A Nursing Analysis of the Causes of and Approaches for Urinary Incontinence Among Elderly Women in Nursing Homes (PART 2)
The Care Plan
Nursing diagnosis. Roy has developed a typology of indications of positive adaptation related to urinary elimination. These include:
1. Effective process of urine formation
2. Stable pattern of urine elimination
3. Effective coping strategies for altered elimination.
The related NANDA diagnoses14 associated with these include stress, functional, reflex, urge, and total incontinence. The NANDA diagnoses closely mimic medical diagnoses and may not be relevant in the nursing home setting where it is almost impossible to confirm diagnoses within the confines of the budgetary constraints that limit access to test such as urodynamics for each and every case of incontinence. Miller2 has developed a new and unique UI classification system that may prove to be much more appropriate for use if adapted for the nursing home setting (see Table 1).
Goals. Once the diagnosis has been made, the appropriate goals and interventions must be stated and planned. Reinforcing Rauen et al's36 belief that assessment and documentation must be relevant to the individual patient, Robinson29 champions an individualized approach that incorporates the resident's goals and builds on appropriate self-management strategies currently in place.
Interventions. Depending on the behavior and stimuli identified in the assessment and its effect on the person, the nurse can use the Roy model to promote and reinforce the stimuli or take actions to change or delete them. Depending on the extent of the incontinence, the intervention may vary in type and intensity. Regardless of the method, intervention must take into account where the resident lives, attitudes of the caregiver, and other environmental factors. Because so many new treatments have been developed in the last decade, the choices are classified as behavioral, pharmacologic, and/or surgical treatments.11
Behavioral approaches, as listed in the AHCPR Clinical Practice Guidelines,5 on UI include the following interventions:
1. Toileting assistance - routine/scheduled toileting, habit training, and prompted voiding
2. Bladder retraining
3. Pelvic muscle rehabilitation - pelvic muscle exercises (PMEs), PMEs with biofeedback, PMEs with weighted vaginal cones, and pelvic floor electrical stimulation.
Behavioral interventions have become popular in the management of the lower urinary tract and are helpful in the treatment of incontinence due to urethral sphincter or detrusor dysfunction as well as urgency and frequency. Many researchers have demonstrated excellent success using behavioral approaches to decrease incontinence in community-residing women.38,42
Assessment of the response to behavioral approaches in the nursing home depends on the definition of success used. If decreased wetness is considered the goal, the toileting approaches of prompted voiding and habit training are a success; however, if achievement of continence is the goal, studies have not demonstrated much progress to date. Pinkowski31 found that prompted voiding is most successful in residents who have lived in the nursing home for a shorter length of time, scored higher on a mental status exam, have more severe incontinence, and are more dependent and less mobile. All of the behavioral interventions except for toileting require the cooperation, involvement, and motivation of the patient for success. This, in turn necessitates a level of orientation that would preclude most demented residents from participating. Various mental status evaluations tools have been recommended to screen for mental ability before initiating extensive behavioral interventions. Schnelle et al43 point out that behavioral programs are well received by families and alert residents, significantly increasing customer satisfaction in the nursing home, but they acknowledge that responsibility for the additional costs involved is less clear.
No literature could be identified regarding the success of pelvic floor exercises with nursing home residents. However, Jewell38 warns that about 30% of women cannot identify the correct muscle. The elderly, particularly, have weak contractions, cannot sustain the contraction, or incorrectly use accessory muscles. Jewell further cautions that performing the exercise incorrectly has been associated with dyspareuria; hence, incontinence, abdominal and low back pain, and hemorrhoids are worsened. Literature is scant regarding use of vaginal cones and electrical stimulation of the pelvic floor with nursing home residents, most likely due to the lack of availability of these interventions in such a financially constrained setting.
