want Care should be put into deciding how teams will be formed to understand why those goals are important and may have and into creating the right environment for teams to more goals to add to the list. practice in. You may find that several of your frontline caregivers are personally excited about the change, are It is generally recommended that the team create most respected by their peers, have expertise in a continence of its own deadlines and timelines, though there may be management, or are interested in developing their skills and certain timelines for projects that have little room for expanding their roles within the organization. Encouraging negotiation. It is important for management to be clear these people to join the team may be just the opportunity up front why those are firm dates and carefully consider they need. how much flexibility they are able to give the group. Management can collaborate with the team to ensure How Big Should Each Team Be? enough time is allotted for activities and that timelines 6 to 10 members is an ideal number of team participants. are reasonable. With too few, members will feel overwhelmed and tasks will take longer. With too many, it becomes more difficult to reach consensus and run effective meetings. You will want to consider the number of units your facility has and the number of caregivers on each unit that you would like to involve in your teams.
14 MEDLINE Mission: The purpose of the continence care team is to work collaboratively to: » Identify problems in a particular area of resident care
» Determine the source(s) of these problems A TEAM ASSEMBLE » Select problems to address » Define the problems clearly Tips for Success! » Identify the people who need to be involved A common pitfall for newly formed » Develop a plan to address the problem teams is being overly ambitious » Mobilize the resources needed to carry out the plans or not allowing sufficient time » Anticipate and address any organizational to achieve goals. If the team challenges to implementing the plans suggests a timeline that seems » Evaluate whether and how well the too ambitious or too slow, plans ultimately worked it’s important to refrain from judgment until you understand the Who Is Involved? team’s rationale. Then you may Because most clinical problems experienced in long-term suggest they give themselves a bit care involve multiple worker types, multiple levels of of flexibility. A conversation with the organization, multiple departments and cross shifts, the team can sometimes lead to teams must model and direct the practice changes in the both sides negotiating the most organization that will allow each organization to enhance reasonable outcome. Working clinical outcomes and improve the work environment. backward from goals, through As such, an effective continence care team will include all the changes that need to be representatives from all the worker groups that will made, the time for education and be involved in implementing practice changes. This will communication, meetings with necessarily include: frontline workers, department heads different staff that will have input, and professional staff from nursing, dietary, the therapies, and the need to develop new maintenance, human resources, purchasing, housekeeping, ways of working will yield a more activities staff and management/administration. reasonable timeline.
What Time Commitment Is Required? The continence care team should allow ample time for communication via meetings, yet also have time to progress with projects. Many have found that a biweekly meeting structure can accomplish these two goals. Meeting less frequently often dilutes the impact of the team and puts them in a position to catch up or put out fires, rather than be proactive.
You will want to set clear expectations for participation because floor staff might find it difficult to get away from their work. Try scheduling meetings when team members are not expected to be on the floor and work to minimize interruptions. Given that many continence care team members do not have an administrative component to their jobs, administration may need to clarify the necessary time commitment with the team members and their colleagues, and provide support to colleagues who might be short- staffed. Additionally, the team member participating in the continence care team might feel guilt or fear of not being on the floor. Verbal support to that person from administration and other continence care team members and, the support their colleagues remaining on the floor cannot be overlooked.
1-800-MEDLINE (633-5463) | medline.com 15 Determine Necessary Team Member Skills. Create the Right Environment. Regardless of how teams are formed, it’s important to reflect Define and model norms and acceptable behavior. on skills present in the team. If management is selecting team Teams also might need assistance from management in members, these skills can be sought when scanning the field. outlining acceptable behaviors and norms for the team. For If the team is volunteer—or election-based, the team can still example, discussing how conflicts will be handled within the assess itself and discover areas of weakness. team before they arise and creating a system to ensure all voices are heard will increase the effectiveness of the team. Establish Participation Policies. It may be useful for management to create formal team Ensure a friendly environment for teams. policies that would apply to all teams in the facility. Uniform It is not enough for managers to verbalize support for policies can lead to less uncertainty and more time spent on teams. It is likely that team members will also need support productive work, rather than figuring out what to do when finding time for meetings and project work. This support something troublesome occurs within the team. It can also is generally more forthcoming from coworkers when they minimize potential pitfalls, such as lack of communication understand what the team is doing, see the staff member throughout the organization and tension among members. as their representative on the team, and appreciate the The issues policies might address are: importance of the outcome the team is working toward. Understanding the goal and the work involved will also help Attendance—Is this a requirement? alleviate feelings by coworkers that team members are getting out of work by joining the team. There is little that is Rewards or Incentives—Are there rewards or incentives? more important to team members than the support of their How will those be implemented? peers. Even if coworkers understand and appreciate the team and its work, there are times when the staff member’s Tracking Progress—Are progress reports expected? When, absence from their usual work may create a hardship for to whom, and in what form? coworkers. Finding a way to help “pick up the slack” will be appreciated by everyone and is a clear message about the Communication Expectations—Will the team have a importance of the team. mechanism to communicate to everyone at the facility, including families of residents? What is the expectation of how often this will occur and in what form?
Length of Service—A one-year commitment is ideal. Will members be asked to continue longer if they wish or will there automatically be replacement at one year, or other determined date?
Decisions—Consensus is a good method to make decisions when time dictates moving forward with plans, however; there can be “buy-in” benefits from making sure everyone agrees with a decision.
Loss of Team Members—What will happen when a team member resigns or quits the facility? How will a replacement be chosen?
16 MEDLINE Empower Your Team. Become communicators in the organization. Just like individual employees, teams work best when they Teams are key to disseminating information about are empowered to do their work. Some things to keep in continence care program activities and plans, and progress mind to support your teams: across the facility. Therefore, it is important to tailor their » Grant the team some decision-making communication to various audiences. For example, the ASSEMBLE A TEAM ASSEMBLE authority—start small, see how they do amount of information and language used can be quite » Act as a coach to the team, not as a manager different when speaking to families versus CNAs or activity assistants versus administrators. » Be sure to allocate resources and help team members find the time they need to attend meetings; use the tools provided and take the online education Choose a good leader and create clear roles for team members. » Support and coach the team to become Voting on a leader and deciding who will be responsible more effective, rather than instructing for tasks, such as taking meeting minutes and reserving them or telling them how to proceed meeting space, are important. Assuming someone will Plan for Team Success. become the natural leader, and that the team will be When setting up a team, there are several factors to happy with that outcome, doesn’t always work. Having a consider that will increase the likelihood of team success: leader appointed before the first team meeting sometimes helps prevent tension among team members and might » The right people to do the job are involved; result in the best person taking the leadership role. Team consider skills necessary and additional training, such as “how to run meetings” leadership also can be done on a rotating basis. This can help spread the workload and help staff develop on the » The mission and tasks are clearly job. For staff who might be initially uncomfortable in a understood by the group leadership role, this can be a valuable opportunity for them » The team must combine their abilities to complete tasks to see behaviors modeled and give them time to boost their » The organization, including peers, must confidence as a participating group member. It is important be supportive of the team’s work to avoid the pitfall of having the lowest paid or ranked employee take meeting minutes each time. Sharing this task Embrace Change. is as important as sharing the leadership. Using a template, This doesn’t mean everything must change, but it means the this tedious task can easily be rotated each meeting. team members will need to have open minds about changes that may occur and challenge themselves to think about the positive aspects of change.
1-800-MEDLINE (633-5463) | medline.com 17 Develop Team Mission and Functions. Which Teams Are of Primary Importance? While each team will have a different mission, there are Two types of teams can impact the likelihood of successful elements that will be important for every team to consider implementation of change in organization: as part of its charge. 1. Leadership Team » Teams will agree to evaluate their successes and A team to shape the direction of the project or change failures and have clear parameters to do so within the facility, be a primary information source and » Teams will solicit input outside of establish a firm link to administration. the team when appropriate 2. Continence Care Team » Teams will reflect effective communication A team connected to frontline care, linking initiatives There are several ingredients that will need to be generally directly to resident care. defined by leaders in the organization and will then be further refined by each team. Leaders should be ready Although there is not a cookie-cutter approach to what to have a core set of expectations in each of these areas these teams should look like in each facility, there are a few and work with teams to connect team mission, goals and important ingredients and processes you’ll wish to consider. objectives to each:
Values Continence Care Team: What are the core organizational values related to Linking Change to the Frontline residents, families, staff and community? How does management expect each team to connect to these values? The prominent industry trends of person-centered care and culture change is primarily about increasing: Mission » Care quality and consistency What is the mission of the organization? What does it » The degree of collaboration across departments broadly hope to achieve? How will each team reflect the » The participation of workers across mission and form a connection to the larger mission of levels of the organization the organization? » Organizational development to promote greater collaboration and follow-through Vision What are the overall goals of the organization? How do they As a consequence, workers at all levels become much more relate to the values of the organization and of the team? adept organizational workers. This extensive involvement How is each team expected to contribute to the goals? of workers at all levels of the organization addresses one of the most significant causes of frontline worker turnover: Philosophy the inability to participate in planning of resident care. The philosophy is the organization’s connection of values, mission and vision. Teams may wish to develop their own Collaboration is required for a successful continence philosophy in line with the organizations, yet related management program implementation across directly to their charge. organizational levels and creating a decision-making structure that engages frontline workers, mid-level Goals managers and upper management. Collaboration is what What the organization wishes to achieve should result in leads to a sense of worker empowerment. As collaborative an extensive list of specific goals. The goals of teams should decision-making proceeds, it becomes apparent that each very carefully relate to the goals of the organization. worker has a vital part to play in both identifying the problems and devising solutions to those problems. This will Objectives clearly help link change activities to frontline work. The organization may not have specific objectives related to the team goals, as those may all rest within teams. If the use of teams is minimal, more work on objectives may need to come from the top. Teams will need guidance on creation of objectives; however, the team will need relative autonomy in shaping those objectives, which should be carefully crafted.
18 MEDLINE Link the Continence Care Team Evaluate Team Progress. to the Leadership Team. Think about what happens when a staff person goes to a It is important to integrate change structures and processes training seminar. The person gathers new ideas, get excited with the rest of the organization. This achieves two things. and returns to work, eager to share those ideas. A few First, it keeps managers informed about and connected to hours into the day and those plans have been forgotten or the changes that are taking place, preventing managers dismissed by the person. The folder of information often A TEAM ASSEMBLE from unknowingly undermining what continence care team goes on the bookshelf and, as the days get busier, nothing is members are attempting to do. It is important to move put into action. What would help change that? forward together, not at odds. In some culture-change initiatives, managers were making decisions that were Any number of factors can influence the likelihood of counter to what a continence care team had decided to moving from an idea to an outcome. Things that can assist move forward with. This can result in frustration of the teams and individuals moving forward include: continence care team members and create needless tension »Removing barriers between managers and staff. This is most likely to occur » Creating precise objectives when managers make decisions in the complete absence of » Measuring outcomes knowledge about what the continence care teams are doing and how the managers’ decisions might affect the team’s » Providing direct, tangible, visible support for the change plans. This can be avoided when the managers are familiar with the continence care team’s plans and the logic and Involve CNAs in Care Planning. thinking behind the plans. Probably the most consistent research finding is that CNAs feel left out of care planning for the residents they care for. NOTE: Managers involved in culture change often express As with other issues already discussed, CNAs and other concern that any involvement on their part might staff seem to have different views about what it means disempower continence care team members. To the to participate in care planning. Nurses often point to the contrary, evidence supports the importance of ongoing important information that is brought to them by CNAs and involvement of managers. It is important to remember that how that information is important for care planning. This is empowerment cannot occur when frontline staff are simply viewed as participation in care planning. left alone to make decisions and carry out plans. This is a mistaken perception that can seriously undermine any CNAs on the other hand do not see this as adequate. change initiative. Empowerment requires information and Providing information for someone else to make a decision resources. This will only happen when managers who are is not the same as being involved in the decision. This is knowledgeable about the organization and the systems and an important distinction that, unfortunately, is often not processes within the organization are involved. appreciated by unit nurses and other managers.
Involve Your CNAs. Your CNAs play a pivotal role in the success of the change. Customers who have directly involved their CNAs when implementing a continence management program have been more successful in sustaining their program. Conversely, for customers whose CNAs were not informed, implementation of the program was very weak and unsustainable. In addition to being well informed about what each of the teams is attempting to achieve, some CNAs can become coaches and mentors for new CNAs. This will increase the level of staff excitement and support for improving practice and a much greater likelihood for success.
Department heads of dietary, housekeeping, activities and therapies have a similar impact on continence management. Department heads making an effort to understand how their staff can be involved and actively supporting these efforts, while assisting them to integrate the implementation activities into their daily work routines, will dramatically increase the effectiveness of implementation.
1-800-MEDLINE (633-5463) | medline.com 19 Remove Barriers. Set Up Teams for Success. As has been discussed in this section and the section on » The right people to do the job are involved; leadership, it is important for leaders to do more than just consider skills necessary and additional verbalize commitment. Removing barriers to participation training, such as how to run meetings in change initiatives and assisting teams in removing » The mission and tasks are appropriate to the group barriers to implementation are vital. » The team must combine its abilities to complete tasks Create Precise Objectives. » The organization, including peers, must be supportive of the team’s work Team objectives should be carefully stated in writing. When a team is clear on a specific task they must accomplish, the » The team will have a sponsor at the administration level to act as an advisor and advocate likelihood of planning and implementation will increase. The team should develop its own goals, with management Support Teamwork Across the Organization. acting in a consultant role. While team goals might be broad, objectives should be something that can be easily measured. » Encourage employee participation » Integrate members from across the organization Measure Outcomes. and ensure management participation If team objectives have been carefully identified and » Define and model norms and acceptable behavior progress has been clearly tracked, it can be a relatively easy » Believe people are assets and should be developed task to measure outcomes. The leadership team should » Ensure a friendly environment for teams develop clear and consistent criteria for how team success » Utilize templates and tools that have been will be measured and might include: provided as part of this program » Has the team created goals relevant to change initiatives? » Has the team created goals relevant Empower Your Team. to resident quality of life? » Grant the team decision-making authority » Has the team met consistently? » Act as a coach to the team, not as a manager » Has the team communicated its mission, goals and objectives to all facility staff, residents and family? » Has the team communicated plans and progress to all facility staff, residents and family as appropriate? » Has the team developed specific, measurable objectives? » Has the team completed any of its objectives? » Is the team making satisfactory progress in completing its objectives and identifying new objectives? » Has the team’s mission been completed, or is it addressing an ongoing need? » Are there reasons to revisit the team’s mission, goals, objectives, composition or work plans?
20 MEDLINE Designate a Continence Care Champion. DESIGNATE A CHAMPION Decide how to measure success of the program. You Can Lead the The champion should look at what information your facility Charge for Change already collects and decide whether it will help determine if the program has been successful. Be careful to find There are several important things the champion can do measures that actually reflect the changes. If you predict during times of change that may help implement continence that implementing a continence management program will care changes in a way that anticipates needs and shows result in a particular outcome, be sure to measure before concern for all employee positions. Some examples of what and after the change—it’s always a disappointment to the continence care champion should do include: discover, after the change, that there is no way to measure whether it has been successful. Help everyone understand why the continence management program is being implemented. Look at whether the daily activities are consistent For every action considered, one must understand why with the changes you have implemented. that particular action is indicated and clearly communicate If you are trying to make staff more involved in problem these reasons to all CNAs. The reasons may seem solving, be sure that the mechanisms you use to solve obvious to the champion but may not be so obvious to problems are inclusive. You are the role model. Your staff others. The champion should share their thinking with will be watching your behavior. When you see staff in the people around them and the people affected by your organization engaging in behavior that is inconsistent the change. The champion will want to strike a balance with the direction of change, it is important to address between overwhelming people with information that that behavior. might not pertain to them and making sure everything is communicated to the right people. Respond to challenges that occur by helping staff clarify the problem. Actively participate in the program. People often jump to a solution without really While having a good idea about what the facility is trying to understanding the problem. This undermines effective achieve, the champion must understand what implementing problem solving and often leads to a deadlock among staff is actually like for the staff. A good way a champion can with differing opinions. Asking questions about the nature do this is to participate actively, visibly, over time and in of a problem and tracing the problem back to its source will different ways with different staff. lead to a comprehensive understanding of the problem.
Act on staff suggestions. Telling the CNAs that suggestions from them are welcomed is not sufficient. Showing them that they are being heard by trying out their suggestions is much more effective.
Anticipate and address staff responses. New ways of doing things often make people anxious. Know this and address it up front—allow the staff to express their concerns, and encourage them to give it a try. This will help staff remain calm. It is also important to not be dismissive of staff concerns.
1-800-MEDLINE (633-5463) | medline.com 21 Select a Continence Care Team Captain. The Team Captain Facilities should consider designating a Team Captain to oversee the continence management program implementation and activities that go along with the program. This person is at the hub of the action, staying connected on a daily basis to every aspect of continence care by linking all teams in the facility. The Team Captain assists with creating and sustaining teams, working with members of teams to identify and prepare for carrying out pre- and post-module implementation plans, and assisting teams to work effectively with each unit. The Captain also will work with department and management representatives to develop support and accountability systems for implementation purposes. This position requires an individual who is organized. Some of the activities the Team Captain may be engaged in include: » Identifying the skills and knowledge that teams and individual team members need to be successful » Arranging for opportunities to gain any missing skills and knowledge » Promoting a supportive environment for team activities » Preparing staff with clear information from the leadership team » Serving as a liaison between the leadership team and other teams » Managing the logistics of staffing teams
The most successful Team Captains will possess sophisticated organizational knowledge, interact effectively with staff at all levels of the organization including leadership and garner respect from staff. Successful Captains also remain vigilant for ways to support implementation of plans, carefully anticipate how implementation plans will impact all levels of staff in the facility, and be able to assist staff in their implementation efforts rather than doing it for them.
22 MEDLINE Problem Solving Tip! The Five Whys is a common way to practice problem
solving. By asking yourself “Why?” at least five times, CAPTAIN A TEAM SELECT you are more likely to get to the root of the problem.
Example: 1. “He was looking for an XL Brief for his resident Tips for Success! that normally wears a medium. Why?” If you designate a current 2. “He thought it was important to employee to be the Team Captain, have a bigger brief. Why?” consider how they will manage 3. “ We don’t stock a lot of medium briefs. Why?” other duties. You will want to 4. “They are always grabbing the wrong brief. Why?” assure this person has time to do 5. “ We don’t have a clear system in place for storing an adequate job of coordinating the resident’s incontinence products. Why?” activities across the facility. While some facilities have joined At this point, solving the problem involves considering together to hire a new position several possibilities that might lead to a satisfactory to undertake these duties, it resolution. For example: may not be necessary or feasible » There needs to be a program in place to ensure residents in every facility. Consider your receive the appropriate incontinence products staff resources and how you can » There aren’t central places on each unit for storage reallocate work to allow for the » CNAs aren’t aware of what is available for their residents asset of a coordinator. » CNAs do not know how to choose the appropriate product
One common mistake that champions make is to solve the problem by themselves instead of determining a solution with input from the staff. Identifying the key players and including them in the discussions about both the nature of the problem and the possible solutions will increase the commitment of staff to implementing the change identified.
Some important questions to ask are: » Who needs to be involved in determining the problem? » Who needs to be involved in determining the solution? » How does the issue, or the proposed change, affect each unit? » Who can help? » Who needs to know about the change?
One useful strategy might be to make a master list of each unit and the CNAs in those units. Go through the list and think about how each would be affected by the proposed change(s). Be sure to include people from each of those areas as you consider the effects of change.
1-800-MEDLINE (633-5463) | medline.com 23 Educate the Nursing Staff at All Levels.
