• Dowling-Castronovo A, Bradway C. Urinary incontinence. In: Mezey M, Fulmer T, Abraham I, Zwicker DA, editor(s). Geriatric nursing protocols for best practice. 2nd ed. New York (NY): Springer Publishing Company, Inc.; 2003. p. 83-98. [26 references]

This is the current release of the guideline.

Urinary incontinence

Evaluation
Management
Treatment

Geriatrics
Nursing

Advanced Practice Nurses
Nurses

• To present a nursing standard of practice protocol for urinary incontinence (UI)
• To discuss the transient and established etiologies of UI
• To describe the core components of a nursing assessment for UI in hospitalized elders
• To identify major treatment strategies for UI
• To provide indications for indwelling catheter use

Older adults hospitalized for acute care

Evaluation for Urinary Incontinence (UI)

1. Review medical and social history
2. Question patient/caregiver about possible urinary incontinence including time of onset, frequency and severity. Inquire about symptoms such as nocturia, hematuria, and hesitancy. Determine patient's current management strategy
3. Perform abdominal, genital, rectal, and skin examination
   Valsalva maneuver for women (if not medically contraindicated)
4. Determine presence/absence of indwelling catheter. If present, determine whether use is indicated
5. Complete functional, environmental, and mental status assessment
6. Review medications and diagnostic test results
   • Urinalysis and urine cultures
   • Bladder sonography or catheter insertion to evaluate post-void residual urine
7. Complete bladder diary or voiding record
   Staff training in use/interpretation of bladder diary

Treatment/Management

1. Scheduled voiding or habit training
2. Patient/caregiver, nursing staff education regarding urinary incontinence
   • Crede maneuver (deep suprapubic palpation)
   • Double voiding technique
   • Pelvic muscle exercises
3. Modification of environment to facilitate continence
   • Call bells within reach
   • Commode, urinal, bedpan
4. Nutrition/hydration management
5. Referral to interdisciplinary team members (e.g., pharmacology, surgery, therapy) as indicated
6. Catheterization only as indicated
7. Avoidance of medications that may contribute to UI

• Number of episodes of urinary incontinence (UI)
• Number of complications associated with UI

Searches of Electronic Databases

Medline, CINAHL, and MDConsult were the databases used.

Not stated

Not stated

Not applicable

Review

Not stated

Not stated

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Internal Peer Review

Not stated

Assessment Parameters

• Document the presence/absence of urinary incontinence (UI) for all patients on admission.
• Document the presence/absence of an indwelling urinary catheter. Determine appropriate indwelling catheter use: severely ill patients, patient with Stage III to IV pressure ulcers of the trunk, urinary retention unresolved by other interventions.
• For patients who are incontinent:
  • Determine whether the problem is transient, established, or both.
  • Identify and document the possible etiologies of the UI.
  • Elicit assistance with assessment and management from interdisciplinary team members.

Nursing Care Strategies

• General principals that apply to prevention and management of all forms of UI:
  • Identify and treat causes of transient UI.
  • Identify and continue successful pre-hospital management strategies for established UI.
  • Complete bladder diary.
  • Develop an individualized plan of care using data obtained from the history and physical examination, and in collaboration with other team members.
  • Avoid medications that may contribute to UI.
  • Avoid indwelling urinary catheters whenever possible.
  • Monitor fluid intake and maintain an appropriate hydration schedule.
  • Modify the environment to facilitate continence.
  • Provide patients with usual undergarments in expectation of continence, if possible.
  • Prevent skin breakdown by providing immediate cleansing after an incontinent episode and utilizing barrier ointments.
  • Use absorbent products judiciously.
• Strategies for specific problems:

  Stress UI

  • Teach pelvic muscle exercises (PME).
  • Provide toileting assistance and bladder training.
  • Consider referral to other team members if pharmacologic or surgical therapies are warranted.

  Urge UI

  • Implement bladder training or habit training.
  • Teach pelvic muscle exercises to be used in conjunction with the above strategy.
  • Consider referral to other team members if pharmacologic therapy is warranted.
  • Initiate referrals for those patients who do not respond to the above.

  Overflow UI

  • Allow sufficient time for voiding.
  • Instruct patients in double voiding and Crede maneuver.
  • Consider use of external collection devices for men.
  • Provide sterile intermittent or indwelling catheterization.
  • Initiate referrals to other team members for those patients requiring pharmacologic or surgical intervention.

  Functional UI

  • Provide scheduled voiding or habit training.
  • Provide adequate fluid intake.
  • Collaborate with other team members to eliminate any medications adversely affecting continence.
  • Refer for physical and occupational therapy.
  • Modify environment to be conducive to maintaining independence with continence.

Follow-up to Monitor the Condition

• Provide patient/caregiver discharge teaching regarding outpatient referral and management.
• Incorporate continuous quality improvement (CQI) criteria into existing program.
• Identify areas for improvement and enlist interdisciplinary assistance in devising strategies for improvement.

None provided

The type of supporting evidence is not specifically stated for each recommendation.

Patients Will Demonstrate:

Fewer or no episodes of urinary incontinence (UI) or complications associated with UI

Health Care Providers Will Demonstrate:

• Documented continence status at admission and throughout hospital stay
• Interdisciplinary expertise and interventions to assess and manage UI during hospitalization
• Inclusion of UI in discharge planning needs and referral as indicated

Institution Will Demonstrate:

• Decreased incidence and prevalence of acute UI
• Hospital policies requiring assessment and documentation of continence status
• Access to the Agency for Health Care Policy and Research (AHCPR) Guidelines for Managing Acute and Chronic UI
• Administrative support and ongoing education regarding assessment and management of UI for staff

Urinary catheterization can be associated with urinary tract infections. Patients requiring indwelling urinary catheters may have a higher incidence rate of infection than patients requiring sterile intermittent catheterization.

Decisions regarding catheterization require careful consideration of the benefits and burdens associated with their use.

An implementation strategy was not provided.

Getting Better

Effectiveness
Patient-centeredness

• Dowling-Castronovo A, Bradway C. Urinary incontinence. In: Mezey M, Fulmer T, Abraham I, Zwicker DA, editor(s). Geriatric nursing protocols for best practice. 2nd ed. New York (NY): Springer Publishing Company, Inc.; 2003. p. 83-98. [26 references]

Not applicable: The guideline was not adapted from another source.

2003

Hartford Institute for Geriatric Nursing - Academic Institution

The guidelines were developed by a group of nursing experts from across the country as part of the Nurses Improving Care for Health System Elders (NICHE) project, under sponsorship of The John A. Hartford Foundation Institute for Geriatric Nursing.

Supported by a grant from The John A. Hartford Foundation.

Not stated

Primary Authors: Annemarie Dowling-Castronovo, APRN-BC, Gerontolgical Nurse Practitioner, New York University, The Steinhardt School of Education's Division of Nursing; Christine Bradway, PhD, APRN-BC, Gerontologic Nurse Practitioner, University of Pennsylvania School of Nursing

Not stated

This is the current release of the guideline.

None available

None available

This summary was completed by ECRI on February 2, 2004. The information was verified by the guideline developer on February 26, 2004.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.