Urinary Incontinence

Urinary incontinence affedts many clients and is a major helath care concern. It is estimated that 30% of older adults living in the community and 50% of older clients in institutions suffer from incontinence (Eliopoulos,1997). Not only is incontinence a psychosocial problem, it is also a psysical problem in that skin breakdown and urinary tract infection may result from incontinence. Etiology and Pathophysiology Urynary incontinence may result from either bladder or urethral dysfunction (or both). The bladder can contract without warning, fail to accommodate adequate volumes of urine or fail to empty completely and become overstretched, resulting in overflow incontinence. These conditions result from neurologic disease, prostatic enlargement, bladder outlet obstruction or trauma in all clients and bladder prolapsed or low estrogen levels in women. Another cause of incontinence is failure of the urethral sphincters to hold urine in the bladder. This may result from trauma, prostate surgery or relaxed pelvic muscles. Impingement of the spinal nerves, such as in tumors of the spinal cord, herniated disk, or spinal cord injuries can interfere with the impulse conduction to the brain, resulting in a neurogenic bladder and causing retention. General principles of Catheterization and catheter care The following general principles apply to the insertion and maintenance of urethral or suprapubic catheters: aseptic technique is always used for insertion. The urethral meatus is thoroughly cleanses before insertion of a catheter. An adult urethra usually takes a size 14F to 18F indwelling catheter; a smaller size may be used for intermittent (straight, single) catheterization. When an indwelling catheter is inserted, the balloon is tested before insertion. The catheter is lubricated with steril water-soluble lubricant and inserted. Never force a catheter if resistance is felt. And indwelling catheter thaht accidentally becomes dislodged is never reinserted but is replaced by a new sterile catheter Catheters are connected to a sterile closed drainage system. Keep the drainage bag lower than the catheter.

Indwelling urethral catheters are changed according to the physicians orders or agency polcy. Provide urethral catheter care twice a day and after bowel movements. Inspect the cystotomy tube site for leakage of urine around the catheter, bleeding or sing and symptoms of infection. Change the cystostomy dressing once per shift or more often if necessary. If a permanent vesicocutaneous (bladder to skin) fistula forms and the size of the cystostomy tube may need to be increased to prevent leakage of urine Unless contraindicated by heart failure or renal disease, clients should be encouraged to drink plenty of fluids (2.000-3.000 ml) especially those that acidify the urine such as cranberry juice. Monitor the client for sign and symptoms of urinary tract infection : fever, chills, hypotension and confusion Monitor fluid balance and laboratory test that measure kidney function.

Assessment and findings Sign and symptoms Clients complain of urgency, frequency, leaking small amounts when coughing or sneezing or complete inability to control urine, depending on the underlying cause. Diagnostic findings Test such as a urine and sensivity, cystoscopy or urodynamics are used to determine the type of incontinence. Medical And Surgical management Treatment is aimed at correcting the disorder causing incontinence (when possible), providing medication to control incontinence, correcting the situational problems that contribute to functional incontinence, or instituting a bladder retraining program. Pharmacologic agents that can improve bladder retention, emptying, and control include drugs such as oxybutynin chloride (Ditropan), which reduces bladder spasticity and involuntary bladder contractions, and phenoxybenzamine hydrochloride (dibenzaline), which may be useful in treating problems with