A Solid Foundation for Change
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The relationship between acquisition (acquiring new A Solid knowledge) and knowledge implementation (or practice change) is complex. Many things can prevent people from Foundation using knowledge they have, even when they want to use it and intend to use it. Fortunately, we know quite a bit about for Change the things that promote (or block) knowledge use. Effective Staff Development All culture-change initiatives rely on change occurring at Experts in staff development and adult learning generally multiple levels of the organization to be successful. This break down learning into three areas. These are: requires staff to learn new things and to go about their » Characteristics of the learner work in new ways. As we all know, changing the way we » Characteristics of the education work is not easy. The most common strategy to achieve » Characteristics of the work environment this involves training, education or staff development. Unfortunately, the degree of change that results from staff Learner Characteristics education or training programs is often disappointing. Learner characteristics include: demographic Despite well-planned and skillfully delivered training characteristics such as age or gender, motivation, and programs, real practice change has been difficult to achieve intelligence or ability. For many years, it was believed that and even more difficult to sustain. This can be quite these were the most important determinants of how well frustrating and can also cause conflicts and bad feelings people learned. We know now that, while these have some among staff. When staff attend training programs and then influence on learning, they are not the most important. seem to ignore what they have learned, continuing to work Although there may be differences in how people learn, as they had in the past, we often interpret this as not caring demographic characteristics do not affect someone’s ability or as deliberately undermining the effort. Typical responses to learn. It is well established, for example, that adults learn to this lack of change or lack of sustained change include: differently from (but not generally less than) children and reminding people of the change they agreed to implement, that older adults learn somewhat differently than younger becoming angry that they are not cooperative, and finding adults, although they are still highly capable of learning ways to keep reeducating staff about the same things. new things. The important thing is to match the way people What’s wrong with this? Research on continuing education learn best with the learning environment. and practice change in long-term care suggests that much of the current effort is destined to fail, that current staff development efforts are not consistent with what we know about how adults learn and how work practices change.
24 MEDLINE Personal motivation has also been seen as a very important Leadership can help immensely in this situation. Together personal characteristic that influences whether or how well leadership and the learner can determine how the someone learns. When someone attends a training program knowledge might be adapted to each situation until the and doesn’t seem to have learned much or isn’t using what learner is comfortable doing this on his or her own. they learned, we often believe they are simply not very Effective staff development requires careful planning, EDUCATE THE STAFF motivated. If only they were more motivated, they would attention to the needs of the learner and a high level of have learned what they needed and put it into practice. integration between the training and everyday practice. Many people who are highly motivated, who really want to Learning that takes place in isolation from the daily work, make improvements in their work, do not actually change or that is not supported by organizational policy, access to much of their practice. This is frustrating for everyone. There information and acceptance from peers and supervisors, is are some important things to know about motivation. We destined to fade away. generally think of motivation as something within a person. She or he is motivated or not. We know from research that CNA Turnover motivation is more influenced by the environment than it CNA turnover in long-term care is a big challenge that is by a personal characteristic of the learner. This means many facilities face today as it has the single greatest that someone who seems unmotivated will become quite negative impact on resident care and the overall bottom motivated under the right circumstances. One of the most line. The turnover rate for CNAs in the U.S. is 51% in the important influences on personal motivation for learning is first 6 months of employment.4 Annual turnover for CNAs the attitude of the learner’s direct supervisor. approaches 100% from first day of employment. High staff turnover has been associated with higher Leadership’s interest in the learner, explicit recognition levels of federal deficiencies and increased complaints of the efforts made by the learner, and encouragement filed against facilities—all of which translate into negative to learn new things and bring them back to the unit all quality of life for residents.5 High turnover also affects have quite an impact on the motivation of the learner to the employees who remain with a facility. As less staff is attend educational sessions and to use what is learned. available, those who stay are often moved from one unit to Recognition, encouragement and support from peers and another to provide necessary coverage. subordinates also affect motivation to learn. Workers who feel they will be chided or ridiculed or simply not Many CNAs want to establish relationships with the appreciated for what they have learned, and what they residents they care for. When CNAs are moved from unit can bring back to the work setting, are unlikely to feel very to unit, establishing and maintaining any relationships with motivated about attending an educational session. residents is difficult, if not impossible. These issues are all related to the work setting, not the learner or even the educational program. It seems that Reasons for Turnover personal confidence is one characteristic that can influence There are a number of reasons for the turnover of CNAs. learning. Sometimes this is a long-standing personal Some of these reasons include: trait and does not respond significantly to the work » Lack of opportunity for career advancement environment. However, it has been shown that personal » Lack of respect and support from confidence can be maintained, increased or undermined by administrators and direct supervisors the work environment, particularly by the direct supervisor. » Lack of permanent and predictable assignments Therefore, finding ways to bolster a learner’s confidence about learning the new material and being able to share it » Lack of autonomy or involvement in decision-making and use it upon return will increase motivation to learn. » Unreasonable workloads » Inadequate or poor training Obviously, leadership and others in the work environment »Low pay are important determinants in whether the staff learn, » Limited benefits how well they learn, and whether they are able to make the desired practice improvements.
1-800-MEDLINE (633-5463) | medline.com 25 Management Must Believe in the Idea and What Is Mentoring? Demonstrate Support for a Mentoring Program. A mentor is defined in the dictionary as “a wise, trusted Training programs for administrative or management staff advisor… a teacher or coach.” A mentor is someone who and supervisors will ensure that there is a smooth transition helps someone else learn something the learner would for the newly trained mentors and reflect the commitment otherwise have learned less well, more slowly or not at that the facility has to CNA development. all. Historically, mentoring has been seen as an oftentimes older, more experienced and wiser person guiding a Selecting Mentor Candidates younger and untested person through a life passage. It The selection process will allow those with an interest in is often a long-term relationship in which the protégé is mentoring to step forward. guided, counseled and assisted in mastering the skills and gathering the knowledge necessary to assure success in Six important characteristics of a mentor: a particular endeavor. A healthy and successful mentor/ » A willingness to share knowledge protégé relationship will move from one of relative protégé »Honesty dependence at the beginning of the relationship, to one » Competency of autonomy and self-reliance as the protégé grows into a » A willingness to allow growth colleague and peer. » A willingness to give positive and critical feedback From the mentor’s perspective, being identified as a mentor » Directness in dealings with a mentee often provides a sense of accomplishment and value. Staff who are chosen or choose to mentor are often respected Facility Leadership Must Provide Opportunities for their skills and leadership abilities and have a sense of for CNA Mentors to Meet Regularly commitment to the career that they have chosen, as well and Encourage Sharing of Experiences as to the facility where they are employed. Though the During the Mentoring Process. mentee or protégé is seen as the main beneficiary of the Creating and supporting a mentor support group will relationship, the mentor can gain satisfaction knowing ensure that mentors will have a safe environment to that he or she has contributed to and influenced the next verbalize concerns about their positions, as well as to generation of workers. Mentors often report a deep sense receive advice and emotional support from their colleagues. of fulfillment and accomplishment as a protégé succeeds.
The protégé or mentee can look upon this relationship as one that can be beneficial in the long-term and short-term, as skills are honed and helping relationships are established. The protégé can be assisted and supported to understand the informal systems of an organization and receive guidance in how to be successful in the organization.
Benefits of Successful Mentoring According to Stone,6 there are 10 benefits of mentoring your own employees: » Faster learning curves » Increased communication of organizational values » Reduced turnover at a time when new recruits may be hard to find »Increased loyalty » Improved one-on-one communication and a sense of team within the work group » Increased employee productivity » More time for yourself » Additional corporate information » Creation of an innovative environment » Allies for the future
26 MEDLINE New Staff Orientation: D. Mentor Responsibilities » Performs regular staff duties as assigned Continence Management Orients new staff to the unit: Program Mentor – Identifies and meets learning needs – Acts as a resource EDUCATE THE STAFF Mentoring programs are specifically designed to increase – Aids in the socialization of the new staff member the effectiveness of orientation programs for new staff. – Makes educational opportunities available (in-service Here is one example of how such a program might work and programs, unit in-service training, staff meetings) what it could include. – Assures that policies and procedures of the facility are followed A. Purpose » Ensures quality resident care during orientation The Mentoring Program provides increased effectiveness in » Assesses performance by providing positive the orientation of new staff. feedback as well as suggestions for improvement » Reviews skills checklists and orientation sheets that B. Definition are provided as part of the Continence Management A mentor is a peer who has been judged experienced Program and reports progress to leadership enough to assist in the orientation of new nursing » Meets with leadership as required personnel to your organization, policies and procedures. The mentor is responsible for providing orientees E. Evaluations with an environment conducive to learning and 1. The mentor will be evaluated by each new staff member growth. The mentor serves as a role model following at the end of orientation. the orientation given by the education directors. 2. The mentor will receive one yearly performance evaluation rated by the nursing supervisors C. Mentor Selection and Qualifications and leadership. Selection could be based on the following criteria: 3. The Mentoring Program will be evaluated by each » Minimum of one year of employment mentor and leadership on a yearly basis. » An above-average or outstanding performance evaluation » Demonstrated knowledge of our policies and procedures » Active participation in continuing education » Demonstrates knowledge of the Continence Management Program and utilizes tools appropriately
1-800-MEDLINE (633-5463)(633 63) | medlmedline.comine.com 2277 4. When prompted, you must enter your state as MEDLINE “Facility State” and your facility as “Facility Name” to see the education UNIVERSITY 5. Once registration is complete, click on “Courses” in the top navigation bar, then click the “Continence Management” banner to view the courses and tools for the Continence Management educational program Welcome to Medline University! 6. Click on a course to view the description, click on “Register” to begin the course You may already be familiar with Medline University and all it has to offer. As a valued customer, you have also been Once you log in, click on the “Programs” tab. granted access to the Continence Management Program and all of its tools. Your Medline Sales Representative has already notified the Medline University Team so all you have to do is sign up or log in if you are a current MU user.
Click on “Continence Management Program” and you will see this screen:
If you are new to Medline University, WELCOME! We are glad you are here! Follow these simple steps to become a member and have access to all the courses, tools, videos and webinars.
1. Go to www.medlineuniversity.com 2. Click on “Create FREE Account” near top right corner Scroll down for list of courses and tools.
3. Enter contact information and answer all required questions
28 MEDLINE For Questions: EDUCATE THE STAFF
Here you can find:
If you have any additional questions or need help, please contact our Medline University Customer Support.
E-mail us directly at: [email protected] or call for Telephone Support: 1.855.761.6127
1-800-MEDLINE (633-5463) | medline.com 29 How to Assign Courses Using Batch Registration Step 1 Step 5 Log in and click the “Admin” tab along the top navigation bar. Click on the “Add Existing Users” button.
Step 2 Click on the “Courses” tab on the left column and click “Course List.” Step 6 Click on your facility name and then the “Search” button.
Step 3 -or- Find the course you want to register and click on the “Edit Course Roster” icon to the left of the course name. To assign a course to a group of members by Job Title or Department, click “Advanced,” then click on the “Medline University User Attributes” tab.
Step 4 To assign by Job Title, type the title in the field to the right Click on the “Go to Batch Registration” button. (for RNs type RN, for CNAs type CNA). Then click “Search.”
30 MEDLINE Step 7 EDUCATE THE STAFF Check the box to the left of the members you want to assign the course to. If you want to assign it to everyone, click the box on the top left corner to “select all” then click “Add Selected Users.”
Step 8 Click “Register.” Once registered, an automated email will be sent out to the user notifying them of their course registration (if they have an email attached to their account).
1-800-MEDLINE (633-5463) | medline.com 31 Super User Individual Course Reporting Access Report Step 1 Step 1 Go to www.medlineuniversity.com To run a list of users who have accessed a specific course, click the “Courses” link in the Super User Menu. Select your Step 2 course by clicking the icon to the left of the course name. Log on using your Medline University username and password.
Step 3 Click the “Admin” tab.
Step 2 The resulting list will show Status, Pre-Test score, and Post- Test score. Open the report in Excel by clicking the “Tools” button and selecting “Export” and “Create Report.”
32 MEDLINE Complete Course Catalog Access Report Step 1 Step 3 EDUCATE THE STAFF To view a report of all the courses your staff have accessed, The report may take a few minutes to run. View the results click “Reports” on the Super User Menu and select “Course in Excel by selecting “Excel” from the dropdown list and Activity By User Name (Table).” clicking “Export.”
Step 2 Fill in the “Start Date” and “End Date” fields to limit results to a specific timeframe. Leaving these fields blank will give a complete history. Select the proper facility name under “Choose Groups” and click “Show Report.”
1-800-MEDLINE (633-5463) | medline.com 33 Finding Correct Answers to Test Questions Step 1 Expand the “Courses” menu on the left and select “Course. List.” Locate the desired course and click the roster icon.
Step 2 Locate the appropriate user from the list, then click the “Answers” link in the “Pre-/Post-Assessment Score” column.
Step 3 This will supply a review of each question, the submitted answer, and the answer result.
34 MEDLINE How To Run a Report for a Single User Step 1 EDUCATE THE STAFF Go to “Admin” -> “Users.”
Step 2 Search for the user. Once located, click the pencil icon (edit account).
Step 3 Click “View User’s Course Registrations.”
Step 4 To save the report, click “Export” at the bottom of the page.
1-800-MEDLINE (633-5463) | medline.com 35 Urinary incontinence is a common problem in residents with Course Descriptions dementia. Often, these residents will develop incontinence Absorbent Product Selection, as the disease progresses. However, the primary reasons Sizing and Application for incontinence are often not because of any significant pathology in the urinary system. Rather, it is due to factors Course Objective(s) outside the urinary system. Review the different types of disposable absorbent incontinence products and the help CNAs learn how to: Maintenance of continence requires mobility, manual 1. Choose the appropriate product dexterity, mental capacity and motivation. Clearly, the 2. Choose the appropriate size person with dementia is vulnerable to developing problems 3. Apply the product in these domains. This course provides a comprehensive 4. Hints and tips to success overview of how the stage and type of dementia may account for cognitive and functional deficits, the emotions Course Description and behavior of the patient and their care environment. Continence management products are designed for Management is directed at preserving independence and protection against moisture and to promote autonomy dignity of the patient, and providing sensitive and empathetic and dignity and should be chosen based on the individual care even if the problem is not completely remediable. resident’s needs. With so many products to choose from, it can be difficult to determine which product should be Nighttime Incontinence Management worn by an individual. This course has been developed to Discuss Nighttime Urinary Incontinence, causes of nighttime help nursing assistants understand the different products incontinence, consequences of nighttime incontinence, available, how to choose and apply the appropriate importance of sleep, how to promote good sleep, nighttime product(s) and how to improve overall resident dignity and incontinence management and strategies. quality of care. Nocturia and nocturnal incontinence is an ongoing challenge Fecal Incontinence Parts 1 & 2 for caregivers. Nocturnal incontinence is associated with In this course, we will cover the following: Definition of development of bedsores and may eventually lead to fecal incontinence and facts, causes of fecal incontinence, skin breakdown, opportunistic infection and mortality. anatomy of the bowel, stool production and elimination, Nighttime incontinence is the most common cause of types of fecal incontinence, bowel assessment and disturbed sleep in the elderly. By constantly disrupting management strategies for fecal incontinence. the sleep cycle, it leads to a negative impact on the quality of sleep and consequently is associated with daytime Fecal incontinence is one of the most psychologically and drowsiness. Nocturia also leads to a decline in cognitive socially debilitating conditions for those who suffer from it. function, depression and is associated with falls and Research has found an association between incontinence fall-related morbidity. The elderly, due to their frailty, are 8 and declining mental health. This course was developed to already vulnerable to further morbidity from falls and help CNAs gain a better understanding of fecal incontinence fractures as well as an incidence of mortality. The costs and how to care for someone with fecal incontinence. associated with nighttime incontinence are enormous. Additionally, nighttime incontinence care in institutions Incontinence and Dementia holds major policy implications as well. Requirements for During this course the CNA will learn about incontinence care have been interpreted to suggest ongoing bed checks care for residents with dementia, discuss common types of every 2 hours throughout the night to aid in the prevention dementia, review typical behavior impact of dementia and of bedsores in those residents that are incontinent while how to provide continence care for those residents who are sleeping. These bed checks are disruptive and continue to suffering from both incontinence and dementia. be questioned. Nighttime incontinence has been associated with immobility and inability to arise from bed. Therefore, it is not surprising that nocturia is among the top reasons why older adults are admitted to nursing homes. This course will help nursing assistants have a better understanding of how they appropriately manage nighttime incontinence.
36 MEDLINE Skin Care for the Incontinent Resident Review the structure and function of the skin, discuss the effects of excessive moisture on the skin, review signs and symptoms of skin conditions in the perineal area, learn how to conduct a perineal assessment, learn how to maintain EDUCATE THE STAFF healthy skin, discuss proper skin care and learn how to manage incontinence.
Urinary and fecal incontinence affects a very large portion of the elderly population. If incontinence is left untreated, a host of dermatologic complications can occur, including incontinence-associated dermatitis, infections and intertriginous dermatitis to name a few. Appropriate management of incontinence can help our elders have a higher quality of life. This course has been designed to help CNAs gain a better understanding of the skin and why it is important to protect the skin from urine and fecal matter.
Urinary Incontinence for CNAs Discuss the overview of incontinence, the impact of incontinence, review of the urinary system, discuss the types of incontinence, and discuss caregiver interventions and management of urinary incontinence.
This course has been developed to help CNAs gain a better, more in depth understanding of urinary incontinence and the effects it can have on their residents. The overall goal of this course is to empower CNAs to make better decisions about how they care for their residents, improving quality of care and resident dignity.
Urinary Incontinence for RNs/LPNs Discuss the overview of incontinence, the impact of incontinence, review of the urinary system, discuss the types of incontinence, and discuss caregiver interventions and management of urinary incontinence.
This course has been developed to help RNs/LPNs gain a better, more in depth understanding of urinary incontinence and the effects it can have on their residents. The overall goal of this course is to empower RNs/LPNs to make better decisions about how they care for their residents, improving quality of care and resident dignity.
1-800-MEDLINE (633-5463) | medline.com 37 The urinary system consists of the kidneys, ureters, urinary Types of bladder and urethra. The kidneys filter the blood to remove wastes and produce urine. The ureters, urinary bladder and Incontinence urethra together form the urinary tract, which acts as a plumbing system to drain urine from the kidneys, store it, & Behavioral and then release it during urination. Besides filtering and eliminating wastes from the body, the urinary system also Programs maintains proper balance of salts and water in the body, pH, blood pressure, calcium and red blood cells. Let’s take The Urinary System a closer look at the Urinary System. Urinary incontinence is the inability to control the flow of Female Male urine from the body and is a problem that you see in many of your residents. In fact, more than half of your residents Kidney are incontinent. Ureters Take a moment to consider what it might be like to be affected by incontinence. There is a good chance that you were thinking of several negative outcomes, including wet Bladder clothes, odors, falls, infections and skin irritation. Urethra
It is important to understand that many of your incontinent Prostate residents often suffer from embarrassment, shame and sometimes depression. Residents with incontinence, on average, suffer a quality of life far below that of the U.S. population as a whole.7,8 Numerous studies report that Upper Urinary Tract incontinence has a strong, if not devastating, impact on The Kidneys are a pair of bean-shaped organs found along 9 quality of life. the posterior wall of the abdominal cavity. The left kidney is located slightly higher than the right kidney because the Many elderly patients are institutionalized because right side of the liver is much larger than the left side. The 10 incontinence is a known burden to caregivers. In bed- kidneys, unlike the other organs of the abdominal cavity, bound patients, urine irritates and macerates skin, are located posterior to the peritoneum and touch the contributing to sacral pressure ulcer formation. Elderly muscles of the back. The kidneys are surrounded by a layer people are already at high risk for falls and fractures; of adipose, a type of connective tissue, which holds them in when they are also incontinent, those risks are increased. place and protects them from physical damage. The kidneys filter metabolic wastes, excess ions, and chemicals from the blood to form urine.
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3 ContinueCoo paagege... hfifi eld,ld IL 600936009 ntinued on next pa kes Drive, Nort c. E | 3 Three La e Industries, In ge... 1-800-MEDLIN emark of Medlin .medline.com | ered trad stries, Inc. | www rved. Medline is a regist Medline Indu c. All rights rese e Industries, In © 2017 Medlin The Ureters are a pair of tubes that carry urine from the GUIDELINES kidneys to the urinary bladder. The ureters are about 10 to 12 inches long and run on the left and right sides of the body parallel to the vertebral column. Gravity and peristalsis of smooth muscle tissue in the walls of the ureters move urine toward the urinary bladder.
