How To try this: Demonstrating and interpreting core geriatric assessments How To 2.6HOURS try this Continuing Education By Annemarie Dowling-Castronovo, MA, GNP, RN, and Janet K. Specht, PhD, RN, FAAN Assessment of Transient Urinary Incontinence in Older Adults A bladder diary reveals patterns. A mnemonic structures the search for a cause. n i e t s k c E d E 62 AJN M February 2009 M Vol. 109, No. 2 ajnonline.com read it watch it try it Overview: Urinary incontinence in older adults is associated with an increased risk of institutionaliza- tion, as well as with urinary tract infections and depression. Transient urinary incontinence arises Web Video suddenly, lasts less than six months, and results from Watch a free online video demonstrating the use reversible causes. Many caregivers erroneously of the bladder diary and the TOILETED mnemon- ic in older adults at http://links.lww.com/A311. consider urinary incontinence to be inevitable in older adults, especially in hospitalized patients. A Closer Look Failure to identify and respond to transient urinary Get more information on why it’s important for incontinence may lead to established incontinence nurses to assess older patients for urinary inconti- and to other poor outcomes after hospital dis- nence. charge. A bladder diary and a mnemonic are two methods nurses can use to assess for transient uri- Try This: The Bladder Diary/Record and the DIAPPERS and TOILETED nary incontinence and its treatable underlying mnemonics causes. For a free online video showing nurses using These are the best practices in their original these methods, go to http://links.lww.com/A311. forms. See page 67. loise Chavez, a 72-year-old widow, lives denly, lasts six months or less, and has reversible alone in the two-story house she grew up causes; however, some cases of acute urinary inconti- in. (This case is a composite based on our nence, such as those resulting from spinal injuries, are experience.) She is hospitalized with a foot not transient—in other words, they’re not reversible. infection she says resulted from a pedicure Established urinary incontinence includes subtypes Eshe had several days ago. Ms. Chavez has type 2 dia- such as stress incontinence, urge incontinence, and betes, hypertension, and osteoporosis; she also had functional incontinence. breast cancer and her left breast has been removed. Nurses often note whether a patient is “continent” At 7 am on the morning after her admission, a nurs- or “incontinent” but give little context or detail. Such ing assistant finds her on the floor next to her bed. documentation is not adequate to demonstrate the The bed and floor are wet with urine. “I’m all right,” presence of transient urinary incontinence. Ideally, Ms. Chavez says. “I just needed to get to the bath- assessment for transient urinary incontinence begins room.” After the nurse determines that Ms. Chavez at admission, when a nurse asks the older adult, suffered no injuries in the fall, the nursing assistant “Have you ever leaked urine?” or “Have you ever cleans her, applies an absorbent undergarment, and lost control of your bladder?” (If the patient can’t returns her to bed. Ms. Chavez reluctantly agrees to reply, a person familiar with the patient can be asked.) wear the absorbent brief in case she has another acci- If the answer is yes, the nurse should attempt to de- dent. Later that day, Ms. Chavez’s daughter says to termine the duration of the urinary incontinence. the charge nurse: “Why is my mom lying in bed with (For more information, see Why Assess for Urinary a diaper on? I don’t understand. She’s never had Incontinence in Hospitalized Older Adults? page 64.) trouble holding her water.” If a patient has had an incident, but no apparent history, of urinary incontinence, she or he is more ASSESSING FOR TRANSIENT URINARY INCONTINENCE likely to have transient urinary incontinence and Urinary incontinence may be described as transient the nurse should gather more detailed information (acute) or established (also known as “chronic”). and assess for underlying causes. For these pur- Transient urinary incontinence usually arrives sud- poses, patients can use a bladder diary to track and [email protected] AJN M February 2009 M Vol. 109, No. 2 63 How To try this: Demonstrating and interpreting core geriatric assessments How To try this Why Assess for Urinary Incontinence in Hospitalized Older Adults? rinary incontinence is so common among hospi- tation noted it in only 3.4% of these cases.5 The Utalized older adults and those in long-term care researchers suggested that physicians may influence the that it’s often seen as inevitable. It can contribute to underreporting of urinary incontinence because they falls and loss of skin integrity and has also been associ- see it as a sign or symptom rather than as a medical ated with depression