Pharmacological interventions for urinary incontinence include the use of anticholinergic agents and tricyclic antidepressants for urge incontinence and alpha-andrenergic agonists and estrogen for stress incontinence. Due to the likelihood of drug interactions, pharmaceutical interventions for incontinence are probably underutilized in the nursing home setting.40 Ouslander et al44 offer data suggesting that tolterodine, a new anti-muscarinic medication, is an option when toileting protocols alone are not effective in nursing home residents with clinically diagnosed urge incontinence and/or other symptoms and signs of overactive bladder. Martin7 refers to another new drug, duloxetine, which has had limited usage for geriatric urge incontinence.
Estrogen, particularly in the vaginal cream form, has led to significant improvements in stress UI in post-menopausal women. This intervention has proven so successful that estrogen has been incorporated into a new standardized protocol for urinary incontinence in primary care.2 An additional benefit is the decrease of both symptomatic and asymptomatic urinary tract infections in elderly institutionalized women.45br> Surgical approaches for incontinence in women include procedures for hypermobility and intrinsic sphincter deficiency. Due to the inherent risks involved, surgery for urinary incontinence in elderly women residing in nursing homes is rarely, if ever, considered. The use of pessaries for treatment of urinary incontinence is neither recommended nor discouraged by the AHCPR.
Utilizing the Roy Model, nursing interventions for UI must reflect the comprehensive nature of the assessment, utilizing all the spheres of assessment of behavior and stimuli. Unique nursing interventions must demonstrate knowledge of the resident and the environment of care. Basic care issues are standard for all residents: the maintenance of adequate hydration and skin hygiene and integrity, observations for changes in the nature of the output, and the interpretation of any test results. Specific disease-based nursing interventions that may affect UI might include preventive actions for impaction that would lead to urinary obstruction with overflow, monitoring blood sugar control in diabetes and administering insulin appropriately, or assessment and safety interventions for delirium postoperatively or post-fall. The administration of medications, and especially the analysis of the potential and actual side effects relative to incontinence, is most important. Changing the timing of medications may promote better adaptation. For example, response to a diuretic may interfere with participation if it peaks during an activity. Using the knowledge of the resident's usual and customary voiding habits may aid in planning appropriate toileting and/or prompting times. Awareness of pain and comfort issues, as well as stressors, will help the nurse plan daily activities appropriately and maximize either continence or the best urinary adaptation possible.
Robinson29 identified a psychological process that nursing home residents engage in called "managing incontinence," a dynamic process involving six strategies that occurs within a context of beliefs and goals. Knowledge of the process may help nurses assist residents in adaptating to UI (see Figure 1). Responding to the resident's developmental and/or personal goals, with awareness of available or lacking family supports, will create more appropriate nursing interventions.
Improving incontinence care in the nursing home environment is dependent on a care philosophy that involves restoring and maintaining function.10 Some researchers disclose the presence of conflicting goals over continence programs between administrators, residents, and nursing home staff. Many authors address the conflict between the needs for additional staff to maintain behavioral programs and the financial resources currently available in nursing homes.3,31,32,38 Schnelle et al22 note that the only incentive is to care for patients with incontinence. A look at current federal and state reimbursement systems using the MDS 2.0 (Minimum Data Set) and the PRI (Patient Review Instrument in New York state) reveals that the reimbursement score for continent residents, even those on toileting and retraining programs, is lower than that for incontinent residents. Therefore, a disincentive exists for continence programs, as improved continence rates in a facility would negatively impact on the financial bottom line.
Three approaches supporting the enhancement of incontinence care are reflected in the literature. These include assigning leadership of the program to a competent, capable individual; targeting strategies to maximize clinical outcomes and limit costs; and perhaps most importantly, educating all levels of nursing home staff regarding incontinence.