38 MEDLINE The ends of the ureters extend slightly into the urinary The Urethra is the tube through which urine passes from bladder and are sealed at the point of entry to the bladder the bladder to the exterior of the body. The female urethra by the ureterovesical valves. These valves prevent urine is around 2 inches long and in males, the urethra is around 8 from flowing back towards the kidneys. to 10 inches long. EDUCATE THE STAFF The flow of urine through the urethra is controlled by Lower Urinary Tract the internal and external urethral sphincter muscles. The internal urethral sphincter is made of smooth muscle and The Urinary Bladder is a sac-like hollow organ used for opens involuntarily when the bladder reaches a certain set the storage of urine. The urinary bladder is located along level of distention. The opening of the internal sphincter the body’s midline at the inferior end of the pelvis. Urine results in the sensation of needing to urinate. The external entering the urinary bladder from the ureters slowly fills the urethral sphincter is made of skeletal muscle and may be hollow space of the bladder and stretches its elastic walls. opened to allow urine to pass through the urethra or may The walls of the bladder allow it to stretch to hold anywhere be held closed to delay urination. from 600 to 800 milliliters of urine. The urinary bladder plays an important role in delaying and controlling urination The kidneys maintain the homeostasis of several important so that the average person only has to urinate several times internal conditions by controlling the excretion of each day instead of constantly leaking small amounts of substances out of the body. urine. The urinary bladder is roughly spherical in shape, although its shape and size vary among individuals and Ions depends greatly upon the volume of urine that it contains. The kidney can control the excretion of potassium, sodium, It is located in the pelvic cavity anterior to the rectum and calcium, magnesium, phosphate and chloride ions into superior to the reproductive organs of the pelvis. urine. In cases where these ions reach a higher than normal concentration, the kidneys can increase their excretion out Many tiny wrinkles line the inner surface of the urinary of the body to return them to a normal level. Conversely, bladder and allow it to stretch as it fills with urine. the kidneys can conserve these ions when they are present A pair of ureteral openings on the inferior end of the in lower than normal levels by allowing the ions to be posterior wall of the urinary bladder allows urine reabsorbed into the blood during filtration from the left and right ureters to enter the hollow lumen. A small funnel forms at the inferior end of the pH urinary bladder leading into the urethra, the tube The kidneys monitor and regulate the levels of hydrogen that carries urine out of the body during urination. ions and bicarbonate ions in the blood to control blood pH. Hydrogen ions are produced as a natural byproduct The urinary bladder is made of several distinct tissue layers: of the metabolism of dietary proteins and accumulate in » The innermost layer of the bladder is the mucosa the blood over time. The kidneys excrete excess hydrogen layer that lines the hollow lumen. Unlike the mucosa ions into urine for elimination from the body. The kidneys of other hollow organs, the urinary bladder is lined also conserve bicarbonate ions, which act as important pH with transitional epithelial tissue that is able to stretch buffers in the blood. significantly to accommodate large volumes of urine. The transitional epithelium also provides protection to the underlying tissues from acidic or alkaline urine. Osmolarity The cells of the body need to grow in an isotonic » Surrounding the mucosal layer is the submucosa, a layer of connective tissue with blood vessels and nervous tissue environment in order to maintain their fluid and electrolyte that supports and controls the surrounding tissue layers. balance. The kidneys maintain the body’s osmotic balance by controlling the amount of water that is filtered out » The visceral muscles of the muscularis layer surround the submucosa and provide the urinary bladder with of the blood and excreted into urine. When a person its ability to expand and contract. The muscularis is consumes a large amount of water, the kidneys reduce commonly referred to as the detrusor muscle and their reabsorption of water to allow the excess water to be contracts during urination to expel urine from the body. excreted in urine. This results in the production of dilute, The muscularis also forms the internal urethral sphincter, watery urine. In the case of the body being dehydrated, the a ring of muscle that surrounds the urethral opening and kidneys reabsorb as much water as possible back into the holds urine in the urinary bladder. During urination, the blood to produce highly concentrated urine full of excreted sphincter relaxes to allow urine to flow into the urethra. ions and wastes. The changes in excretion of water are controlled by antidiuretic hormone (ADH). ADH is produced in the hypothalamus and released by the posterior pituitary gland to help the body retain water.
1-800-MEDLINE (633-5463) | medline.com 39 Blood Pressure Normal urination is a complex and dynamic process The kidneys monitor the body’s blood pressure to help involving several structures and processes of the human maintain homeostasis. When blood pressure is elevated, body. One’s ability to maintain continence depends on the the kidneys can help to reduce blood pressure by reducing normal function of these structures and processes, mental the volume of blood in the body. The kidneys are able to awareness of the need to void, and the mental and physical reduce blood volume by reducing the reabsorption of water capacities to reach a toilet or toilet substitute at the into the blood and producing watery, dilute urine. When appropriate time. blood pressure becomes too low, the kidneys can produce the enzyme renin to constrict blood vessels and produce When the bladder is full, receptors on the inner wall of the concentrated urine, which allows more water to remain in bladder submit a signal to the brain via the sensory nerve the blood. pathway, through the spinal cord. The micturition center in the brain registers the request and we sense an urge to Inside each kidney are around a million tiny structures empty our bladder. At will, a signal is transferred back along called nephrons. The nephron is the functional unit of the the sensory nerve pathway to release the closed muscle kidney that filters blood to produce urine. Arterioles in the of the pelvic floor and bladder. As the urethra releases kidneys deliver blood to a bundle of capillaries surrounded the bladder contracts, and voiding begins as the bladder by a capsule called a glomerulus. As blood flows through the pressure exceeds the pressure in the urethra. glomerulus, much of the blood’s plasma is pushed out of the capillaries and into the capsule, leaving the blood cells and a small amount of plasma to continue flowing through the Incontinence capillaries. The liquid filtrate in the capsule flows through The need to urinate is experienced as an uncomfortable, a series of tubules lined with filtering cells and surrounded full feeling. It is highly correlated with the fullness of the by capillaries. The cells surrounding the tubules selectively bladder. In many males the feeling of the need to urinate can absorb water and substances from the filtrate in the tubule be sensed at the base of the penis as well as the bladder, and return it to the blood in the capillaries. At the same even though the neural activity associated with a full time, waste products present in the blood are secreted bladder comes from the bladder itself, and can be felt there into the filtrate. By the end of this process, the filtrate in as well. In females the need to urinate is felt in the lower the tubule has become urine containing only water, waste abdomen region when the bladder is full. When the bladder products and excess ions. The blood exiting the capillaries becomes too full, the sphincter muscles will involuntarily has reabsorbed all of the nutrients along with most of the relax, allowing urine to pass from the bladder. Release of water and ions that the body needs to function. urine is experienced as a lessening of the discomfort. Urination Incontinence occurs when either the bladder muscles contract suddenly or muscles surrounding the urethra relax After urine has been produced by the kidneys, it is suddenly. There are many clinical conditions can cause transported through the ureters to the urinary bladder. The disturbances to normal urination. Let’s take a closer look. urinary bladder fills with urine and stores it until the body »Chills is ready for its excretion. When the volume of the urinary » Headache bladder reaches anywhere from 150 to 400 milliliters, its »Sweating walls begin to stretch and stretch receptors in its walls send signals to the brain and spinal cord. These signals » General feeling of restlessness result in the relaxation of the involuntary internal urethral » Distension of the abdomen sphincter and the sensation of needing to urinate. Urination » Nonverbal residents may have a sad or pained may be delayed as long as the bladder does not exceed expression or engage in repetitive movements its maximum volume, but increasing nerve signals lead to greater discomfort and desire to urinate. Risk factors for urinary incontinence include sex, age, genetics, obesity, medications, and cognitive and Urination is the process of releasing urine from the functional impairment. Other possible risk factors urinary bladder through the urethra and out of the body. include menopause, hormone therapy, hysterectomy, The process of urination begins when the muscles of the smoking and family history. urethral sphincters relax, allowing urine to pass through the urethra. At the same time that the sphincters relax, the smooth muscle in the walls of the urinary bladder contract to expel urine from the bladder.
40 MEDLINE Sex Stages of Micturition Urinary incontinence is far more common among women In healthy individuals, there are several physiological than men. processes that occur during both phases on micturition. Urine is produced as a waste product by the kidneys. It Pregnancy and Childbirth passes through the ureters into the bladder, where it EDUCATE THE STAFF Pregnancy and childbirth can increase the later risk for is stored until it is eventually eliminated from the body urinary incontinence. The risk is highest with the first child, through the urethra. In a normal bladder, the detrusor and there is an increased risk in women who have their first muscle, the main contractile element of the bladder, remains child over age 30. Vaginal birth can cause pelvic prolapse, relaxed during bladder filling. The pressure in the urethra a condition in which pelvic muscles weaken and the pelvic and pelvic floor muscles increases as the volume of urine organs slip into the vaginal canal. Pelvic prolapse, and the increases. In order to maintain continence, the pressure surgery used to correct it, can cause incontinence. within the urethra must exceed the pressure within the bladder during this phase. If the pressure within the bladder Childbirth Injury becomes greater than the pressure that holds the urethra Vaginal childbirth, particularly with a long second stage of closed, urine will be able to flow out of the bladder.11 labor and/or a large infant, is a known risk factor for stress urinary incontinence. Both muscle injury and nerve injury The Micturition Cycle occur during childbirth; this dual injury may contribute to The micturition cycle has 2 stages: bladder filling and the prolonged impairment of bladder function sometimes bladder emptying.11 During the filling process, messages seen in postpartum women. regarding changes to the bladder are sent between the bladder and the Central Nervous System (CNS). When Smoking the urethral and pelvic floor muscles are contracted and Studies have reported a higher risk for incontinence in those detrusor muscles relaxed; urine is stored in the bladder.12 who have a history of smoking. At around 150–200ml the nervous system usually signals the first sensation to void. A healthy person can choose Obesity voluntarily not to void and the detrusor muscles remain Being overweight is a major risk factor for all types of relaxed and the urethral sphincter contracted—continence incontinence. The more a person weighs, the greater their is maintained. At about 400–500ml a person will usually risk for urinary incontinence. voluntarily choose to void. But if they are unable to find a toilet, suffer from overactive bladder (OAB) or stress Medical Factors incontinence, or the pressure on the bladder wall exceeds Urge incontinence is more common among postmenopausal the pressure of the urethra, they may void involuntarily.11 women who have a history of diabetes, have had a The bladder emptying stage starts when the pontine hysterectomy or have had two or more urinary tract micturition center is activated and messages are sent to the infections within the past year. urethral sphincter and pelvic floor muscles to relax and the detrusor muscle to contract. When the bladder is emptied Age the urethral sphincter and pelvic floor contract, and the The prevalence of urinary incontinence increases with age, detrusor muscles relax.11 This returns bladder pressure back however, incontinence should not be considered as a normal to its normal level and ends voiding. part of aging.
Storage PhaseVoiding Phase Storage Phase Prostate Surgery Transurethral resection of the prostate, or TURP, and radical prostatectomy are both associated with urinary incontinence.
Medications Any medication that depresses cognitive function and sensation can contribute to incontinence.
Bladder First Sensation Normal Desire Bladder Filling to Void to Void Filling
1-800-MEDLINE (633-5463) | medline.com 41 What happens when the bladder Urge incontinence is when urine leaks before getting to reaches its capacity? the toilet. Symptoms may be worse at times of stress if The specific volumes at which a strong desire to void is felt the person has an infection or is constipated. Degeneration may vary greatly between individuals. Generally though, of the detrusor muscle is a specific cause of incontinence, once urine volume reaches approximately 400–500ml which is considered to be a normal part of the aging in adults, a strong desire to void is felt and the individual process. This results in the bladder having reduced capacity generally finds a place to do so.12 The decision whether and contractility, increases post-void residual urine volume, or not to void is made in the brain.11 increased frequency of inhibited bladder contractions and lower urethral pressure. What processes are involved in voiding? If the individual chooses to void, the pontine micturition Normal bladder function is dependent on a combination center is activated, signaling the muscles of the pelvic floor of voluntary and involuntary muscle and nerve activity.13 to relax.11 Urethral resistance decreases and the trigone OAB can present owing to a number of different reasons, contracts, which pulls open the posterior portion of the from behavioral consequences, such as caffeine intake or bladder neck, occludes the openings to the ureters, and obesity, to physiological conditions, including abnormal prevents any backflow of urine. The bladder outlet acts neurological signals, diabetes or cancer.14 The symptoms of as a funnel, facilitating the outflow of urine.12 OAB are frequently associated with detrusor overactivity (mistimed or poorly regulated bladder contractions), but What happens when more urine enters the bladder? some patients with OAB do not have this condition. OAB The urge to void will disappear after a short while, and may be classified as “dry” or “wet”.14 urine will continue to accumulate in the bladder. After an additional 200–300ml of urine has collected, the impulses Stress Urinary Incontinence (SUI) are sent again and the individual must once more decide Stress urinary incontinence is usually a pre-existing whether to urinate.12 condition commonly seen in post-menopausal women due to the depletion of estrogen, multiple pregnancies What happens if the urge is still ignored? and childbirth, in men due to the effects of an enlarged Eventually, the urge to micturate becomes overwhelming prostate gland and in both sexes due to the chronic cough. and the urine is voided.12 Symptoms present as a small leak of urine during laughing, coughing or exercise and often occur when getting up from Types of Urinary Incontinence the bed or chair. It is usually associated with bladder outlet Incontinence may manifest as near-constant dribbling or as incompetence due to weakness of the supporting pelvic intermittent voiding with or without awareness of the need floor muscles. to void. Some patients have extreme urgency (irrepressible need to void) with little or no warning and may be unable Mixed Urinary Incontinence to inhibit voiding until reaching a bathroom. Incontinence Described as the involuntary loss of urine associated may occur or worsen with maneuvers that increase intra- with urgency and frequency (overactive bladder) and also abdominal pressure. Post-void dribbling is extremely exertion, effort, sneezing or coughing (stress incontinence). common and probably a normal variant in men. Identifying The most bothersome symptom is usually treated first. the clinical pattern is sometimes useful, but causes often This is very common in the older population. overlap and much of treatment is the same. Overflow Incontinence Overactive Bladder Syndrome—Also Known as More common in men than women and is most often Urge Urinary Incontinence and Detrusor Instability associated with prostatic enlargement. May also be caused Presents as an urgent desire to pass urine (urgency) by urethral stricture, bladder stones or bowel impaction. resulting in the person not being able to delay going to Presents with the person dribbling urine; poor stream; the toilet and may be incontinent of urine before reaching hesitancy; intermittent stream with straining to pass urine; the toilet. Urgency is usually accompanied by the frequent post micturition dribble; nocturia and all the associated desire to pass urine (usually more than 7 or 8 times during symptoms of overactive bladder. the day)13 known as frequency. Nocturia is considered if the person has to pass urine more than 3–4 times at night.
42 MEDLINE Detrusor hypoactivity occurs when the bladder muscle Management of Urinary Incontinence becomes atonic or if there is dysfunction between the bladder Management of urinary incontinence will largely depend on and sphincter contractions (dysinergia). This is caused by the person’s mental and physical status. peripheral nerve damage in conditions such as MS, diabetic neuropathy and spinal cord damage. The bladder sensations The simplest option for management, offering briefs, should EDUCATE THE STAFF reduce or cease causing the bladder to overstretch. The not be the first choice. Long-term use of briefs is expensive person empties a small frequent amount of urine but and is arguably a deterrent to functional continence, and maintains a large residual in the bladder. If unresolved, this does nothing to treat the underlying cause. may cause ureteric reflux and kidney damage. If indicated by assessment, early management strategies Functional Incontinence should include optimizing toilet access and a review of This results from barriers that prevent the person from current medications. Improvement in mobility may also voiding in the appropriate place or time. Usually a normal be of benefit in reducing the risk of falls and improving bladder pattern is presented however due to mobility confidence, especially for those who experience nocturia. dysfunction, cognitive impairment or sensory impairment Prompted voiding programs can be highly effective in the person develops a functional incontinence. residents that are mobile but less cognitively aware. Behavioral treatments such as pelvic floor exercises and Assessment of Urinary Incontinence bladder retraining programs may be useful to mobile, The medical history of the resident presenting with cognitively aware residents. incontinence is likely to be complicated and the primary aim should be to rule out any transient causal factors. Management of Urinary Incontinence Holistic assessment of the person is required taking into » Improve mobility and/or toilet access account their medical history, mobility, medication use (both » Treat any medical causes prescribed medication and over the counter medicines) and the environment. Simple aids to improve mobility, » Modify fluid intake and if appropriate medication use environmental changes to aid toileting, or medication » Trial behavioral techniques changes may be required. – Prompted voiding – Bladder retraining Potential causes of Transient incontinence: – Pelvic floor exercise D – Delirium » Trial pharmacological agents appropriate to symptoms I – Infection » Refer to specialist if unsuccessful A – Atrophic Vaginitis, Vaginitis P – Pharmaceuticals Medication should only be contemplated when behavioral P – Psychological, especially depression and environmental modifications have proved fruitless and E – Excess urine output should be used with caution in the older population. R – Restricted Mobility S – Stool impaction
Key aspects of the clinical history: 1. General medical, neurological, genitourinary and gastroenterological history 2. Characteristics of the presenting incontinence – Duration – Frequency – Amount (and with fecal incontinence, consistency) – Impact on the quality of life – Any other presenting factor 3. Other related symptoms (e.g., nocturia, dysuria, hesitancy, pain, constipation) 4. Fluid intake (include alcohol and caffeine), fiber intake 5. Laxative use 6. Previous treatment for incontinence and their outcome 7. Expectations of the treatment
1-800-MEDLINE (633-5463) | medline.com 43 Investigations Management All residents reporting symptoms of urinary incontinence All residents reporting symptoms of urinary incontinence should have the following baseline investigations: should have the following baseline interventions:
Comprehensive Assessment—may need to be collaborated Review Fluid Intake—ensure that the person drinks by family/caregivers. Identifies pre-existing symptoms between 1.5–2 liters of fluid per day, unless on a restricted and determines a baseline for all care given. The intake. Caffeinated drinks such as tea, coffee, hot chocolate comprehensive assessment should include medical, surgical and cola should be avoided. These drinks may stimulate and gynecological history, mobility, dexterity, hearing and the bladder and have a diuretic effect. Alcohol has a similar eyesight assessment and mental alertness assessment. effect on the bladder as caffeine based drinks.
Frequency Volume Chart/Bladder Diary—should be Review Dietary Intake—ensure adequate fiber intake to recorded accurately for a minimum of 3 days/72 hours. fluid intake.
Urinalysis—to exclude urinary tract infections, glycosuria Treat Underlying Chest Conditions to Reduce Coughing and hematuria.15 Episodes—chronic cough causes extra strain on the pelvic floor muscles. Encourage smoking cessation to reduce the Bowel Diary—rule out constipation/impaction. associated cough.
Additional investigations: Bowel Diary—a distended bowel will impact on the (Note: these investigations should only be performed by a bladder’s normal function. Keeping a bowel diary (minimum medical professional or a specialist nurse) recorded time should be for two weeks to establish bowel 1. Physical examinations include evaluation for any pattern) will allow for early recognition of constipation anatomic, local complications or neurological (ensure staff document stool type using the Bristol Stool abnormalities that likely could contribute to or cause Form Scale). symptoms of urinary incontinence.16 Testing in females can include vaginal examination for prolapse and for Review medications that affect the bladder and bowel males a prostate assessment, to rule out prostate- directly or indirectly. specific conditions.17 Additional examinations can include perineal and genital examination for sensitivity, and Time voiding is a fixed time interval of assisted toileting pelvic and anorectal examination for pelvic mass and for dependent persons. First use a toileting chart—record muscle function assessment.18 voiding pattern/amount voided/wetting episodes for 5–7 days. If a pattern emerges times of voids can be set, thus 2. Imaging procedures such as ultrasound or X-ray are not pre-empting the wet episodes. If no pattern emerges, then routinely recommended, but may be useful in individuals regular times for taking the resident to the toilet should be with symptoms associated with possible lower tract or considered every 2–3 hours.19 pelvic disorders.18 3. Measurement of urine flow rate during voiding and the Prompted voiding is a behavioral intervention that amount of urine left in the bladder (post-void residual encourages people with or without cognitive impairment volume [PRV]): to determine whether voiding problems to actively initiate their own toileting needs. Use a toileting are present in addition to urine storage problems.15 chart—record voiding pattern/amount voided. If a pattern emerges prompts of voids can be established, thus pre- empting the wet episodes. If no pattern emerges, then regular times for prompting the patient to go to the toilet should be considered every 2–3 hours.19
Mobility and Cognitive Function—adapt clothing for ease of access. Reduce distance from the toilet; consider the use of urinal or commode. Assess for appropriate walking and toileting aids. Ensure sufficient time is provided to reach the toileting area. Make the toilet area easily recognizable and accessible. Use picture cards to assist people with speech and language difficulties.