sphincter control. Sometimes medication to control incontinence results in retention and must be discontinued. Occasionally clients who can easily perform CIC may optfor medication-induced retention and CIC because it allows them stay dry. Surgeries to improve urinary control include bladder augmentation, a procedure that increases the storage capacity of the bladder; implantation of an artificial sphincter that can be inflated to prevent urine loss and deflated to allow urination; surgeries to provide better support for urinary structures damaged by trauma. Nursing Management Goals when caring for a client with urinary incontinence include maintaining continence as much as possible, preventing skin breakdown, reducing anxiety, and initiating a bladder training program. Determine if the client is truly incontinent or if situations prevent the client from getting to the bathroom. Such situations include impaired mobility, physical restraints and use of sedatives. In addition to assessing for functional causes of incontinence, obtain details regarding the pattern of incontinence and use of medications that may play role in the problem. Assess for skin breakdown and determine methods the client has used to manage incontinence. Instruction centers on exercise it increase muscle tone and voluntary control (kegel exercises), techniques to assist bladder emptying and bladder training. Refer to nursing guidelines 64-2 for teaching Kegel exercises. Success of a bladder retraining program depends not only on the cause of incontinence but also on the motivation of the client and the amount of skillful help and encouragement received from the health care team. Bladder Training One method of bladder training for the client with an indwelling urethral catheter is to alternately clamp and unclamp the catheter. The clamping and unclamping of the catheter begins to reestablish normal bladder function and capacity. In the beginning, the catheter may be unclamped for 5 minutes every 1 or 2 hours. Gradually lengthen the interval to every 3 or 4 hours, giving the bladder a chance to fill more completely. When possible, teach the client to release the clamp at scheduled times. The catheter later is removed. At this point, or when training clients who have not had an indwelling catheter, instruct the client to try to void every hour. Usually the client is not able to retain urine longer than an hour, and frequent voiding is necessary to prevent incontinence. Gradually lengthen the interval between voidings to 2,3, or 4 hours. At first many clients do not empty the bladder and they must be catheterized after voiding to remove residual urine. When the client is catheterized for residual urine, record the amount removed. When client is unable to control the storage and passage of urine or when a bladder training program fails, clients may exhibit varying degrees of anxiety and depression. Offer constant

encouragement throughout the bladder training program. Anxiety may be reduced once the health care team. If an accident occurs, change the bed linen promptly and assure the client that accidents are to be expected during the retraining process. Reducing anxiety may, in some instances, contribute to the success of a bladder training program. Barrier Garments and External Collection Device If it is not possible to establish a voiding routine and incontinence persists, work with client to devise a system collecting the urine. Male clients can use a condom catheter over the penis and connect the tubing to a closed drainage system or disposable urinary drainage bag. External drainage systems are available for women, but it is difficult to get the devices ti fit securely. Male and female clients may choose to wear protective pants with a plastic outside layer and absorbent material inside. These pants can be pinned or snapped in place. Liners also are available and are worn next to the skin. They are nonabsorbent and thus the urine passes through them to the absorbent layer. For this reason the liners dry quickly and leave the skin dry and free of urine, even though the absorbent material is soaked. Clients who are incontinent may have problems with odor and maintaining skin integrity. Ureasplit-ting microorganism, such as Micrococcus urea, cause the urea in urine to react with water, creating ammonia and causing urine odor, skin breakdown and ammonia dermatitis. One way to protect the skin is to avoid any contact with urine. When contact is unavoidable, use soap and water after each episode to thoroughly clean the skin. Dry the skin completely and apply a skin barrier or moisture sealant to protect the skin. When possible, expose the affected area to air. Client and family Teaching Encourage clients to actively participate in whatever methods used to empty the bladder. Demonstrate procedures as needed for the client and family to understand. Develop a teaching plan based on the clients individual needs to include one or more of the following : Control odors by frequent cleansing of the perineum, changing clothes and incontinence briefs (eg, Attends, depends) when they become wet, and using an electric room deodorizer; avoid using perfume or scented powders, lotions or sprays. Mixing a perfumed scent with a urine odor may intensify the odor, irritate the skin or cause a skin infection. Wash garments as soon as possible in warm, soapy water. Use plastic to cover objects, such as mattress and chairs to prevent staining and lingering odors. The plastic must be washed with mild soapy water daily or more often if needed. Instruct the client to place a sheet or blanket between the skin and the plastic. Follow the recommendations of the physician about clamping and unclamping the catheter ( when this method is prescribed) or changing the catheter or cystostomy tube.

Keep a record of fluid intake. Drink plenty of fluids during waking hours. Drink most of the required fluids in the morning and early afternoon hours and decrease the intake toward evening. Follow the recommended bladder training program. Times is required to achieve success. Contact the physician if any of the following occurs: increased discomfort, rash around the perineal area, pain in the lower abdomen, fever, chills or cloudy urine. Symptoms Cause Involuntary loss of urine from infact uretra

Type of incontinence Stress incontinence