Identifying "program champions" willing to take ownership of the program, including oversight and monitoring, has been shown to improve outcomes.44 A master's prepared Wound, Ostomy, Continence Nurse (WOCN) Specialist would be ideal for this position. The multiple abilities of an advanced practice nurse to assess and treat individuals, as well as to evaluate the entire system of care, would be well used in meeting this challenge. The core competencies for advanced practice nursing described by Hamric, Spross, and Hanson46 include: expert coaching and guidance, consultation, research skills, clinical and professional leadership, collaboration, and ethical decision-making. Each of these skills is essential to the development, implementation, and monitoring of a comprehensive nursing home incontinence program. Capable of evaluating the current research, the WOCN utilizes evidenced-based practice when available to guide incontinence programming decisions. As new knowledge is gained in this largely underexplored area, the WOCN shares findings with colleagues by presenting at conferences and publishing findings. Additionally, the WOCN has the ability to develop protocols for nursing care of incontinent individuals in the nursing home, including the use of assessment tools, products, and policies and procedures. The utilization of these protocols and evaluation of the outcomes in this population becomes an additional source of information to be shared with fellow professionals. Program areas for development include: voiding diary and incontinence evaluation, treatment protocols, skin care management for incontinent residents, toileting programs, bowel management, bladder retraining, and urinary catheter evaluation and management.
In addition to assigning appropriate leadership for incontinence programs, the literature supports focusing on only those residents who are most likely to benefit from a specific intervention. Targeting is recommended as a venue to improve individualization of care, cost effective use of limited resources, and improved ability to monitor outcomes. An example of a targeted approach is the Protocol for Management of UI, developed by Miller2 for use in primary care (see Table 2). In this nurse-designed system of care, three primary levels of treatable UI are identified and standardized actions are recommended for each level. Only patients assessed at the more complicated levels (4 and 5) are referred for urodynamic testing. Although this precise protocol would not necessarily work in a long-term care setting, it serves as a prototype for future work. A nurse-developed protocol for the provision of nursing care may be the most appropriate answer to managing and treating incontinence within the nursing home setting. The WOCN, practicing within the nursing home, is equipped with the skills and knowledge to develop such a protocol and to make the challenging and difficult ethical decisions regarding program availability.
To provide effective care, staff must be educated to increase awareness of patient and caregiver attitudes and beliefs with respect to the aging process and its affect on the genitourinary system.10 The WOCN is a skilled educator, capable of teaching all levels of nursing staff, as well as the interdisciplinary team, about the needs of incontinent residents in nursing homes. Because incontinence programs may be difficult to initiate and continue within the nursing home setting, the WOCN's ability to motivate staff may be tested acutely. Maintaining the fine balance between collaboration with and coercion of staff to follow through on promised interventions underscores the WOCN's political savvy and requires ongoing evaluation of the resident's needs as well as an awareness of the demands placed on an already overburdened nursing staff. In addition, addressing the existence of age bias and attempting to change what may be a long-standing institutional culture may seem insurmountable tasks. The WOCN, as a member of the nursing department, may use formal and informal influences to achieve the goal of a comprehensive, effective and realistic incontinence program in the nursing home setting. Finally, WOCNs experienced in working with this population are in the best position to work with legislators to guide public policy to address and correct the current financial disincentives for continence in the long-term care setting.
Care of elderly women with urinary incontinence in the nursing home is a complex and growing issue. Optimal care requires cohesive and coordinated planning, evidenced-based practice, and a realistic appraisal of available resources. Nursing goals are not always the same as the goals of medicine. In the nursing home setting, the best adaptation for an elderly woman with urinary incontinence might be management of the wetness, not correction of the cause. Conversely, the best adaptation might be achieved by the active pursuit of continence by use of all currently obtainable means. Only through comprehensive nursing assessment and care planning will the optimum outcome for an individual be realized. The use of a nursing model of care, such as the Roy Model, aids nurses in this pursuit. The utilization of a WOCN to develop a comprehensive incontinence program and to advocate for changes in public policy and the reimbursement system that would be more supportive of a therapeutic future is a possible route to improved holistic care in the nursing home setting. Indeed, "Perhaps it is time to stop looking at diseases, impairments and syndromes in isolation and begin considering a more unified approach."24