44 MEDLINE Additional Interventions Additional Strategies: Behavioral management should be adopted in the Management of Urinary Incontinence management of overactive bladder; Bladder retraining Type of with urge suppression involves educating the person Management Strategies Incontinence about the mechanisms underlying their condition, Stress EDUCATE THE STAFF using scheduled voiding intervals and an urgency • Weight reduction Incontinence control strategy that teaches distraction and relaxation • Pelvic floor muscle exercises strategies. This requires a motivated, actively • Treat constipation or fecal impaction independent resident. • Treat chronic cough • Review resident’s medication Anticholinergic Medications—should only be – Remove alpha-adrenergic blockers introduced with caution and once behavioral – Trial alpha-adrenergic agonists rehabilitation is established. Urge • Exclude urinary tract infection Incontinence • Treat constipation or fecal impaction Pelvic Floor Muscle Rehabilitation—should be • Reduce caffeine and alcohol intake encouraged, together with bladder retraining. The • Bladder retraining person needs to be well motivated and have the • Biofeedback cognitive capacity. • Review residents medication • Trial Anticholinergic Catheterization—should only be considered where Mixed Treat presenting symptoms as above the person has a residual urine >200mls under medical Incontinence instruction. Intermittent catheterization should be Overflow Consider whether the retention is due to: Incontinence considered as preferable to indwelling catheters if it • Bladder outlet obstruction or is clinically appropriate and a practical option for the • Detrusor contractile dysfunction/ 20 resident. Where an indwelling catheter is inserted it bladder failure, fecal impaction, should be removed as early as possible. spinal pathology • Review medication When surgery is not a treatment option for the cause of • Confirm diagnosis by Urodynamics the obstruction, other treatments may be considered. • Remove any outlet obstruction (referral for surgery) Good Toileting Habits • Discourage excessive Take care to ensure the resident is sitting on the toilet abdominal straining comfortably with their knees slightly higher than their • Clean intermittent self- hips with the back straight and elbows on their knees catheterization—prevent reflux so that they are leaning forward slightly to pass urine Functional • Exclude UTI and constipation/ and empty their bowels. Use a footstool or support to Incontinence fecal impaction achieve this position. Always ensure that they sit on • Improve access to toilet the toilet and don’t “hover” over it. Give the resident • Manage mobility time to relax on the toilet and don’t rush them during • Manage dexterity, modify clothing the process. (i.e., Velcro, not buttons) • Consider bedside commode or urinal Double voiding techniques may be required (should • Educate staff and family members only be used if the resident has the sitting strength to • Arrange chairs/beds that lean forward and back when sitting on the toilet). are easy to get up from • In cognitively impaired, apply prompted/ timed voiding and clearly identify toilet
All Types • Review regularly and titrate any medications • Refer to specialist if unsuccessful
1-800-MEDLINE (633-5463) | medline.com 45 The Bowel System Stool Production and What is fecal incontinence? What Influences It Fecal incontinence is a sign or a symptom, not a diagnosis. Therefore, it is important to diagnose the cause or causes A normal stool output per day is around 150–200g. The for each individual. proximal colon defines the consistency and volume of delivery of contents to the rectum. Defecation in a healthy Fecal incontinence occurs when people lose the ability to person may vary from three times a day to three times control their bowel movements, resulting in unplanned a week. Stool consistency can vary and its production is 26 leakage of feces. A resident with fecal incontinence may influenced by gender, diet and health. have bowel accidents that are caused by not being able to get to a toilet quickly enough, or they may experience There are 7 types of fecal consistency as defined in the 27 soiling or leaking from the bowel without being aware of it. Bristol stool chart overleaf. Type 3 and 4 is usually considered a normal stool for the general population. Fecal incontinence may have many different causes. It can be distressing and can severely affect everyday life. Many Positioning is also very important in achieving regular residents with fecal incontinence find it very difficult and bowel functioning. A pictorial diagram is located in the embarrassing to talk about it to doctors and nurses, or to “forms” section of this guide, depicting the correct position tell their family and friends. Once fecal incontinence has for opening your bowels. been identified there are treatments that can help manage or sometimes cure it, as well as strategies to help people Diet cope with the condition and discuss it openly.21 Consider intolerances to certain foods as these may make the problem worse. A Normal Colon Has 5 Main Functions: 1. Storage—stores unabsorbed food residue. Low Residue—reducing fiber could decrease motility of the 2. Absorption—sodium, water and some vitamins and gut, making the stool firmer. medication including steroids and aspirin are absorbed in the colon. Wheat or Dairy—possible food intolerance causing a loose 3. Secretion—mucus is secreted to lubricate the feces. stool or bloating. 4. Synthesis—a small amount of Vitamin K is produced. 5. Elimination—peristaltic movements of feces into the Exclusion Diets—to establish trigger foods that may be rectum, which is detected by sensory nerve endings a causing the dysfunction, such as highly fermenting foods. sense of fullness is experienced, followed by the need to pass feces.22 Bulkers—whole grain cereal may bulk the stool, to soften hard stool or firm a loose stool. Normal Defecation Increase Fiber Intake—increasing fiber such as whole Diet—increasing fiber into the diet increases stool bulk, wheat bread and wholegrain cereals. which in turn improves peristalsis and stool transient time. 23 This results in a softer stool being delivered to the rectum. Portions and Regularity—small regular meals rather than one large one. Positioning—it is important that the correct posture for opening the bowel is adopted. Crouching or “crouch-like” Spicy Foods—these may irritate the bowel 24 posture is considered anatomically correct. increasing motility.
Exercise—physical activity has been found to have a Supplementary Drinks—may induce diarrhea due to their 25 positive effect on peristalsis, particularly after eating. high nutritional value.
Probiotics and Prebiotics—may improve the balance of bacteria within the bowel.28
46 MEDLINE Fluid Intake Sub-Types of Constipation Residents with hard stools and/or clinical dehydration Primary or Idiopathic Constipation should aim for at least 1.5 liters intake of fluid a day, Linked to immobility, poor diet, slow colonic transit and 21 unless contraindicated. pelvic floor abnormalities. It is not associated with any
other complaint and has no pathological cause. EDUCATE THE STAFF Milk—possible intolerance. Secondary Constipation Coffee/Caffeine—may increase motility of the bowel. Secondary to another disorder: metabolic, psychological or neurological disorder, there is a cause for the constipation Diet Drinks—may contain ingredients that could act that can be identified. as a laxative. Functional Constipation Herbal Teas—peppermint, fennel and ginger aid digestion. More commonly known as chronic idiopathic constipation diagnosed when a person is experiencing constipation 28 Alcohol—excessive quantity can increase bowel motility. symptoms, but no specific cause for the problem can be identified. In order to be diagnosed, constipation symptoms Constipation need to be present at least two days a week for at least three months. Symptoms may include: It has been defined as persistent, difficult, infrequent » Feeling of incomplete evacuation or incomplete defecation, which may or may not be » Hard, lumpy stools accompanied by hard dry stools.29 Encourage people with » Straining during bowel movements hard stools to aim for at least 1.5 liters of fluid intake per day, unless contraindicated. Urinary output should be » Three or fewer bowel movements per week measured where intake is in doubt.21 Rectal Outlet Delay People with constipation can be divided into two A feeling of anal blockage on more than one in four main categories: occasions and prolonged fecal voiding (more than 10 1. Those with difficulty defecating minutes to complete evacuation). (but normal bowel motion frequency) 2. Those with a transit abnormality Fecal Impaction (can present as infrequent defecation)30 The rectum and lower colon is full with either hard or soft stool. The person is unable to evacuate unaided which leads 32 Constipation Can Be Associated with: to impaction and may result in over flow. » Abnormal bowel opening for the individual Medication Associated with Constipation » Abdominal pain or cramps »Opiates » General malaise or fatigue and bloating » Antidepressants » Nausea, anorexia »Diuretics » Headaches, confusion, restlessness »Aluminum antacids » Retention of urine, fecal incontinence »Codeine The condition may be exacerbated by dehydration, » Anti-hypotensives inactivity, emotional upsets, conditions such as » Anti-cholinergics hemorrhoids and poor toilet facilities.23,31 » Iron supplements » Overuse of laxatives33
1-800-MEDLINE (633-5463) | medline.com 47 Assessment Diarrhea The cause of diarrhea needs to be identified before Diarrhea can be defined in the terms of stool frequency, effective treatment can be instigated. Investigations consistency, volume or weight.34 Diarrhea is defined by the may include stool cultures for bacteria, fungal and World Health Organization as having three or more loose viral pathogens or a more formal evaluation of the or liquid stools per day, or as having more stools than is gastrointestinal tract.36 normal for that person.35 A comprehensive assessment is essential and should include Signs and Symptoms the following: » Increased frequency of bowel movement » History of onset, frequency and duration » Loose watery stools » Consistency, color and form of stool, including the presence of blood and mucus »Urgency » Pain, nausea, vomiting, fatigue, weight loss and fever » Incontinence (leakage of stools) » Recent life style changes, emotional disturbances »Rectal pain » Fluid intake and dietary history » Lower abdominal pain or cramping » Regular medication, including antibiotics, »Nausea laxatives, oral hypoglycemias, statins » Loss of appetite or weight loss » Effectiveness of any antidiarrheal medication used » Significant past medical history such as Acute Diarrhea Causes bowel resection or pancreatitis Common Problem Infective: » Hydration, evaluation of mucous Sudden onset –Viral e.g., C. diff membrane and skin turgor Usually lasts less –Bacterial (usually associated with food) than two weeks Antibiotic related Treatment Usually resolves on Dietary—too much fruit or alcohol » Avoid dehydration its own without any Allergy to food/fluid constituents » Encourage fluids (water) little and often special treatment » If infective cause suspected, isolate from others Chronic Diarrhea Causes immediately, implement standard and contact precautions and refer to local Infection Control policy Generally lasts longer Colonic (i.e., ulcerative colitis than 2–4 weeks and Crohn’s disease) » Extra precaution over hygiene to prevent Small bowel (i.e., Celiac disease) cross infection, i.e., hand washing and use of personal protective equipment Pancreatic (i.e., chronic pancreatitis) Endocrine (i,e, diabetes hypothyroidism) » Observe for signs of infection—fever, Other causes (i.e., misuse confusion, reduced urine output of laxatives, drugs) » Consult physician » Consider rehydration drinks » Consider anti-diarrhea medications33
48 MEDLINE Clostridium Difficile Infection (CDI) A healthcare-associated diarrhea. When certain antibiotics EDUCATE THE STAFF disturb the balance of bacteria in the gut, Clostridium Difficile can multiply rapidly and produce toxins that cause illness and diarrhea. When a resident presents with diarrhea a possible infection should be considered as the cause and that resident should be isolated.
The following SIGHT mnemonic protocol should be applied by clinicians when managing suspected potentially infectious diarrhea such as CDI:
Suspect that a case may be infective where S there is no clear alternative cause for diarrhea
Isolate the resident and consult with the infection I control team while determining the cause of diarrhea
Gloves and gowns must be used for all G contacts with the resident
Hand washing with soap and water should be H carried out before and after contact
Test the stool for toxin, sending a T specimen immediately
1-800-MEDLINE (633-5463) | medline.com 49 Disposable products with super absorbent polymer Products should be chosen over those without as they reduce skin wetness and therefore help reduce the risk of dermatitis and skin breakdown. Use of Disposable Products also have an odor control system that works in two ways: Incontinence Products 1. Helps prevent the formation of ammonia and odors 2. Helps maintain a healthy skin pH Incontinence products may be required as a short-term treatment option or as part of an overall management plan They also have an impervious back sheet to enhance for residents who do not wish more active treatment or protection for the wearer. Stand-up leak guards ensure that when active treatment is inappropriate or ineffective in all urine is absorbed directly into the pad, reducing the risk restoring full continence. of urine leakage.
Products should not be used as an alternative to continence Absorbent products are available in a range of designs promotion but rather as an additional support. A wide with a wide variety of sizes and absorbencies to suit light variety of products are available to help manage urinary through to very heavy incontinence. If there is doubt incontinence, while maintaining dignity and an acceptable about what level of absorbency of a product a person falls quality of life. into then it is recommended that the individual should be offered smaller products for light incontinence first and It is important that the person receives the continence the size and absorbency of the pad titrated upwards as products that are most suitable to them and a thorough necessary. Using a product that has insufficient absorbency assessment is crucial to achieve this. It is suggested that can increase the risk of skin irritation. the key to the success or failure of a product usually lies in 23 the initial accurate assessment of the individual’s needs. A key element in the management of urinary incontinence is that there is consistency among all members of the A number of factors should be taken into consideration healthcare team in relation to adherence to the chosen when making an assessment for the provision of product. The FitRight Assessment Tool is designed to assist incontinence products and they include: in the choice of absorbent products for residents and » The type of urinary incontinence incorporates the full range of products for both fecal and » Mobility urinary incontinence. » Manual dexterity and eyesight »Mental function Underpads » Personal hygiene Please note the use of washable furniture protectors » Skin condition and local anatomy otherwise known as “pink pads or reusable pads” for the » Personal preference and perception of need sole management of incontinence is no longer regarded as » Availability of product best practice for a number of reasons including (but not »Support Services limited to the following): » Laundry facilities » Reduced privacy and dignity for the resident due to »Costs 23 the need to be naked from the waist down and poor odor control during the use of these products Disposable Products for Urinary Incontinence » Increased risk of pressure damage due to the Absorbent incontinence products are designed specifically thickness of the product detracting from the to absorb and contain urine. They have an acquisition layer pressure relieving qualities of the mattress that promotes the fast passage of urine through to the » Interference with support surfaces for moisture control inner core of the pad, and also allows the dispersion of urine such as low air-loss mattresses and overlays37 into the absorbent core. The core contains Super Absorbent » Lack of moisture management and containment Polymer that locks away the urine in the form of a gel keeping the user dry.
50 MEDLINE In addition, disposable, plastic-backed pads, or “chux,” are STAGE 4—Fit the pad as usual. for use only during clinical procedures and should not be used to manage incontinence since they are: STAGE 5—During the lifespan of the pad, note whether » Not breathable there has been any leakage during use. Any incidents of wet clothing or bedding must be recorded. » Are not able to keep residents’ skin dry EDUCATE THE STAFF » Cannot manage moisture appropriately STAGE 6—On removal, weigh the product again as soon as » Cannot manage odor is practical and record the result. This will be referred to » Do not provide containment as the ‘wet weight’. Discard any pads that contain feces, blood, any other material that will affect the weight of the Where a patient is incontinent and requires a disposable product (the weight should only reflect the weight of pad absorbent incontinence management product, it is important plus urinary output). to choose a product that works with the support surface with research suggesting the avoidance of cloth and other STAGE 7—Subtract the dry weight from wet weight to plastic backed incontinence pads due to their ability to retain establish the volume of urine passed. heat, moisture and increase skin pressure.38 Products with breathable back sheets are the preferred option. Summary An effective pad-monitoring chart can supply a great deal Sample Protocol for Weighing of information. Disposable Absorbent Products Some pad-monitoring charts ask if the pad was wet or dry. However, there is no great benefit in noting this as, Key Issues on one hand you would expect the pad to be wet at some » CNAs are having a hard time determining point in time and on the other it is difficult to tell if the pad when to toilet residents is completely dry, hence the need for wetness indicators. » There is a need to obtain all resident output If there is evidence of wetness this indicates that either the pad leaked, was fitted incorrectly or was the incorrect » You suspect the resident’s level of product for the resident’s needs. Close monitoring of incontinence has changed this situation will eventually confirm which one of these Introduction categories applies. A process of regular pad weighing can generate a great deal of information, from a reasonably accurate measurement The only accurate way to tell if a pad has served its purpose of how much urine someone passes, to the efficacy of a is to weigh it. This will quickly identify the resident’s output product and through to how much time elapses before a and determine the suitability of the absorbency chosen resident receives attention. (remembering to also monitor if the clothing or bedding was wet or dry). Methodology
Incontinenc STAGE 1—Each resident selected should have a 3-day Solutions e e Incontinencn Disposable A Solutions n Selection andbsorbent Product SelectionSelectio Purpos Sizing enentnt Product e ben ts To promote no Guidelines bladder diary completed prior to the start of the pad Absorbent Product gested Produc ug mainta rmal bladder eSugeS ining CMS F- es cattion for Us must be identi function an sIIndicationnddic for Us Tag 31 and in Need fi ed 5 compliancepliance an dividualized,ividual di Absorbancy level of continen , assessed and tr ized, di d effieffi gnifi ed and leakage protecce, ability to und treated to promote cient resouroptimalopti bladdered incont TIVE ce inence care while ss incontinenceincocontinence PROTEC ders utilizationiliza » Stre EAR tion wi tand mal bladdertion . 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Medlin remove the adhesive tape prior to weighing as, when wet, e is 115–130 lbs. –42" (81–107 cm ) a regi Assess for Medium/R stered egular trademark 130–175 lbs. 40–50" (102–127 cm) Assess for Regular/Large48– of Medlin 175–235 lbs. 58" (122–147 cm) e Indu X-Large5 stri 235–25 9–66" (150–168 cm es, Inc. 0 lbs. XX-Large or Mesh Pant ) s60–69" (1 250 lbs. & heavierBariatric 52–175 cm) 69" & up (175 cm +) Male (weight) Brief Size 120–150 lbs. Medium ColorWaist or Hip* 150–20 20–32" (51–81 cm) the strip will have been removed by the user. 0 lbs. Assess for Medium/R egular 200–235 lbs. 40–50" (102–127 cm) Assess for Regular/Large4 200– 8–58" (122–147 235 lbs. X-Large cm) PRODUCT EDUCATION FORMS
1-800-MEDLINE (633-5463) | medline.com 51 Storage Guidelines Skin Individually Wrapped Pads Pads should not be removed from the packet until they are Care ready to be used. This helps to prevent any product damage The skin is the largest organ in the body and is made that may affect its ability to work properly, and will also up of three layers: the epidermis, the dermis and the reduce the risk of contamination from dust particles and subcutaneous layer. Skin acts as a water barrier, prevents bacteria in the air. Pads are not sterile, but since they do harmful substances entering the body and helps regulate come in to contact with sensitive, intimate areas of the body, body temperature. With age, the skin changes and becomes it is important that they be kept clean when being stored. more susceptible to damage. The outer layer gets thinner and is more prone to damage from moisture, friction and Opened and Sealed Packets trauma; it also produces less sebum, which affects its Packets of pads, whether opened or sealed, should functionality as a barrier. always be stored in a clean, dry environment kept at room temperature. Incontinence exposes the skin to friction, moisture, bacteria, enzymes and ammonia, which can all cause damage to the Never Store Disposable Absorbent skin. It is reported that the main physical health consequence Products in the Bathroom of urinary and fecal incontinence is skin damage.39 Incontinence pads are thirsty! They have a super-absorbent core designed to soak up moisture. A bathroom is a damp Poor health, frailness, aging, limited mobility, neurological environment due to steam from baths and showers. The conditions, diabetes mellitus, prolonged sitting on hard pads will begin soak up some of this steam and will not toilet seats, poor nutrition, dryness of the skin and work as effectively when they are fitted to a resident. continuous soiling are all factors that may the exacerbate risk of skin breakdown.21 Never Store Pads Outside or in Cold, Damp Storage Rooms Regular assessment of the risk and resident’s skin by Areas exposed to the cold are also likely to be damp; a healthcare professional is critical to recognizing any therefore, the same can happen as in bathrooms. The pads complications associated with incontinence. Regular will start to soak up the dampness and won’t work as inspection of the skin after toileting should be considered.28 effectively when fitted to a resident. Patients with reduced sensation due to neurological Unopened Boxes conditions are at high risk of pressure damage associated with These boxes can be stacked in a clean, dry storage area at toileting. Consider the use of padded toilet seats and avoid room temperature. However, if the boxes start to collapse prolonged sitting on toilets, commodes and shower chairs. and crush the packets, this may cause damage to the products and make them unusable. Skin care for individuals with fecal incontinence is essential in preventing the bacteria present in fecal matter Rotate Stock from destroying the skin’s cellular defenses, thus causing It is considered good practice to rotate the stock of skin damage. products so that unused products are not left for long periods of time without being used. There may be some Although absorbent pads will contain very loose stool, loss of performance noted if products are used after their offering a feeling of security for the resident, skin integrity expiration date. may be compromised. Therefore, it is imperative that skin- » Store in a clean, dry environment protective measures are employed. » Do not expose products to sources of dirt or bacteria » Do not store in areas where moisture is present » Do not allow packets or boxes to become damaged » Rotate stock regularly to ensure new stock is opened last