and social isolation, increased risk diagnosis or consider it a lower priority than the other of nursing home placement, and increased strain on conditions older adults may have. family caregivers.1-4 The financial costs of incontinence REFERENCES care include staff time for assessment and toileting assis- 1. Fantl JA, et al. Urinary incontinence in adults: acute and tance, clothing and linen changes, incontinence prod- chronic management. Rockville, MD: Agency for Health Care ucts, catheter care, and laundry services. Policy and Research; 1996 Mar. AHCPR Publication No. 96- 0682. Clinical Practice Guidelines; http://www.ncbi.nlm.nih. Risk factors for urinary incontinence include older gov/books/bv.fcgi?rid=hstat6.chapter.9995. age, caffeine intake, limited mobility, impaired cognition, 2. Bogner HR, et al. Urinary incontinence and psychological diabetes, medications such as diuretics, obesity, fecal distress in community-dwelling older adults. J Am Geriatr impaction, malnutrition, delirium, Parkinson’s disease, Soc 2002;50(3):489-95. 3. Thom DH, et al. Medically recognized urinary incontinence stroke, pelvic muscle weakness, and prostate problems. and risks of hospitalization, nursing home admission and Hospital discharge records may significantly under- mortality. Age Ageing 1997;26(5):367-74. report urinary incontinence. A 1999 study by Berlowitz 4. Cassells C, Watt E. The impact of incontinence on older and colleagues found that although incontinence was spousal caregivers. J Adv Nurs 2003;42(6):607-16. 5. Berlowitz DR, et al. Geriatric syndromes as outcome meas- present in more than 40% of 17,004 nursing home ures of hospital care: can administrative data be used? J Am residents on admission, hospital discharge documen- Geriatr Soc 1999;47(6):692-6. record urination patterns. And nurses can use the additional comments. Those that assess response to TOILETED mnemonic to alert them to possible treatment, such as exercises to strengthen the pelvic sources. floor muscle, will have a space to record pertinent A bladder diary, also known as a frequency– information, such as the number of exercises per- volume chart, bladder record, or voiding chart, is formed. Some include a column for recording voided the patient’s record of daily bladder activity. It can volume, which would have to be filled out by the capture real-time objective data on bladder activity, nursing staff. First, urine is collected, either in a establish baseline function, and track response to plastic measurement device that fits in the toilet or interventions. In comparison, the information ac- from a bedside commode, bedpan, or urinal. After quired by retrospective questionnaires, which rely it’s measured and the amount is recorded in the on the patient’s or caregiver’s memory, may be less bladder diary, the nurse can identify maximum, accurate. In a bladder diary, each 24-hour period is mean, and minimum voided volumes.1 Voided vol- subdivided into one-to-two-hour time frames. The ume data recorded over a 24-hour period may help type of data recorded varies but usually includes at to identify nocturia,2 a risk factor for urinary incon- least the following elements (see Urinary Inconti- tinence, and data on liquid intake may help to iden- nence Assessment in Older Adults, page 67): tify a pattern of disproportionate evening fluid intake, • the number of urinations in the toilet which is associated with nocturia. • episodes of incontinence and amount of urine A three- or seven-day diary can provide a detailed leaked overview of relevant factors and patterns; however, • the reasons for incontinence episode (for exam- in an acute care setting, it may be more realistic to ple, “had an uncontrollable urge,” “leaked when have the patient complete a one-day bladder diary. sneezed”) The nurse discusses the use of the bladder diary with • the type and amount of liquid drunk Ms. Chavez and her daughter: “Ms. Chavez, I’d like • the number of bowel movements you to keep a bladder diary for the next three days. • incontinence pads or other products used The diary is a record of when you empty your blad- Some bladder diaries also have a column for der, how much urine you empty, and any episodes of 64 AJN M February 2009 M Vol. 109, No. 2 ajnonline.com your bladder emptying before you get to the bath- impaction higher in the colon. An abdominal flat room. Also, please record what and how much you plate radiograph may be needed to determine the drink. The diary helps to determine why you’re hav- degree of impaction. ing problems with bladder control, how often it’s Ms. Chavez’s last bowel movement was prior to happening, and how we might help you have better admission, about three days ago. She has not com- control. This form will make it easy for you to record plained of abdominal discomfort, and her abdominal the information.