52 MEDLINE Incontinence-Associated Dermatitis (IAD) Using Disposable Absorbent Incontinence Incontinence-associated dermatitis is a skin irritation Management Products caused by urine and/or feces. The affected areas appear Myths red, swollen, sore, crusty and/or weeping, and the resident may complain of itching, pain, burning or local stinging. » It is better for a resident to be left open-to-air than to wear a disposable incontinence product EDUCATE THE STAFF Factors that may contribute to this problem include » Incontinence management products can’t be the aging process, slower cell renewal and excessive used with pressure relieving mattresses dehydration caused by incontinence—all of which make the » Using two disposable briefs is the best skin more prone to problems. This risk is increased in those method to avoid a wet mattress who are doubly incontinent or have loose stools. » Skin should be cleansed after every product change » Talcum powder and barrier creams should be Frequent washing of the area with alkaline soaps and coarse used liberally with incontinence pads washcloths and prolonged exposure to enzymes from incontinence can reduce skin integrity, putting the individual Facts at risk of developing incontinence-associated dermatitis.37 » Disposable incontinence management products ensure wetness is held away from the body Good Skincare » Wetness indicators allow a visual inspection Soap should be avoided, unless it is an emollient to prevent without removing the product the skin from drying. Gentle patting of the skin is preferred » Products must be fitted well to ensure efficiency for drying to avoid friction damage. Barrier creams should » Product absorbency is not linked to product size be applied sparingly, gently layered on in the direction of the hair grain rather than rubbed into the skin.40 Skin » You must select the correct absorbency or skin integrity can be affected cleansers are available that do not affect the pH of the skin; they contain antimicrobials and moisturizers and require no rinsing. It is advised to: » Gently wash the skin immediately with Incontinenc an appropriate cleansing product Solutions e Clinical Decision Tree for Bathing
MDS 3.0 Sect ion G0120—Ba » Pat the skin dry rather than rubbing thing Considerations 0 Self Incontinence -Perform re INDEPENDEN 1 ance Solutions n Ca No help T SUPERV Skikinin provided ISIO 2 Over N rineal sight help PHYSIC Pe od) only AL 3 or Perineal Skin CareM0150 Limite HELP okback peri—Is this d to tran PHYSIC ququired lo resident at sfer only AL » Use only water-based barrier creams and ri In pa HELP 4 or the rerequired lookback period) sk of developing pressure ulce rt of (f 4Cleansin bathin TOTA inenceence (f gTED g activity L Clinical Decision Tree Contf NOT RARATE Soothe & DEPENDENCE 400— 3 hahadd Cool rs? in or Re No = 0 300 & H0 AALWAWAYSAYS MoisturiResident medy Cleanser 2 T ze/er s ction H0 NTINEN Sk cathet UENTLY IINCOCONTINEN Protecta MDS 3.0 Se FREQEQ s of g,Soot he & 1 ALLY T No episode (i(indwellinndwellin y Cool avoid over application as this may reduce the INCOCONTINENNTINEN s of t voiding dom), urinarurinary or Remedy CASION con 0 OC T episode continen M0150— no Moisturizers more episode bowelIntact , or No WAYS NTINEN s 7 or or ntinent bo ostomyostomy,Is this resident at Rins AL INCO y incontinence or co or e Soothe T than 7 episode urinaryrinar s of s e output or ri Cool & CONTINEN Less or episode momovementvement Cleansingurin sk of developing pressure ulce and Remedy inence 2 or more , Cleanser of incont wel inence bowel movementRemedy s e of bo wel incontincontinence e entire Cleanser 1 episod bo episode for th s rs? at least 1 Moisturi Yes = 1 bubutt at iding ze/days effectiveness and absorbency of products incontinence inent vo Protect 7 of cont Remedy Considerations bowel movement Moisturi or M015 zers 0—Is this resident at risk of developing pressure ulce No Rinse Re Cleansing Cleanser medy 0 s rs? No = Remedy sure ulce Cleanser rs? ear Skin s No = 0 » If it is necessary to use creams, smoothly and sparingly sk of developing pressure ulcers Moisturize/ ri Protect 0—Is this resident at Soothe & M015 Cleanseranser y-to-T Cool or or Remedy N//A Remedy & Cool M0150— Moisturi y Soothe Is this resident at risk of developingzers pressure ulcers No Rins Wipes, an e So g Barriers Cool othe & Cleansin tatatittive Ba Cleansing and Remedy emedy Preven Cleanser apply in a downward motion, being careful not to go Cool or Re Remedy s Dry, Read Cleanser & Cool Soothe & Soothe s = 1 Moisturi s ? Yes = ze/ zer cerss? Ye ze/ 1 Moisturi Moisturi ressure ul Protect Protect Remedy
risk of developing pressure ulcers Moisturi Skin zers 0—Is this resident at M015 Cleanser No against the hair follicles—apply only to the affected area tact medy N//A Rins & Cool or Re e Remedy
In othe Cleanser any So s g Wipes, rriers Cleansin tatatitive Ba PPreven r Remedy & Cool or Re Soothe Remedy 0 ze/ zer rs? No = Moisturi Moisturi ure ulce Protect g pressure » Choose the most appropriate product and risk of developing pressure ulcers? Is this resident at M0150— CleanCleansernser medyedy N//A othe & Cool or Re any So or Remedy Wipes, Cool INZO or Re Cleansing ononene Sootothehe & Dimethicmethic d or Hydraguard Remedy otothehee Nutrashiel absorbency level for each resident iers or So Cool Barr Soothe & INZOO s = 1 ze/ zer & Cool ceMedlinrs?rs? Ye Moisturi Moisturi e Indu t pressure ul © stries Protec oping 2017 Medlin , Inc. | sk of developing pressure ulce e Indu www.medline ri stries .com | , Inc. All 1-80 Is this resident at rights re 0-MEDLIN Cleanser served E | 3 M0150— memedyedy . Medlin /A Thre or Re e isN/ a regist e Lakes othe & Cool ered Drive, Nort any So Remedy trademark hfi eld, Wipes, INZO or Re of Medlin IL 6009 » Check the wetness-indicator lines on the back of & Cool e Indu 3 ononee otothehe &
Cleansing DimDimethicmethic So or Hydraguard stries, Inc. ddened, Chapped Skin Chapped ddened, d Remedy otothehe Nutrashiel rss orr So Re Barrie Remedy INNZOO ze/ zers & Cool ... Moisturi Moisturi age Protect ntinued on next pa products—these lines give an indication as to when Chart CoContinue the product requires changing, thereby reducing the risk of urine being in contact with the skin for CLINICAL DECISION TREE FORMS FOR any length of time and avoiding the unnecessary BATHING AND PERINEAL CARE changing of pads in some circumstances41,42,43
1-800-MEDLINE (633-5463) | medline.com 53 Educate the Family. Once you have received your posters: Arrange a Family Night Meeting 3. Fill out and hang your posters in well-lit areas where Life changes can occur at the most unexpected times, in friends and family members often congregate when the most unexpected ways. When a new resident enters visiting. Be sure to hang them up 2 to 4 weeks in your facility, often they are scared and unsure of what advance to ensure a good turnout. their life will be like in your facility. And while you and your staff are working very hard to make the resident feel If your Medline sales representative is attending the welcome and safe, it is important to do the same for your meetings with you, be sure to contact him/her the week resident’s friends and family members. When the resident is before to: incontinent, it can further complicate things as incontinence 4. Re-confirm dates and times. can often stir up a mixture of conflicting emotions. 5. Review talking points.
Hosting a family night is a great way to engage friends, The day of the Family Night Meeting: family and loved ones to help them deal with the life and 6. Be sure to gather samples of the products you use in health changes that they and their loved one may be your facility. experiencing. Arranging a family night provides a great 7. Be sure to grab the CNA toolkit so you can show the opportunity to educate residents’ family members and family members the tools you use to ensure their loved friends about incontinence and absorbent product options. one is in the correct product. 8. If you are serving refreshments, make sure you have To help ensure a successful meeting, be cups, tables and chairs for everyone to sit and relax. sure to utilize the tools that Medline has 9. Make sure there is someone at the entrance of your available and take the following steps: facility to greet and guide everyone to the meeting area. 1. Contact your Medline sales representative and ask him/ 10. GET STARTED! her for several of the FAMILY NIGHT posters and 25 Understanding Incontinence pamphlets. Here is one example of a FAMILY NIGHT script: 2. Ask your Medline sales representative if they can attend Thank you so much for coming here this evening. Nothing the meeting(s) to discuss the Medline incontinence means more to us than caring for your loved one. Tonight products you are using in your facility. we are going to talk about incontinence. Feel free to ask questions along the way. We will also leave time at the end to address any additional questions, comments or concerns.
Incontinence Solutions Continence is the ability to control urine comfortably and to void in an appropriate place. Incontinence is the involuntary loss of urine. If you have noticed that your loved one is wearing a disposable incontinence care product, it is because they have some type of incontinence issue.
Here at (YOUR FACILITY’S NAME HERE) we promote Family Night individualized care and are committed to a coordinated and Come join us for a family night to The discuss In comprehensive nursing care plan that encompasses the Medline Representa continence Products. on the new products tive will be on hand to give demonstrations and answer any questi ons you may have. values, needs, strengths and desires of your loved one.
Date
Time
Location Refreshments will be served. A nursing care plan outlines the nursing care to be provided.
© 2017 Medline Indu stries, Inc. All righ ts reserved. Medlin e is a registered trademark of Medlin e Industries, Inc. It outlines a set of actions that all of our care staff will perform routinely to ensure your loved one receives the FAMILY NIGHT very best care while in our facility. POSTER
54 MEDLINE When your loved one arrived, we screened and/ or assessed them to determine what type of, if any, incontinence they had. These assessments help us plan how we are going to care for them. Our goal is to promote
comfort, dignity and independence. EDUCATE THE FAMILY
If your loved one is continent, an individualized plan of care to promote independence and dignity has been developed. Tips for Success! If your loved one is incontinent now but has the potential The Family Night meeting is also a to be continent again, an individualized training protocol great time to talk about all of the has been developed. Some of our residents may be unable things that you do to educate your to toilet independently but may benefit from a toileting staff on incontinence. Talk about schedule, so an individualized toileting routine has been all of the courses you have your developed for them. And for those who are incontinent CNAs take on Medline University, and require disposable incontinence care products they the educational tools that they use have been assessed for product type and fit. Product type to ensure their loved one is in the will depend on what kind of incontinence your loved one appropriately sized product. Talk has. There are several types and levels of incontinence about how they are required to and thankfully, there are also several types of disposable participate in on-going training and incontinence products to help manage them. If you open have to demonstrate what they your QUICK REFERENCE GUIDE we can go through the have learned. various types in more detail. We have also gone through this guide with your loved one.
Incontinence TipsTips FFor Better LeakagLeLeakage Solutions If thethhe incontinencinc Care. ontinenc e prp oducts you selected ar »M akeaake sure leg cucuff »E» Ensure the appropffs are plac e leaking, do the following: nsuure the app ed snugly in the cr »E» Ensurensur the corr ropriater product is being used re the co eases be »C»Con rrectect sizes tween the perineal ar onfirmm that the backsheetbac is being sur used »B» Be sure the product is ea and the thighs e suree the pr oduc face in the area of the leg elas »»R educ t i ce e uusage of ntered from front to back and side to side »I In male petropetrolatum mo tics is s, ensuree the penisp is pointingisture downward barriers facing ou »E Evvaluate ababsorben twards bsor bency bby chec king the change rate and Skinn IrritationIrrrrittat Iff y tion consider a more ab ou ence ounter irritation, do r irritation sorbent product »»E Ensure the leg cu nsuree the leg the following: »E» Ensurensure pe p cuffs are plac perineal carec is being edpe snug in the creases be »C heck thatth the productcare is isbe the co hat the pro rformed with each incontinenttw episode »»E Ensurensure that tha the backoduct is een the perineal ar hat th rrect size e baccksheet is facing ou ea and the thighs Blistetersrss tward Iff you observ e blisters,b dod »E» Ensurensure that that all al ou do the following: »C ll outside pap heck applicatapplicatio parts of the product are not touching the sk »E» Ensurensure that that the th iosideon »C e sside heck and revireview applicationflaps area method in eww applicatio completely unfolded before applying the brie Quick ion s Reference Guide f QUICK REFERENCE GUIDE
1-800-MEDLINE (633-5463) | medline.com 55 Assess New Residents and Reevaluate Current Residents. When should I do an assessment on a new resident? Continence Assessment Guide If the resident in question has a history of being incontinent Respecting Residents’ Rights During or is known to be at risk for being incontinent, the a Continence Assessment assessment should start as soon as possible. There are 3 As with any other aspect of conducting a continence trigger questions that you should start with: assessment, it is important to be sensitive to the private 1. Do you leak urine before getting to the toilet? nature of a resident’s bladder and bowel elimination 2. Do you suffer from constipation or diarrhea? habits. For this reason, the way in which information is 3. Does your bladder or bowels ever cause you obtained about a resident’s continence status, frequency embarrassment, pain or discomfort? of voiding, frequency of using their bowels or stool type should be done discreetly. It may not always be possible to Why 72 hours? obtain information about a resident’s bladder and bowel The bladder assessment should be active for a minimum habits, however in the context of providing day-to-day period of 3 complete and consecutive 24-hour periods personal care to residents, residential aged care staff are (including day and night). Three days is the average time generally well placed to discreetly observe and identify that it takes to identify residents’ bladder patterns. Some signs and symptoms that will help provide a comprehensive residents may need a longer period of monitoring. continence assessment. Some residents may resist staff attempts to provide continence care: particularly residents How often should a residents’ urinary continence who have dementia and who may misinterpret staff actions. status be checked (during assessment)? It is recommended to monitor the frequency of the resident’s bladder elimination and urinary continence Frequently Asked Questions status closely during the assessment period. More frequent About Completing the observations provide more accurate information on which to base a care plan. Bladder Assessment Conduct manual checks every hour or two hours. When should an assessment start with a resident? The frequency of checks and the manner in which they The best time to begin a 72-hour bladder assessment are conducted should not interfere with the resident’s is when the resident is settled and familiar with their usual activities. surroundings. This timing varies from resident to resident but usually it can be done one to two weeks after the How is information collected to complete resident is admitted to the facility. Other times that the the 72-hour bladder assessment? 72-hour bladder assessment may be appropriate to use are Ideally, information to complete the 72-hour bladder when you are reviewing the resident’s continence status assessment should be provided by resident’s themselves, and when you wish to monitor the effectiveness of care. however, due to dementia and other health related conditions, this is often not possible.
Identify if the resident is continent or not during the designated time periods. Discreetly observe for urine loss when providing personal care. If the resident is using a pad, check for a wetness indicator (usually located on outside of pad). Also observe and document how many drinks the resident has within the designated time periods; what type and what amount.
56 MEDLINE What should be done with the What should be done with the information information from the Assessment? from the Seven-Day Bowel Assessment? Information from the Assessment should be used to Information from the Seven-Day Bowel Assessment can complete the Continence Assessment Form and Create an be used to complete the Continence Assessment Form Individualized Care Plan. to develop an individualized continence care plan that is responsive to the resident’s needs. ASSESSMENT Frequently Asked Questions In particular, it will help you to complete the section on About Completing the Seven- Bowel assessment. Review the information collected over the 7-day period to decide whether or not a resident has a Day Bowel Assessment predictable pattern of using their bowels. If yes, develop and put in place an individualized toileting program that When should the Seven-Day is based on this pattern. If no, ensure the resident has the Bowel Assessment start? opportunity to use their bowel regularly. As there are some The best time to start a Seven-Day Bowel Assessment special techniques or strategies available to help people is when the resident is settled and familiar with their develop regular bowel elimination, you might like to involve surroundings. This timing varies from resident to resident a Registered Nurse, Continence Nurse or the resident’s but usually it can be started one to two weeks after the General Practitioner. resident is admitted to the facility. Other times that the Seven-Day Bowel Assessment may be appropriate to use are when you are reviewing the resident’s bowel Additional Triggers for management program and when you wish to monitor the effectiveness of care. Assessing Resident(s) Some medical conditions can impair the resident’s ability Why maintain the Assessment for seven days? to identify the urge to pass urine or use their bowels. This The Seven-Day Bowel Assessment should be maintained for could be due to a lack of sensation or because they are a minimum period of 7 complete and consecutive 24-hour unable to interpret the sensation, or because they are periods (including day and night). If it is not possible to unable to communicate the need for assistance. Observe monitor the resident’s bowel elimination over 7 consecutive the resident for individual behaviors such as agitation and days, the chart can be completed over 7 separate, complete pulling at clothing that indicate they need to use the toilet. 24-hour periods. Seven days is the average time that it takes to identify residents’ bowel patterns. Some residents Can the resident tell you where the toilet is? may need a longer period of monitoring. Some residents have medical conditions that make it difficult for them to identify the location and/or use of How frequently should residents’ bowel the toilet. Remind the resident to go to the toilet regularly continence status be checked? and provide direction if required. Other strategies include It is preferable to monitor the frequency of the resident’s placing the resident close to the toilet, leaving the toilet bowel elimination and bowel continence status closely light on at night and ensuring the toilet is easy to identify. during the assessment period. More frequent observations provide more accurate information on which to base a care Can the resident walk to the toilet independently? plan. The frequency of checks and the manner in which The ability to walk is critical for the maintenance of they are conducted should not interfere with the resident’s continence. Mobility programs have been shown to improve usual activities. residents’ continence status. If the resident is unable to walk to the toilet or if this involves unnecessary risk or pain, How is information collected to complete consider the use of other devices (i.e., bedpans, urinals, the Seven-Day Bowel Chart? commodes or absorbent pads). Ideally, information to complete the Seven-Day Bowel Assessment should be provided by residents themselves, Can the resident get on and off the toilet however, due to dementia and other health related independently? conditions, this is often not possible. Identify if the resident Although some residents may be able to complete some is continent or not during the designated time periods. aspects of toileting, they may require assistance with other Discreetly observe for fecal loss when providing personal aspects, such as getting on and off the toilet. Assistive care (i.e., during toileting or hygiene assistance). devices such as handrails and/or a raised toilet seat may provide the levels of support needed for residents to use the toilet with more independence.
1-800-MEDLINE (633-5463) | medline.com 57 Can the resident undress and dress Medications such as diuretics can also affect the frequency themselves before and after toileting? of passing urine. Because an older person’s bladder There are a number of factors and conditions that may generally holds less urine, people over the age of 65, often make it difficult for residents to complete all aspects of the need to pass urine every 3–4 hours. It is important to toileting procedure. Consider using clothing that is easy for consider whether or not there are any medical conditions the resident to manage if dressing/undressing is a challenge. or reversible factors that are causing the resident to pass urine frequency and if so, how bothersome the resident’s Can the resident use toilet paper frequency of passing urine is to them. If a resident passes and wipe themselves? urine too frequently or has trouble passing urine, this Some residents may need help with this aspect of personal should be reported to the RN, Continence Nurse or GP. care. Provide assistance as required. Consider offering Difficulty with passing urine in elderly men may indicate pre-moistened wipes. a problem with the prostate.
Does the resident cooperate with staff when During the night, how many times does they assist with toileting or changing? the resident need to pass urine/go to the Some residents may have difficulty understanding staff toilet on average (from 7pm–7am)? efforts to provide continence care. The activity of removing It is normal for older people to pass more urine at night and the resident’s clothing may be interpreted by them as an act to have the urge to pass urine 1–2 times. If this occurs more of violation. If this is a problem, it is important to assist the frequently, it is important to consider whether or not there resident to understand your actions. Respect their right to are medical factors that need to be investigated. Another decline and suggest that you will come back later to see if factor to consider is the resident’s risk of falling at night as they are ready. they attempt to respond quickly to the urge to pass urine. This will affect your management at night (i.e., consider Does the resident experience pain that a bedside commode/call bell being accessible etc.). restricts their toileting, transfer, clothing adjustment and/or hygiene? Does the resident experience urine Because pain can reduce a resident’s mobility and exhaust leakage during the day or night? their physical and emotional reserve, it may also deter There are many possible reasons for residents’ experiencing them from going to the toilet. This is also true for people incontinence during the day and/or night. Reasons for with dementia. If pain is a contributing factor, consider the daytime incontinence may differ from reasons for night- use of other devices (i.e., bedpans, urinals, commodes) or time incontinence. Conducting a continence assessment will continence products (i.e., absorbent pads). help you to identify possible causes and a plan of action. Some residents will respond however to regular and timely Most people pass urine 4–6 times a day and 1–2 times at toileting assistance. night (if >65yrs of age). If the resident passes urine too frequently or infrequently, they may require a medical Does the resident have a predictable pattern assessment. If they need to pass urine at night, it is of passing urine (including urine leakage)? important to assess their risk for falling. If the resident has a predictable pattern of passing urine, they may respond to an individualized toileting program You may need to develop a continence care plan for day and where you either prompt or assist them to the toilet at another plan for night. The frequency of bowel elimination times that are based on their usual pattern. Alternatively, varies considerably from individual to individual. Aim for if there is no predictable pattern, they may respond to residents to use their bowels regularly (at least 3 times a fixed time toileting program. This involved taking the per week) and to pass a stool that is soft and formed (Type resident to the toilet at fixed regular intervals. If the 3–4 on the Bristol Stool Form Scale). Refer to the 72-Hour resident is not suitable for a toileting program, you may Bladder Assessment and Seven-Day Bowel Assessment for choose to put in place a pad check and change program. assistance answering some of these questions. This involves regular checks of the resident’s continence status and changes of pads (if wet). During the day, how many times does the resident need to pass urine/go to the Does the need to pass urine or incontinence at night toilet on average (from 7am–7pm)? make it difficult for the resident to go back to sleep? Some residents may have medical conditions that affect how Getting up to pass urine at night is commonly experienced often they pass urine. Congestive Cardiac Failure is one such by older adults. For many, this is not a problem, however for condition. Urinary tract infections are another. Constipation some people, it is disruptive and they find it difficult to get and fecal impact may also cause bladder symptoms. back to sleep.
58 MEDLINE How often does the resident Does the resident drink an adequate normally use their bowels? amount of fluid to maintain hydration and Normal healthy bowel elimination is characterized healthy bladder and bowel function? by the following factors: Inadequate fluid intake can result in urinary frequency, » Regular bowel movements (frequency urgency and urge incontinence because it may lead to varies from person to person) either a UTI or to urine that is highly concentrated and ASSESSMENT » A stool that is brown in color, soft and formed irritative to the bladder. It may also result in the resident the ability to recognize the urge (i.e., sensation) becoming constipated. Most people rely on thirst as an to use one’s bowels—usually in the morning indication of the need to drink—older people are at risk of following breakfast and a warm drink experiencing an impaired thirst mechanism, putting them » A stool that is easy to pass (i.e., no straining) at risk of dehydration. » The ability to hold on until reaching the toilet Some medical conditions or side effects of medications » Feelings of satisfactory defecation can result in people drinking excessive amounts of fluid which can contribute to increased urinary symptoms. As people age, the bowels are slower. For older people, Alternatively, some people associate drinking fluids with this change in bowel function does not cause problems. their urinary incontinence, and avoid drinking, leading to a However, when combined with reduced mobility, reduced deterioration of their symptoms. Encourage or assist the food and fluid intake, constipation may develop. resident to have their preferred drinks regularly. Allow adequate time for resident to consume all of their drinks, In the past two weeks has the resident and/or encourage relatives to assist if available. leaked, or had accidents or lost control with stool/bowel movement? Does the resident eat an adequate amount There are many other factors that can combine to make it of food with fibrous content to maintain difficult for residents to have healthy bowel elimination. healthy bladder and bowel function? A continence assessment will help you to identify these Fiber is important to draw water into the feces in the large factors. Does the resident have any of the following intestine, enabling passage of formed, easy to pass stools. It symptoms when they use their bowels? also assists peristalsis—the muscular movement of the bowel » Pain and discomfort that moves the feces along. Offer the resident a variety » Straining of fiber sources. Some residents may prefer small meals »Bleeding more regularly. If the resident wears dentures, check them » Hard, dry motions regularly for correct fit, and ensure they are in at meal times. » Very fluid bowel motions Skin Care These symptoms are often associated with constipation, Aim for the resident’s skin to remain intact and free from fecal impaction or some other anal/rectal pathology. rashes, excoriation and pressure ulcers.
Residents’ urine should be tested on admission as a standard Does the resident’s skin around their buttocks, groin and admission screening procedure and periodically (i.e., perineal area appear: according to facility policies). Any abnormalities should be » Very thin or fragile reported. Normal pH of urine may range from 4.5 to 8 and » Reddened 7 is the point of neutrality. Normal specific gravity in adults » Unusually pale is > 1.000 g/ml. Urine is normally free of blood, nitrates and » Have a discharge leukocytes. The presence of any of these factors indicates » Have a foul or bad smell the need for further investigation. The resident’s GP should be promptly notified of any abnormalities. » Broken, ulcerated, have a rash or have lumps and blotches
Nutrition (fluid & diet) Aim for the resident to have 5–10 cups of fluid per day unless otherwise indicated and limit known bladder irritants. Aim for the resident to have 30gm of dietary fiber per day unless otherwise indicated.
1-800-MEDLINE (633-5463) | medline.com 59 Skin provides a barrier to elements such as heat, moisture The following is a list of different options and bacteria. Constant exposure to urine and feces may put for the treatment of incontinence: the skin at risk, as indicated by the symptoms listed. For Medication example, presence of a foul-smelling discharge may indicate There are many different medicines that target the fungal infection. Urine and feces, especially presence of both condition/symptom of incontinence. The choice of drug on the skin, may lead to irritant dermatitis, characterized depends on the underlying cause of the problem and the type by red and thin skin. If a resident is incontinent, cognitively of incontinence. Potential side effects must be considered impaired and immobile, they are at greater risk of friction and and the resident must be monitored during treatment. shear related injury and pressure ulcers. Bladder training To avoid skin breakdown wash and dry Bladder training aims to increase a person’s bladder the skin soon after incontinent episodes. capacity, the interval between voiding and ability to defer Apply skin creams as directed. Avoid thick layering of voiding. This is done by progressively increasing the interval barrier creams as these can rub off on the products worn between voiding over a number of weeks. Bladder training by resident, rendering it ineffective at absorbing the urine. is suitable for individuals who are cognitively alert and able Ensure the pad that has been selected fits appropriately to follow a structured program. and is adequate for the degree of wetness—if a pad leaks it is likely the skin will be unnecessarily exposed to moisture. Pelvic floor muscle training Pelvic floor muscle exercises are designed to strengthen the Is the resident currently using a continence pelvic floor muscles through actively tightening and lifting product to manage their incontinence? them at intervals. Weakness of the pelvic floor muscles may The ability to maintain social continence (incontinence result in incontinence. Pelvic floor muscle training is suitable managed or contained with products) is crucial to one’s for individuals who are cognitively alert and able to follow a sense of well-being. As many residents admitted to a structured program. residential aged care facility have a pre-existing problem of incontinence, they may have already established an Resident’s Perspectives effective management strategy. It is important to consider It may not always be possible to obtain accurate their past management and their personal preferences information from the resident about their preferences for when assisting them to choose the most appropriate form continence care or about how they feel about incontinence. of continence management. At the same time, their perspectives and their past management should be considered. It may be appropriate Medical Factors to ask a family member for information. Keep in mind that It is important to distinguish between residents who have some residents may hold low expectations of improvement. incontinence that may be caused by a potentially reversible An important aspect of your role is to provide information cause/condition and residents whose incontinence is about healthy bladder and bowel elimination and to ensure chronic and not responsive to treatment. Identifying that the resident has access to further assessment and potentially reversible conditions which may be causing or intervention as required. exacerbating incontinence can be challenging in residents who may also have dementia or health conditions that make It is important to have the conversation with your resident. it difficult for them to communicate their needs. Confusion Ask them the following questions if they are experiencing a associated with delirium for example may be difficult to bladder and/or bowel problem: distinguish from confusion associated with dementia. Similarly, incontinence, urinary frequency or increased What kind of assistance would you prefer? : confusion may be the only symptoms evident in residents with bladder infections. » No assistance » To be assisted to go to the toilet at (specific time) » To wear pads during the day » To wear pads during the night » To wear pull-ups during the day and a brief at night
Additional options may be discussed based on your facility’s ordering.
60 MEDLINE Ideally, all residents should be consulted about their preferences for continence care. Family members may also How to Review Residents’ be a valuable source of information about the resident’s Continence Status preferences or past coping strategies. While it may not be possible to accommodate all of their preferences, they Why should the Continence Review be conducted? should nevertheless be considered. While the resident’s continence status may remain stable,
it may also change—particularly if their health deteriorates. ASSESSMENT If you are experiencing a bladder problem, It is important to regularly review the resident’s continence how much of a problem is this to you? status and to update their continence care. By identifying » No problem changes in a resident’s continence status early, you will be able to address potentially reversible conditions in a » A bit of a problem timely manner, or improve their quality of life by providing » Quite a problem symptomatic treatment. » A severe problem When should the Continence Review be conducted? Asking the resident about the extent to which they are Quarterly, or if there are significant changes affected by bladder and/or bowel symptoms conveys with the resident. respect for the resident. Incontinence is commonly associated with depression and reduced quality of life in What information should be obtained older persons. If a person appears unconcerned about in relation to Continence Review? incontinence, you might like to consider the possibility that The resident may not require a full re-assessment. they may be depressed especially if they have experienced A review involves responding to the following questions: other losses in their life. Has the resident had their continence If you are experiencing a bowel problem, status assessed in the last 90 days? how much of a problem is this to you? Yes: continue on with the next review questions. » No problem No: Consider screening the resident for issues by asking » A bit of a problem top 3 trigger questions. » Quite a problem Has there been any change in the resident’s » A severe problem continence status since the last review? Review the assessment and care plan, and make a judgment Some bladder and bowel symptoms may be more about whether the information is still current. bothersome to a resident than other symptoms. The degree to which the resident is bothered by their symptoms should Does the resident’s continence care be considered when deciding whether or not to seek further plan need to be changed? specialist advice. Review the responses to the above questions, and review the care plan if not already completed. If you currently wear an incontinence product, does it keep you dry and comfortable? »Yes »No » I don’t know
1-800-MEDLINE (633-5463) | medline.com 61 The more concentrated the urine, the higher the urine specific Assessment Tips and Facts gravity. A low specific gravity may indicate renal disease Toileting Ability, Cognitive Skills & Mobility and certain metabolic disorders (e.g., diabetes insipidus). Although continence may not be achievable for all The normal specific gravity range in urine is 1.020–1.030 g/ml. residents, it is nevertheless important to encourage all Levels above or below this range warrant attention. residents to participate as much as possible in toileting activities so that they remain as mobile and independent Blood in Urine as possible. Another aspect to keep in mind is the resident’s Otherwise known as hematuria, blood in the urine can be personal preferences for continence care. visible to the naked eye or it may be microscopic. There are many possible causes of hematuria including urinary tract Voiding < 3 Times During Day infection, inflammation/infection of the prostate, stones, If the resident has difficulty voiding and/or voids an injury to any part of the urinary tract, excessive exercise, infrequently, this may indicate a prostate problem (in men) certain medications (e.g., blood thinning agents), kidney or a neurological problem that results in incomplete bladder disease and/or cancer of the kidney, prostate or bladder. If the emptying. The symptom should be considered in relation resident has hematuria, it should be promptly investigated. to other symptoms (e.g., a sensation of incomplete bladder emptying, etc.). A medical assessment may be warranted. Nitrates in Urine Under normal conditions, urine is sterile and free from Voiding > 6 Times During the Day/ bacteria, viruses and fungi. The presence of nitrites in Voiding > 2 Times During the Night urine indicates a urinary tract infection. This should be If the resident voids frequently during the day and/or further investigated. night, this may indicate an underlying health problem that requires attention, or it may be the result of medication. Leukocytes in Urine The symptom should be considered in relation to other The presence of leukocytes in urine is indicative of a urinary symptoms (e.g., urgency, urge incontinence, symptoms tract infection. This should be further investigated. of UTI etc). A medical assessment may be warranted. Impaired Skin Integrity The Use of a Urinary Catheter If the resident has impaired skin integrity, they will require Residents with indwelling urinary catheters are at high risk a care plan that specifically addresses this issue. A Wound for developing bladder infection. It is important to develop Care Consultant may be able to provide additional advice a catheter care plan that minimizes catheter related and assistance. problems. A medical assessment and/or involvement of a Continence Nurse may be warranted. The catheter should Delirium not be removed unless it is clear that it is safe to do so and Delirium causes acute confusion which may result in the that the resident will be able to independently void. resident being unable to perform toileting tasks and/or communicate need for assistance. Catheters should be avoided for continence management unless there is a clear benefit to the resident. Bladder Infection Bladder infections cause bladder irritation which in turn Urine pH can cause symptoms of urgency and urge incontinence. 7 is the point of neutrality on the pH scale. The lower the pH, the greater the acidity of a solution; the higher the pH, the Constipation greater the alkalinity. Urine pH is an important screening test Constipation can affect the bladder by causing symptoms for the diagnosis of renal disease, respiratory disease and of urgency and urge incontinence, and pressure caused by certain metabolic disorders. Depending on the person’s constipation/fecal impact may affect bladder emptying. acid-base status, the pH of urine may range from 4.5 to 8. Levels above or below this range warrant attention. Irritable Bowel Syndrome Irritable bowel syndrome can cause symptoms of fecal Urine Specific Gravity urgency, fecal incontinence, or alternatively, may result Specific gravity measures the kidney’s ability to in constipation and incomplete bowel emptying. It often concentrate or dilute urine in relation to plasma. Because responds to dietary measures. urine is a solution of minerals, salts and compounds dissolved in water, the specific gravity is greater than 1.000.
62 MEDLINE Atrophic Vaginitis Atrophic vaginitis is caused by a lack of estrogen to the Assessment of walls of the vagina and is common in older women. It results Bowel Elimination in thinning of the vaginal wall and symptoms of stress incontinence. It also causes vaginal irritation. Local estrogen Desired Outcome / Objective: therapy may be indicated. 1. There is timely identification of those at risk of
developing bowel elimination problems ASSESSMENT Unstable Diabetes 2. Where a bowel problem exists, appropriate, thorough Unstable diabetes can cause urinary frequency, urgency and prompt assessment is provided and urge incontinence because of the presence of glucose 3. The assessment is clearly documented in urine—which in turn can be irritating to the bladder wall. 4. Management and treatment is appropriate, and Longstanding diabetes may also cause damage to the nerve contemporary and based on a thorough assessment supply to the bladder and/or bowel. Stabilizing the resident’s diabetes can improve bladder and bowel function. Individual bowel management programs are consistent with contemporary practice in the area, implemented, and Depression reviewed at regular intervals. Treatment and management Depression is common in older adulthood and particularly of any bowel condition is based on a thorough individual among individuals with multiple health problems. assessment, and the rationale for treatment and Depression can lessen a person’s motivation to engage in management are clearly documented. self-care activities—including continence care. Defining a Normal Bowel Pattern Enlarged Prostate It is not necessary for people to open their bowels every As men age, their prostate increases in size and, in some day. While it is true that some people do have daily bowel cases, can result in voiding problems. Symptoms include actions, most people don’t. It is considered normal for a urinary frequency, difficulty passing urine (hesitancy), person to open their bowels anywhere from 3 times per nocturia and a sense of incomplete emptying. A referral day through to 3 times per week. It is more important for to a urologist may be indicated. a person to have a regular, relaxed and easy bowel motion than it is for them to go every day. Medications that May Affect Continence Many residents take either prescribed or over-the-counter When defining normal bowel patterns, a number of factors medications (including laxatives). Although medications need to be considered as well as bowel motion frequency. are important for managing specific conditions, many A normal bowel motion should be: have side effects that can affect bladder and/or bowel » Regular and within the normal frequency range function. For example, laxatives are the most common » Soft but formed, not hard or watery cause of fecal incontinence in residential aged care settings. » Easy to pass without straining or pain Similarly, diuretics (commonly used to manage chronic heart conditions) give people a strong sensation of urinary » Followed by a feeling of having emptied the bowel properly urgency that prompts them to rush to the toilet. During its peak effect, diuretics also give people a sense of wanting to pass urine frequently. It is important to inform the resident’s General Practitioner of any possible side effects so that their medication can be reviewed.
1-800-MEDLINE (633-5463) | medline.com 63 3. A physical examination may be conducted and Assessment documented by appropriate staff and may include: Routine Screening of Bowel Patterns » Examination of the abdomen for signs The residents should have their bowel elimination needs such as abdominal tenderness, a mass assessed routinely. This assessment should include: or decreased bowel sounds » Details of normal bowel habit » Perineal inspection, looking for abnormalities such as evidence of soiling, rectal prolapse, peri-anal scarring, » When bowels were last opened a gaping anus or perineal descent or hemorrhoids » Currently used management such » A rectal examination to determine amount and as laxatives or special diet type of feces in the rectum, the presence of any » Presence of past/current bowel problems rectal mass and the state of anal sphincter tone
Bowel pattern during the admission should then be What Is the Bristol Stool Form Scale? recorded on the daily observation form or on the daily The Bristol Stool Form Scale is a visual aid designed to help bowel record if this is the routine practice in the unit. you to classify the consistency or form of the stool. The seven types of stool are pictured on the left. The scale is Assessment of a Specific Bowel Problem widely used in practice and has a strong research base. If there are concerns about a resident’s bowel status, or a problem is identified, a more thorough assessment Why Should the Bristol Stool Form Scale Be Used? is required. Stool consistency (i.e., stool form) is an important factor to consider in assessing bowel function. By referring to the A specific assessment of bowel function should be Bristol Stool Form Scale, you will obtain more accurate initiated if/when: assessment information than through other methods 1. Resident is thought to be at significant risk of of evaluation. developing a bowel problem 2. A bowel problem has been reported or noted What Is a Normal Stool? 3. The resident’s bowel status deteriorates or changes If the resident has types 1 and 2 stool, this indicates 4. A resident on a bowel management plan needs constipation. Types 3 & 4 are considered normal stools and periodic review types 5–7 denote looser stools or diarrhea. The most ideal stool type is type 4 as this is the easiest to pass. The assessment should be commenced as soon as possible following the identification of the problem and completed Bowel Motions < 3 Times per Week within 7–14 days. Individuals vary widely in how frequently they use their bowels; however, most people defecate 3 times a week A Bowel Elimination Assessment Will Include: or more. If they defecate less than 3 times a week, and 1. The assessment form, which assists in collecting all the also have a hard stool that is difficult to pass, this may data required for a nursing bowel assessment including: indicate constipation. Healthy bowel elimination is primarily » A history of bowel elimination pattern, characterized by regular bowel movements, a soft, formed including continence status stool and a stool that is easy to pass (i.e., no straining). » A history of relevant general conditions The resident may require increased fiber, fluid, activity or that may impact on bowel status laxatives to achieve this. » A review of medications that may impact on bowel status Pain and/or Discomfort when Using Bowels » A review of nutritional status in Pain/discomfort during defecation is not normal and should relation to bowel elimination be investigated. It may indicate an underlying pathology such as hemorrhoids, or the individual may be constipated. 2. Observation, which includes observations of: Straining to Use Bowels » Frequency and timing of bowel movements Some straining to use bowels is normal. Excessive straining » Consistency or form of stools (using indicates constipation and/or an underlying pathology the Bristol Stool Form Scale) (e.g., neuropathic damage). Keep in mind that people with » Amount or size of stools chronic health conditions may have difficulty in achieving » Presence of straining or pain associated abdominal pressure that facilitates bowel clearance. with a bowel motion » Presence of abnormalities in the stool such as blood, mucous, fat or undigested food
64 MEDLINE Bleeding when Using Bowels Treatment and Management Bleeding during defecation is not normal. It may indicate A decision regarding the type of bowel elimination hemorrhoids or other underlying pathology. problem is made following thorough assessment. An individual management plan is based on this assessment Hard, Dry Bowel Motions in consultation with medical staff and with the person as Bowel motions should be soft and formed. Refer to the appropriate. The plan of care is documented as per the Bristol Stool Form Scale for assistance in differentiating unit’s protocol. ASSESSMENT between a healthy and unhealthy motion. There are numerous factors that result in motions that are too hard Evaluation (e.g., medication side effects, inadequate fluid, exercise and The management program is to be evaluated to determine fiber) or in motions that are too loose (e.g., diet, irritable if the caregiver interventions are achieving the goals of bowel syndrome, gastroenteritis, medication side effects). care. A bowel evaluation should be completed for at least 3 days, and preferably a week, while the management plan is Suggestions to Help with Assessment: in place. If the resident’s bowel pattern is demonstrated to 1. Involve the resident in their bowel assessment, if possible be satisfactory and continues to meet the care plan goals, and appropriate, by giving them an illustrated stool form no further assessment is required. However, the bowel chart so they can observe their own bowel motions assessment may need to be repeated if the evaluation 2. Maintain a detailed assessment only as long as required demonstrates a problem, or if a problem is identified by either 3. Limit the number of residents being assessed to one or the resident or the caregivers between routine evaluations. two per unit at a time to minimize staff workload and reduce the risk of confusion
The Bristol Stool Form Scale
Type 1 Separate hard lumps, like nuts (hard to pass)
Type 2 Sausage-shaped but lumpy
Type 3 Like a sausage but with cracks on its surface
Type 4 Like a sausage or snake, smooth and soft
Type 5 Soft blobs with clear-cut edges (passed easily)
Type 6 Fluffy pieces with ragged edges, a mushy stool
Type 7 Watery, no solid pieces ENTIRELY LIQUID
Reproduced by kind permission of Dr. KW Heaton, Reader in Medicine at the University of Bristol. Produced by Norgine Limited, manufacturer of Movicol®
1-800-MEDLINE (633-5463) | medline.com 65 Type 4: Snake-Like, Smooth and Soft Bristol Stool Form Chart This form is normal for someone defecating once daily. “How to Interpret” Guide The diameter is 1 to 2 cm (0.4–0.8"). The larger diameter suggests a longer transit time or a large amount of dietary Type 1: Separate Hard Lumps fiber in the diet. These stools lack a normal amorphous quality, because bacteria are missing and there is nothing to retain water. Type 5: Soft Blobs with Clear-Cut Edges The lumps are hard and abrasive, the typical diameter This form ideal. It is typical for a person who has stools ranges from 1 to 2 cm (0.4–0.8"), and they can be painful twice or three times daily, after major meals. The diameter to pass, because the lumps are hard and scratchy. There is 1 to 1.5 cm (0.4–0.6"). is a high likelihood of anorectal bleeding from mechanical laceration of the anal canal. Fermentation of fiber is not Type 6: Fluffy Pieces with taking place so flatulence is not likely to happen. Ragged Edges, a Mushy Stool » Typical for acute dysbacteriosis, post-antibiotic This form is close to the margins of comfort in several treatments and for people attempting fiber-free diets respects; consider it borderline normal. This kind of stool may suggest a slightly hyperactive colon (fast motility), Type 2: Lumpy, Sausage-Like excess dietary potassium, or sudden dehydration or spike Represents a combination of Type 1 stools impacted into in blood pressure related to stress (both cause the rapid a single mass and lumped together by fiber components release of water and potassium from blood plasma into and some bacteria. The diameter is 3 to 4 cm (1.2–1.6"). the intestinal cavity). It can also indicate a hypersensitive This type is the most destructive by far because its size is personality prone to stress, too many spices, drinking water near or exceeds the maximum opening of the anal canal’s with a high mineral content, or the use of osmotic (mineral aperture (3.5 cm). Can cause extreme straining during salts) laxatives. elimination, and most likely to cause anal canal laceration, hemorrhoidal prolapse or diverticulosis. To attain this form, Type 7: Watery, No Solid Pieces the stools must be in the colon for several weeks instead Diarrhea; typical for people affected by fecal impaction— of the normal 72 hours. Anorectal pain, hemorrhoidal a condition that follows or accompanies Type 1 stool. During disease, anal fissures, withholding or delaying of defecation, diarrhea the liquid contents of the small intestine (up to and a history of chronic constipation are the most likely 1.5–2 liters/quarts daily) have no place to go but down, causes. Minor flatulence is probable. A person experiencing because the large intestine is stuffed with impacted stools these stools is most likely to suffer from irritable bowel throughout its entire length. Some water gets absorbed; syndrome because of continuous pressure of large stools the rest accumulates in the rectum. on the intestinal walls. The possibility of obstruction of the small intestine is high, because the large intestine is filled How to Interpret Bristol Stool Chart Scale to capacity with stools. Adding supplemental fiber to expel To avoid referencing non-descriptive numbers, use the these stools is dangerous, because the expanded fiber following definitions: has no place to go, and may cause hernia, obstruction or perforation of the small and large intestine alike. Types 1, 2 and 3 = hard or impacted stools » Typical for organic constipation Type 4 and 5 = normal or optimal Type 6 = loose stool, subnormal or suboptimal Type 3: Sausage Shaped, Cracks in the Surface Type 7 = diarrhea This form has all of the characteristics of Type 2 stools, but the transit time is faster, between one and two weeks. The In such cases as acute hemorrhoidal disease, anal fissure or diameter is 2 to 3.5 cm (0.8–1.4"). Irritable bowel syndrome is the inability to attain unassisted stools, loose stools (Type 6) likely. Flatulence is minor, because of dysbacteriosis. The fact are acceptable. that it hasn‘t become as enlarged as Type 2 suggests that the defecations are regular. Straining is required. All of the To restore and maintain normal stools (from Type 4 to 6), adverse effects typical for Type 2 stools are likely for Type 3, the colon and rectum must first be free from hard stools especially the rapid deterioration of hemorrhoidal disease. (from Type 1 to 3). » Typical for latent constipation
66 MEDLINE Hard stools can be small, regular, and large. Equally What Is Latent Constipation? important, a small stool for one person can be large for In the past, the term “costivity” was broadly used to another, because the perception of size isn’t determined describe hard stools and straining, while the term by a caliper, but by the aperture of one’s anal canal. If the “constipation” was used to describe irregularity, meaning anal canal is constrained by enlarged internal hemorrhoids, a failure to move the bowels daily. even small stools, such as Type 4, it may be difficult to pass.
The rule is: If stools are hard, as in difficult or not easy, or Now, the terms costivity and constipation have blended ASSESSMENT irregular, they are HARD. into one, while the “failure to move the bowels for three consecutive days” has become the official definition of clinical Unless stools are Type 4 to 6 (normal), they are impacted. constipation. Painful and bloody stools within these three Impacted stools can be small, large, hard, soft, dry, moist— days has become a mere irregularity. In practical terms, the it doesn‘t matter. What impacted means is that they had a definition of constipation has become vague and unspecific. chance to pile up and compress in the large intestine. Functional Constipation As you can see from the Bristol Stool Form Chart Scale, This condition commonly follows a stressful event, surgery, normal stools don‘t have to be round. This is because colonoscopy, diarrhea, temporary incapacity, food poisoning the anal canal is not round (when shut, it’s actually or treatment with antibiotics, as well as the side effects of flat), particularly if there is already enlarged internal new medication and circumstances that damage intestinal hemorrhoids. A flat shape is okay. In fact, when stools flora and/or interfere with intestinal peristalsis. A person are already round as in Type 4, it means there is already becomes irregular, stools correspond to the BSC scale Type 1 a slight degree of impaction. Otherwise their shape would to 3, and straining is required to move the bowels. be flattened up while passing through the anal canal. Latent Constipation In Summary: If the intestinal flora, stools and peristalsis aren’t properly » Abnormal stools are any stools that require restored following adverse events, functional constipation straining and/or there is pressure felt from eventually turns into the latent form because the effects stools passing through the anal canal of fiber or the laxative on stools creates the impression » Abnormal stools may be small or large size- of normality and regularity. The stools become larger, wise, depending on fiber consumption heavier and harder (usually the BSC Type 3) and straining and frequency of defecation more intense; but for as long as the bowels keep moving » Normal stools can be loose or slightly every so often, and without too much pain, there is still an formed (such as BSC Type 5) impression of regularity. This is, by far, the most concerning » Normal stools (between BSC Type 4 type of constipation. and 6) aren’t perfectly round » Normal stools for one person may be abnormal Organic Constipation for another—the degree of normality is As time goes by, large and hard stools (between Type 2 and determined by the anatomy of the anal canal 3) keep enlarging internal hemorrhoids and stretching out » Normal stools require zero effort and the colon. This, in turn, reduces the diameter of the anal zero straining for elimination canal even more, causes near complete anorectal nerve damage, and slows down or cancels out completely the » Normal stools pass through the anal canal without any perception of pressure propulsion (motility) of stools alongside the colon. At this juncture, the person no longer senses a defecation urge, Once there is damage to the anal canal, achieving absolute and becomes dependent on intense straining and/or normality may be difficult. One may have to accept a small laxatives to complete a bowel movement. degree of abnormality, such as Type 6 stools.
There is a possibility that after a certain degree of prior damage, caused by fiber, one won‘t be able to attain unassisted defecation and normal stools because of irreversible nerve damage, stretching of the large intestine, significantly enlarged hemorrhoids and similar factors.
1-800-MEDLINE (633-5463) | medline.com 67 FitRight® Assessment Tools Assessment The FitRight® Assessment Tool has been designed to help The complex nature of incontinence can make the your staff determine which type of disposable incontinence assessment process a challenge. To ensure your staff gets management product is needed for each individual the very best information out of the assessment, use the resident. Once an assessment is completed, your staff will Medline FitRight® Assessment tools. These tools offer a know the following: contemporary package that meets all of the requirements » The best product for a comprehensive assessment. » The correct size » Level of absorbency required to manage output Completing and Interpreting a Voiding » How much product will be needed each week/month and Bowel-Elimination Diary Diaries are used to objectively document patterns This information is automatically generated for your staff of elimination and leakage and the effects of the upon entering resident information like: environment, fluids and/or dietary intake on elimination/ incontinence. Use the information obtained to determine »Waist size individualized interventions to regulate elimination and »Height prevent complications of incontinence. »Level of independence » Assistance for toilet use Urinary Continence Assessment » Urinary continence and Implementation Form » Bowel continence The goal of the continence assessment is to obtain the individual’s history and identify any actual or potential » Resident’s ability to express ideas and thoughts bladder or bowel issues that will require further assessment. » Resident’s ability to make decisions
Bladder/Bowel Assessment These forms are used to assess continence status following admission or to fully re-assess if there is a significant change in a resident’s continence status. Record voiding pattern or dysfunction, use of aids and impacting behavior.
Incontinence Solutions ntinent Diary e resident has been inco oiding , document if th eas) ion((s). Lq = LiLiquidqui 24-Hour V ropriate elimination(s). rmed Lq = y 1-2 hours. Using key below (for thoseme arnt app H = Hard fo e resident ever toileted, docu S = SoSoftft formed Check th to be toileted. If Stool/BM ) or needs Saturated (urine, stool or both t S =
D = Damp W = We corded by: y: Incontinent Urine Re Ke bladder : c/o incomplete of 3 Date Notes:Notess: (ee.g.g.,g., c/ Day: s trainininingg w/ elimination, on Diary for FoodsFood empttyinyingngg, sstra w/ acacttivity) Eliminati Fluids urine, leakagleakagee Aware Of malomalodorouododoroous Toilet/ Bladder Scan Urge To nitials Commode/ kindkind?I t Eliminate? c) W What Incontinen nd?Intake (c Bedpan oid What ki -Void Post-V Incontinenc Void BM Yes No Pre e tool Dry Y / N Solutions Time UrineS 12 am Urinary Continen 1 am Assessment and Implementation Form 2 am ce Resident : 3 am Room #: Assessed by 4 am : Date of la Current Product Info 5 am rmatio Date: Diagnosis: n Si 6 am ze: Type : st MDS: Medications: Fr 7 am equency of Leak age: 8 am times/we e 1. Determine Ty ek o Incontinenc None 9 am Question pe of Inco Solutions sCage... Resident pantinenc 10 am a Voiding is co Continued on next pa e Does re ntinent sident ------Does re leak 11 am when sident he/she coughs, and Interpreting Does re need to sident urinat rush s sneeze uddenly s, exercise ircle one I mpleting Does re e more than 7 times/ to the toilet s, laughs Co sident ? ? f “Yes idates after transient en Does have a we ------NY ,” Then... Cand resident ak st day or 2 Proc sidents have ream of ur times/nigh NY eed to ntinence have be Does re frequent ine? t? section and Bowel Elimination DiaryIncontinent re inco ons, sident dribblin ------Stress 2 es of medicati have g? NY ) caus burnin ------cute Chart g or blood in NY Urge (a eated (UTI, c.). The diary urine? e tterns of ted and tr Is Urge ctiv fects of the evalua l impaction, et the incontinence ------NY Obje the ef such relate Overfl ctively document pa on as inabili d to NY ow obje take vaginitis, feca mponent of an initial ty somethin To y in rtant co Does to undo g ot Overfl ion and leakage andor dietar the re a zipper her NY ow is an impo so may help monitor sident ? than urinar Tr eliminat fl uids and/ Does th have a post ------y trac ansien t, e the information e resident -v t, t environmen ized assessment and al narcotic take oid residual analgesi stool soft greater ion/incontinence. Us cs ener than ine individual progress while on a toileting program. or othe s, antips 200 cc eliminat term Female r drug ycho ? de s that tics, anticholinergi ------NY ined to may af obta ntinence. Is ther fect continen cs, NY Functional entions to regulate elimination and e presen ce interv Is th ce of pelvic ? ------Overfl mplications of inco e vagina prolapse ow ent co y. Is l wall re or prev there abno ddened other NY ion diar rm and/ abnorm al discharg or th al fi ndin Furt frame in? ------g? her evaluation ma e d time y). Male e? ------edur both) an y be Proc bowel, Is necessary resident in need of voidingdder, and bowel eliminatek for a bowel diar y the foreskin NY fy g assessed ar abno St 1. Identi sessment (bla Is ther rmal NY ress of as what is bein es, fl uid and dietcur. e drainage fr (diffi cult fy type ys for a voiding diary, one we , leakag Is to draw Transient 2. Identi three da the urethral om the peni back NY ntinent episodes ation meatus s? , reddened)? Tr (minimum is the resident being assessed, cument obst ------ansient aff er of days the assessmentrt do will oc ructed ------ate to st d numb etc. ? ------Communic e) an e 24-hour repo . Chec 3. wel and/or bladder eliminations, co g on th 3, or 3 of 3, oid residual k th NY (e.g., bo t includin 2 of st-v e type of incontinence areness of need to eliminat Sugges y day 1 of 3, NY Transient intake, aw rms. o ation fo Urge that most NY Transient ice per day to assess if theret) and is po review fi Voiding and Elimination tDiar tw (each shif Sudden urge, large o ts the re Overfl 4. Provide document oid at leas ation. Stress sident ow -v atus of the resident amounts, can base to note resident on t’s document Leakage o d on an ation of the st . to toilet in ’t get when Mixed swers ab cument time coughing, standing ove: 5. Bladder scan the residenters responsible post for residenty is do documentation . Combination of o f memb up, sneezing. Overflo gn staf ctation of the diar urge and str w 6. Assi The expe the reduplication of any of the previous shif ess Weak o ctation. urs, not symptoms. stream, Functional expe two ho dribbling, inc Unable o every one to ined to determine management of bladder and bowel incontinence voiding. omplete to get Transient ta o hours. toilet to ation ob tw without Temporary Utilize inform y one to assistance ( or 7. . mobility recent onset, y ). iding Diar . variety of er to assess the resident ever cate cause mpletion of Vo ff memb i ent or incontinent episodesoid or defe ASSESSMENT TOOLS
68 MEDLINE Implement Care Plans and Select Products. Clinical Decision Tree for CARE PLANS Disposable Incontinence Products Incontinence Solutions Flowchart To Identify, Assess and Provide Individualiz
Flowchart Assessmen ed Treatment for Ur t Evaluate fo r Temporary Incontinenc inary or Fecal Inco e Voiding/BM P attern ntinence Behavioral Pr ogram Evaluate fo START HERE r Response T HERE to Programrogram Absorbent Pr This chart is used to identify, assess and provide oduct SelectSelection, Pr Sizing, Proper ion r Skin CarCare oper AS Re e SESS Unde sident rstand independent » Hist directions? ory or minima Tria MDS 3.0 l l BladderBladder » assist? Re Physical B0800=0 YES MDS traininaining Resident YES 3.0 G011 & Kegels for » or 1 (a 0, 1-I = YE els for individualized treatment for urinary or fecal incontinence. Urinalysis aware lways 0, 1, 2 (If fe S EVVALUATEUA PrograPro 8– ATE m or usually) cal 12 weeks YE in » PVR/Bladder of urge? incontinence S placeplac continue : Refer R Resident d Scan Prompted N-LPN show YESYES 4 and suppo (If PVR is gr Workboo improvement? rted eater Vo k pp by than 200ml, iding) 38 and 41 absorbenab t cons prodproducts ult MD) NO MDS 3.0 NO 12 H0200 C = 1 » Identify Ty or 2 pe of NO Incontinence Refe r RN-LPN 3 Workboo NO k pp 27 -32 YES 444 Trial Prompted YES
3-day Voiding/ diary Toileting Incontinence Refe Care Plans Refer RN-LPN r RN-LPN
Wo EV Workbook pp rkbook pp VALUAATE Solutions NO 33–34 38 and 41 Are acute/ Skin Care transient Resident show causes rineal ) improvement? identifi ed? Pe or Trial Scheduled back period Vo YES iding/Toiletin These care plan forms have been designed to walk your g 3 orRefe the required look NO (f r RN-LPN Wo 4 rkbook pp TED Clinical Decision Tree ContinencefTreat acute/ 38 and 42 NOT RA 400— 3 had transient ca YS Resident EVVAL 300 & H0 use ALWA T UUATE 2 1. MDS 0 Section H0 INCONTINEN 3.0 B0800a catheter = 2, 3 Re FREQUENTLY s of2. g,(s ometimes sident show MDS 3. 1 T episode MDS 3.0 G011(indwellin y , rare staff through the various steps that need to be taken to ALLY No g 0 1-I =), 3, urinar ly) improvement?improvem CASION INCONTINEN s of t voidin3. MD ndom 4 (severe 0 OC T episode continen S 3.0 H0200Bco = 0 (no immobility/bed © 2017 more or t 4.bowel or no bound) WAYS MedlineINCONTINEN Indu s 7 or ntinen MDS ostomy, improvemen AL stries, Inc.episode incontinence or co 3.0 H0200B = or t) T than 7 All rights urinary s 1, 2 (d 3 CONTINEN Less reserved. M s of vement urine outputecreased wetn NO or edlinmoree is aepisode registered mo ess, dr inence 2 or trademark, wel movement y) of incont wel inence of M bo bo wel incont edline Indu 1 episode of bo episode stries, Inc. for the entire t at least 1 help the resident manage the type of incontinence they bu iding Managed with incontinence t vo 7 days of continen incontinen Considerations t producpr ts or bowel movement have. These forms also provide nursing interventions. = 0 rs? No
risk of developing pressure ulce Is this resident at M0150— Cleanser medy N/A & Cool or Re any Soothe Wipes, iers Cleansing tative Barr medy Preven Cool or Re Soothe & Soothe & Cool ze/ zer rs? Yes = 1 Moisturi Moisturi Fecal—is the loss of control of bowel movements. It can in Protect risk of developing pressure ulce Is this resident at M0150— Cleanser medy N/A & Cool or Re Intact Sk Intact any Soothe Wipes, iers Cleansing tative Barr range from an occasional leakage of small amount of stool medy Preven or Re Soothe & Cool medy to complete loss of bowel control. i e/ Re ? No =0 CLINICAL DECISION TREE AND FLOWCHART Functional—is when someone feels the urge to urinate and can hold it, but cannot get to the bathroom by themselves.
Incontinence Solutions Functional Incontinen ce Care Resident Name: UnitPlan
Start Date: No Unit tification :iti Nurs of Ph RoRoom Number e’s Signature: ysicia n: No om Number No : Mixed—is a combination of both stress and urge e otification of DireDirect ct Ca re Staff: Incontinenc Solutions Plan : re om Number Nursing Diagnosis: Ca Ro aff: ce : re St Urinary ct Ca Incontinence, ntinen of Dire Related to Functional : tification : (check all that appl o Impaired manual de y) f: Fecal Inco o xterit om Number af n: No Access to toilet y As evidenced by: St ysicia o /toilete subs nced by: re incontinence. Many older people, especially women, have of Ph Impairedp red phys physical mobilit substitu o (check all that appl Ca te Inabili ct fication ty to mo y) Ro ti o AlteredA co ty o ve purposefpurposefully Resident Name: Unit cognitio Inability within Plan : of Dire o n to dress the environmen Visual di o self ion ffi cultie Limited muscle t cat art Date: No o s strength tifi St Pain o Impaired coordination e: y) coor Care gnatur o o e’s Si ll thath t appl appl Poor motivation Depression ce Nurs vavation n : (check all that appl o o Incontinence No Other, sp Othe ecifciffy: r, specifcify:y Solutions evidenced by l inence As stoo ntinen n: Physical exam Bowel Incont ¨ ary leakage of co ysicia this type of incontinence. of Ph Unit ¨ Involunt y: ecif Date In r, sp and Sign PlanPPla Nursing Diagnosis: Othe ann andannd Outc d cation ¨ Th ome (c fi heck all that apply) iss ReResidsidentident Wi heck all that ti : (c Will: appla y) xe lated to (anal sphincters)th e Re ¨ Decr : ss ltiple Incontinenc ease incontinen Mi re Muscle damage ry, mu t St ¨ episodesepisodes by Targ e damage due to childbir Solutions et Date ent Name No Nerv ¨ within Date ¨ es, spinal cordetes inju Use toilet days Achieved sid r ri substitutsu days Re inju s or diab ocele, e devices, . e: ct fi stulas ¨ suchsuc as urinal t Date: ur sclerosi VoidVVoid in , commod ar ce Care Plan toilett at e when gnat ntinence, Urge, ctal prolapse,fi ssures, re or annd least 50% of appropriate.ppropriat St co g the bladde ¨ Re ntinen toileting thethe timet e. ’s Si n Inco program:p accordin y In e hemorrhoids, ow : –roro (circle one)on g to individualized rse ur erfl outine schedulesched e) Nu ct Ov om Number duled toiletin d schedule ru a : Ro –promptep g Urinar y) st ¨ Diarrhea rrompted vo –hab r tipation y or traum Date f: iiding it training fl oo ¨ Cons rger es et Care Staf tal su caus Targ Achieved of Direct ¨ –scheduled that appl rophy tification Maintainn times: or muscle pelvic surroundi n l at Anorec nown) Date tain intact us tio sa ¨ (unk Resident Name: n: UnitNo sks in/experienc tr om c co of Physicia e heck all fr tification ¨ no furthe (c f de t ¨ Idiopathic Maintaintaain r skin brea o ty or increaseincreasease kdown. Nursing Diagnosis:ty or infe ili to mu art Date: No extremitiemmitie strength ivi ue ¨ Immobility y: St s to assi th and endurance ct tion . ¨ sts in toiletin e of uppe lated to: ral supporita a d specif y) days Clothing/bedding g proc r/lowe th rr or instabhr ¨ Other, appla ngg/bed ess. r Re r i s l that s Signature: ding remainreemain Hypera de u k al Nurs e’ s dry during ¨ etr e (check within –liner the om –pad day and nigh Poor ure d Outc ll: –brie t using: (c ¨ an Wi s by f ircle one) Local blad Overflow—is a constant leakage of a small amount of urine Plan sident de –other: ¨ This Re ent episodeepisod Sign Neuropathic d s and oss. fl ow ¨ y) Date ease incontinent ool l ce, Over Incomplete closure of uret ¨ Decr ary sts continen ication causes . Urinary In ¨ y: involuntvolunt days Med athic ce no Nursing Diagnosis: ¨ perien y n. specif ke) ¨ Ex everevver kdow e) Idiop r, ... stool in brea e on y) ¨ ge ed r sk (circl heck all that appl formed furthe :in (checkg: all that appl Othe : (c e soft e no Related tto us ¨ Have d nigh Co by y s while awa e) inat next pa ¨ xperiencxpeer y an struction ntinuedntintinued on next pa ur ) ty skin/e e da¨ Outlet ob od inat on tact th age... ri tivi d in in y during her: er equenc2 ho ac ue ta ns dr –¨ot tate canc ge... y y ur pe sire to ur n ¨ Main remain Pros y fr or nti ding brief c Hyperplasia ever ho de Co d – gn Prostati As evidencedinar 24 th tion d ¨ Beni Ur nce frequenc because the bladder never completely empties. ¨ Clothing/bed –padpa e Continued on next) pa ¨ tion exer ur ty strict ctivivi ( > o es in a cal liner ¨ Urethral r muscle undera inary exer – der (detruso rd injuryry,, Ur ¨ Hypotonic blad cord inju ¨ ia ical physi ue to diabetes, spinal n) ( > 8 timur ine while asleepth (d y or radiation) ct ur phys dominal pressure ¨ Neurogenic bladder from surger No ing up > 3 timesine per loss night associated of to urth wi e damage ¨ ak y iated wi d ab pelvic nerv (w y ur age se ar pass ine wi s Urgenc y e assoc ¨ Medication ¨ lunt ar in increa nvo th ecify: I loss of ur ¨ Other, sp ¨ ed Involuntrv Incontinenc ¨ loss of ur ssociated wi Obse rted Solutions ¨ po y: y) e Re e loss a cif (check all that appl teterr ¨ in e y sphincinc Ur r, sp As evidenced by: through urinar ¨ he ¨ Urine passively leaking OtO when the urge is felt Stress ¨ ¨ Inability to void even In y stream continen ¨ Weak urinar uria ¨ Noct cc Resident Name: ce Ca Unit ¨ Post-Void Residual > 200 re Plan St ¨ Bladder Scan art Date: Noti r, specify: Stress—happens when you put stress, or pressure, on your ¨ Othe Nu rse’s Signatur fication e: of Ph ysicia n: : Ro No Incontinence omm NumberNNu tification of Direct : Solutions Nursing Diagnosis: Ca : are SSt Pla Ur ... aff: Re d on nextinar page Incontinence re Plan om Number lated toContinue y Inco Ca f: ¨ : (check all that appl ntinence Care Plan Solutions ce Staf Urethral hype , St ntinence : Ro Care ress Urge Inco bladder with physical activity such as sneezing, laughing, U pelvic rmob suppor y) ntinen of Direct ¨ t (lax ility sec cation Intrinsic sphincter depelvic onda om Number: tifi ¨ ry to : Ro N Urethral sphincter incompetence fl oor mu s/ poor anatomic fi scle ¨ ciency s) Resident Name: Unit re Staff: Urinar (defect in ur al tification of Direct Ca n: No ¨ y tra ysician: No Transient Inco ysiciacia Medication ct infe ethr tification of Ph ctio a) t Date: No of Ph ¨ s n p pros Star fication Idiopathic causes tatect ti ¨ omy Othe Nurse’s Signature: Resident Name: Unit r, sp ecify t Date: No coughing or lifting something heavy. A small amount of Star e: gnatur As evidenced by rse’s Si d Nu ¨ Obse : (check all that appl Urinary Elimination, Impaired ¨ rved loss of ur Nursing Diagnosis: Re port ine wi y Elimination, Impaired physicaled loss of ur th y) Urinar physical : (check all that apply) ¨ exer ine associated wi ex Related to Urine loss associatedtion or acwi ertion troke, diabetes, t ¨ ¨ ivity th Neurological disorders (s iple sclerosis) Positive provocative rkinson disease and mult Nursing Diagnosis: ¨ th Pa (check all that apply) Ot increa trusor hyperrefl exia ia, depression her, se ¨ Detrusor instability or de specif stress test d abdominal pressure ) urine leaks out during these activities. Related to: , dement y (detrusor contractions ) er ¨ Delirium TI ethritis ion (U s or ur ¨ Bladder stones or bladder canc ct ti y tract infection ¨ Infe ¨ Acute or chronic urinar Atrophic vaginis and tumors ¨ tion ¨ Utero-vaginal prolapse Medication ¨ ¨ Idiopathic causes cess urine producty ¨ Ex mobili cted n ¨ Medications Restri ctio ¨ pa ¨ r, specify: ool im Othe ¨ St ¨ Trauma ss Stre ¨ : (check all that apply) y: As evidenced by ¨ Idiopathic ecifcauses r, sp ¨ Urinary frequency ¨ Othe y) while awake) (> once every 2 hours heck all that appl ¨ frequency : (c Urinary riod) (> 8 times in a 24 hour pe As evidenced by ¨ Nocturia e) inat ¨ Physical examexam (waking > 3 times per night to ur e y incontinencece Cognitiv ¨ Urgency ¨ th desire to urinate Transient—is a temporary form of incontinence that goes ine loss associated wi y ur ¨ New onset urinar Continue ¨ Involuntar gege...... d on next pa New onset fecaly: incontinen a ¨ ary passage of urine while asleep ¨ specif Involunt r, d on next pa ge... ¨ Othe ¨ Other, specify: Continuentinued on next pa
... away once the cause is treated. Illness is a common cause Continued on next page of transient incontinence. CARE PLANS Urge—happens when people feel a strong urge to urinate and cannot hold it long enough to get to the toilet. People with urge incontinence have to urinate more frequently and often wake up during the night with the urge to urinate.
1-800-MEDLINE (633-5463) | medline.com 69 Create an Incontinence Product Identification System. Stickers and Lanyards Discreet I.D. Tools Instructions for use: In situations when it is necessary to use disposable Step 1: Identify the proper product type using the decision incontinence products, it is essential that the products tree for disposable incontinence products. provide each resident comfort and security as well as Step 2: Measure the resident and identify proper size using odor control. It is important that a full line of products the sizing guide or sizing matrix. be available to meet the needs of each resident on an Step 3: Select sticker with symbol representing product individual basis as well. With so many options available, category and size. it can be a little confusing for your staff to stay on track. Step 4: Place sticker next to resident’s nametag or That is why we developed the Discreet I.D. Tools. designated location. Step 5: Instruct staff to use proper product type and size The Discreet I.D. product identification system has been for identified resident. designed to promote proper product selection, fit and comfort, and includes the following: Helpful Hints Select the correct symbol based on the following: Tape Measure The color-coded tape measure was developed to make it Resident’s Condition Product Symbol super easy for your staff to measure and then choose the Stress incontinence Pads Seahorse appropriately sized disposable brief. When your staff uses Ambulatory or combative Protective Underwear Frog the tape measure they should measure the waist, hips or (Alzheimer’s) thighs (select the largest area). They will measure left to Ambulatory, weight- Liners Turtle right. The size will be indicated by the color on the tape bearing (1-person assist.) measure at the right side of the body (at the widest part). Bedridden, contracted Briefs Fish The color on the tape indicates the color of the brief the or combative resident should be in. Bedridden, chronic diarrhea or agitated Overnight Briefs Dolphin at night Sizing Wheel Open-airing, low- DryPad Seal The sizing wheel can be used to help choose and size any air-loss system Medline disposable incontinence product. The front side of the wheel was designed to help your staff choose the Provide one lanyard to each CNA and encourage them to appropriate product. The back of the wheel was designed wear it with the employee identification badge. It is a great to help size the product chosen. All the CNA has to do is: tool for them to use as a reference. » Gather the resident’s weight and height using the latest available data » Determine the resident’s weight and on the Product Sizing side of the wheel locate it at the top window » Locate resident’s height above the lower windows on the wheel » Note the color-coded triangle below the height indicator; this is the size brief required
70 MEDLINE Door Cards The door card is another great tool to help your staff stay on track with product usage. They can affix it anywhere that is appropriate. Only one per resident. The door card has a daytime product slot and a nighttime product slot. CREATE SYSTEM I.D. AN They can either write the size and type of the product that should be worn by the resident or they can place a sticker in each slot. The goal is to keep the resident in the appropriately sized product. Facilities that utilize this system often see a reduction in poor product usage, i.e., abuse of XXL and bariatric products.
MX MX MX MX MX MX MX MX MX MX
MX MX MX MX MX MX MXM MX MXMX MX
MX MXM MX MX MXX MX PERSONALPERS CARE MXM MX O MX MX DISCREETDISCREDISCR ET IIDENTIFICATION SYSTEM
MX MX MX MX MX MX MX MXMX Incontinence MX MX Solutions MX MX MX /Bed MX MX MXX MX MXMX MXMX Room Number MX
50 MAXIMUM LINERS MKT1435249 / LITTURTLEMAX / 1M / PCO / 22 c.c es, In stristri .)) Indundu back i e Indu on trt p of Medlin e stris k esivivev stri (Adh trademar stered a regieegistered e is a Medlin ed. Medlin serv ts rerese l righ c. Al s, In / 10 (Adh es / SG dustri 72 / 100M100M Medline / InduLIT8 © 2018 T1795561 MK
50 D DRRYYPPADSADS STICSTICKERSKERS
MKT1435072 / LITSEAL / 1M / DP / 22 1M / DP / 22
DOOR CARD, TAPE MEASURE, LANYARD, STICKERS AND SIZING WHEEL
1-800-MEDLINE (633-5463) | medline.com 71 Maintain and Sustain. Recommendations Give explanations and information. for Implementing and Offer choices when appropriate.
Sustaining Practice and Use interactions that make residents feel comfortable, such as humor, reassurance, Organizational Changes friendliness and professionalism. » Include all managers in the organizational Avoid use of interactions that are curt or and practice change initiatives authoritarian or breach the resident’s privacy. » Create strategies to introduce changes that engage staff at all levels Obtain the resident’s consent prior to » Design changes with active, on-going input from staff performing any activity or procedure. » Ensure active engagement in planning and supporting the Medline Continence Management Program Be extra vigilant in situations where a loss of and practice changes involving frontline staff dignity is more likely; for example, during intimate » Explore and address the organizational procedures or when residents are unable to take influences on planned practice changes steps to promote their own dignity. Appropriate staff » Acknowledge and address barriers behavior can promote dignity in these situations. to clinical practice change » Support the development of Promote a culture of accountability so that staff take problem-solving skills among staff appropriate action if they consider a patient’s dignity » Create accountability systems that will provide is at risk due to the environment or staff behavior. timely and effective feedback about the changes » Ensure roles of participating staff are clear and Practice consistent with the goals of implementation » Start a discussion with CNAs about dignity: » Create accountability systems that will provide – Imagine how it feels for a person who has always timely and effective feedback about the changes been independent to require incontinence care. » Ensure roles of participating staff are clear and – What would it feel like to have the curtain consistent with the goals of implementation or door open during a brief change? – Reassure residents with incontinence that it is not their fault, and then promptly change Dignity the residents’ clothing and linens. It is important for CNAs to be aware of the importance of » If you see another staff member doing preserving the resident’s dignity with each interaction. something really good for a resident, point Dignity is often related to how they treat residents. Dignity it out. Start a “Good Catch” program. is preserved when the resident is seen as a whole person, » Arrange for routine gatherings of staff, family and the staff respects the resident. Other actions that members and residents to discuss how to improve convey an appreciation for dignity and respect are when dignity in your facility. Treat every resident as an individual with specific feelings and opinions. CNAs provide privacy and listen to the resident. Offer staff sensitivity training on the topic of incontinence management and communication. Here are some things CNAs can do to preserve the patient’s dignity: If you feel that your CNAs are not preserving or promoting dignity in your facility, try conducting empathy exercises. Close the curtains fully in semi-private rooms. You can find several empathy exercises online as part of the Medline Continence Management Program—each Enter the room with a knock, announcement developed to help cultivate empathy. and consent from the resident.
Minimize body exposure during care and treatment.
72 MEDLINE MAINTAIN AND SUSTAIN
1-800-MEDLINE (633-5463) | medline.com 73 17Abrams P and Andersson KE. (2007) Muscarinic receptor antagonists for overactive bladder. BJU Int. 100 (5): 987–1006.
References 18 Abrams and Andersson 2010 Fourth International Consultation on Incontinence Recommendations of the International 1Lyons SS. How do people make continence care happen? Scientific Committee: evaluation and treatment of urinary An analysis of organizational culture in two nursing incontinence, pelvic organ prolapse and fecal incontinence. homes. The Gerontologist. 2010; 50(3):327–339 Journal of Neurology and Urodynamics. 29, 213–40 2 Smith DA. Learning to live with F315 incontinence 19Getliffe, K. and Dolman, M (Eds). 2003 Promoting a Clinical management. Long-Term Living. April 2006. Available at: Research Resource 2nd Edition London Balliere Tindall www.ltlmagazine.com. Accessed: January 26, 2011 20 EAUN 2012 Evidence based guidelines for best practice in urological 3Doyle D & Kuhlor A. Effectively assessing and managing urinary health care. Catherization, indwelling catheters in adults: Urethral incontinence in older adults: evaluating a population at risk. and Suprapubic. Arnhem: European Association of Urology Nurses Presented at: National Association of Directors of Nursing/Long Term Care (NADONA/LTC) National Conference; June 2010; Atlanta, 21NICE 2007 Faecal Incontinence: The Management of Georgia. Available at: http://www.nadona.org/pdfs/MONDAY/ Faecal Incontinence in Adults: Clinical Guidelines. London: Kuhlor%20_Doyle_2010-1088-27AB.pdf Accessed January 26, 2011 National Institute for Health Care Excellence 4Seavey, D., “The Cost Of Frontline Turnover In Long-Term Care,” A 22 Winney, J. (1998) Constipation. Nursing Standard, 13 (11): 45–56. Better Jobs Better Care Practice & Policy Report, October 2004 23Norton C 1996, Nursing for Continence 2nd 5 Dresser, L., Lange, D. and Sirkus, A. “Improving Retention of Frontline Edition. Bucks: Beaconsfield Publishers. Caregivers in Dane County,” Center on Wisconsin Strategy, March 1999 24Taylor C 1997 Constipation and Diarrhoea. In Bruce L and Finlay. 6 “Mentoring, ” Institute for Management Excellence, Online TMD eds. Nursing Gastroenterology. Oxford: Chuchill and Livingstone Newsletter, October 1999
74 MEDLINE 36 Kornblau, A., Benson, A., Catalono, R. et. al. (2000) Management of Cancer treatment related Diarrhoea: Issues and therapeutic Strategies. Journal of Pain Symptom Management. 19 (2):118–129.
37Nix, D. and Haugen, V. (2010) Prevention and Management of Incontinence Associated Dermatitis. Drugs Aging. 27 (6): 491–496.
38
Fader, M., Bain, D. and Cottenden, A.(2004) Effects of REFERENCES absorbent incontinence pads on pressure management mattresses. Journal of Advanced Nursing. 48: 569–574.
39Ersser, S.J., Getliffe, K.A. and Voegeli, D. (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.
40 Le Lievre, S. (2002) An overview of Skin Care and Faecal Incontinence. Nursing Times, 98 (4) (Suppl): 58–59
41Le Lievre, S. (2000) Care of the incontinent client’s skin. Journal of Clinical Nursing, 14(2): 26–30.
42 Williams, C. (2001) 3M Cavilon Durable Barrier Cream in skin problem management. British Journal of Nursing, 10(7): 469–472.
43 Hampton, S. (2007) You can save your skin. Charter Continence Care.11: 11–12.
1-800-MEDLINE (633-5463) | medline.com 75 In a complex healthcare world, Medline’s mission is to help our customers achieve both clinical and financial success. We do that through a personalized approach to listen and better understand our customers’ needs in an environment that tirelessly demands lower costs and better outcomes.
Because of our capabilities and engagement with other clinical and industry thought leaders, we deliver a robust product portfolio and patient-care solutions to help healthcare providers perform at their very best. This is who we are. This is why customers choose us as their trusted business partner.
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