Promotion of Continence and Management of Incontinence - Assignment Example

Promotion of Continence and Management of Incontinence Physiology of urination Urination is also known as micturition and basically, it is the process of passing urine (Wylie, 2000, p. 142). The bladder can accommodate an increasing amount of urine without having to increase pressure. This mechanism is made possible by the relaxation of the detrusor muscle (University of Oklahoma, 2001). When the bladder distends in order to accommodate 300 ml of urine, the stretch receptors in the wall of the bladder are stimulated and they send the message to the spinal nerves (Wylie, 2000, p. 142). The spinal cord through the spinal reflexes then opens the internal sphincter in the urethra in order to allow the entry of urine (Wylie, 2000, p. 142). The process of relaxation is controlled by the sympathetic stimulation of the B-adrenergic receptors and by parasympathetic inhibition (University of Oklahoma, 2001). The adrenergic receptors in the internal urethral sphincter then increase the sphincter tone. The preceding processes are all involuntary. And when the person is not in a convenient place to urinate, through the voluntary contraction of the external urethral muscles, the process of urination is delayed (Wylie, 2000, p. 142). The external urethral muscles, which are innervated by the pudendal nerve and the sacral efferent nerves act as additional safety guards against involuntary urination (University of Oklahoma, 2001). Until such time that the bladder becomes overdistended, it shall continue to take in urine. When the bladder becomes overdistended, the voluntary control of the external urethral sphincter will be defeated and the person will void even if he or she is not yet in the proper place of urination (Wylie, 2000, p. 142). During the urination process, the diaphragm and the abdominal muscles increase pressure on the abdominal cavity in order to empty the bladder (Wylie, 2000, p. 142). The sphincter and the levator ani muscles relax, the somatic inhibition is released, and the adrenergic sympathetic system is stimulated; the detrusor muscles also contract and the parasympathetic cholinergic receptors are activated (University of Oklahoma, 2001). Through coughing, laughing, and sneezing, the abdominal muscles are also pressured; and for some people, this may cause the involuntary passage of urine. This is known as stress incontinence (Wylie, 2000, p. 142). Physiological causes of incontinence Urge incontinence Urge incontinence is considered to be a sudden and intense urge to urinate. It is followed by the uncontrollable passage of urine (Ouslander, 2007). It is common among older people and no definite cause for this condition has been established as yet. Nevertheless, anatomical studies reveal that among the elderly with urge incontinence, their bladder muscles are overactive, meaning there is an involuntary contraction of muscles even before the bladder is full (Ouslander, 2007). Some studies have revealed that a possible cause of this condition is due to changes in the frontal lobe of the brain which controls urination; the changes which interrupt the nervous system’s inhibitory functions can sometimes also be seen in diseases manifesting with brain disorder like stroke and dementia (Ouslander, 2007). An overactive bladder is common among the elderly and often causes them to urinate several times in the day and the night. Among women who are past their menopausal age, their lack of oestrogen add to atrophic vaginitis or the thinning of the vaginal tissues, consequently leading to irritation, exacerbating the urinary urgency (Ouslander, 2007). Stress incontinence Stress incontinence “is the uncontrollable loss of small amounts of urine such as with coughing, straining, sneezing, lifting heavy objects, or performing any manoeuvre that suddenly increases pressure within the abdomen” (Ouslander, 2007). Among young and middle-aged women this type of incontinence is the most common. Studies indicate that stress incontinence is credited to the weakness of the urinary sphincter which is often caused by childbirth, by pelvic surgery or by the abnormal position of the urethra or the uterus (Ouslander, 2007). Again, for postmenopausal women, their lack of oestrogen weakens the urethra’s resistance to urine flow and among men, prostate surgery may cause stress incontinence, especially if the upper part of the urethra is injured (Ouslander, 2007). Obesity also increases pressure on the abdomen and the bladder, thereby producing urinary incontinence. Overflow incontinence Overflow incontinence is known to be the uncontrollable leakage of small amounts of urine from the bladder which does not empty well (Ouslander, 2007). This condition may be caused by a blockage or by a weak bladder contraction due to nerve damage or bladder muscle weakness (Ouslander, 2007). Due to blockage or due to the inability of the bladder muscles to contract, the bladder becomes enlarged. As a result, due to the increased pressure in the bladder, small amounts of urine are expelled from the bladder (Ouslander, 2007). Among men, the enlargement of their prostate may block the passage into the urethra from the bladder, or the bladder neck may be narrowed due to prostate surgery or radiation therapy (Ouslander, 2007). In some instances, constipation can also cause overflow incontinence because the stool may fill up the rectum to a point wherein it already presses on to the bladder neck and urethra (Ouslander, 2007). Some drugs have also been known to impact on the brain and the spinal cord and interfere with the reception and the transmission of messages. The following drugs have been known to cause overflow incontinence: anticholinergic effects, antihistamines, antidepressants, antipsychotics, and opioids (Ouslander, 2007). Other conditions like nerve damage and diabetes mellitus have also been known to cause overflow incontinence. Functional incontinence Functional incontinence is a condition which refers to loss of urine due to the inability to get to a toilet. Most common causes of this condition include immobility (caused by stroke or arthritis), and other conditions which interfere with mental function (such as dementia caused by Alzheimer’s disease) (Ouslander, 2007). There are also some cases of patients who are too emotionally disturbed and distraught that they do not even want to go to the toilet. This condition is known as psychogenic incontinence. Mixed Incontinence Mixed incontinence is made up to several types of incontinence; this is also the most common type of incontinence for elderly women who sometimes have the urge incontinence alongside the stress incontinence as their affliction (Ouslander, 2007). Many elderly patients also suffer from urge and functional incontinence. Aspect of clinical practice Assessment An area of clinical practice which may be improved in order to enhance client care is the improvement of the assessment phase of the health care process. The assessment process is the initial part of the health care process and it involves skills and mastery on the part of the health care provider in order to ensure a thorough, accurate, and efficient assessment of the patient and the patient’s condition. Following this line of thought, there is a firm belief that by mastering the assessment of the urinary incontinence patient, it is possible to achieve better patient outcomes. The assessment of urinary incontinence can be improved by implementing the bladder diary. This bladder diary is the best assessment technique because it helps collect data about urinary incontinence (Dowling-Castronovo, 2004). The bladder diary can gather information from the client, more particularly, data involving the loss of control of urine, how often urine may be lost, the triggers for urine lost, how often the patient wears a pad or a diaper, how long the problem has been going on, and a description of the problem itself (Dowling-Castronovo, 2004). A bladder record can also be used in order to indicate patterns of urination in the toilet, incontinence, reasons for incontinence, type of liquid intake, pad use, and bowel movement. The following mnemonic (DIAPPERS) can also be used in order to identify the causes of incontinence: delirium, infection, atrophic urethritis, pharmacology, psychosocial disorders, endocrine disorders, restricted mobility, and stool impaction (Dowling-Castronovo, 2004). By establishing these patterns in the patient’s urination and incontinence can provide a framework in assessing the risk for the development of urinary incontinence. It is important to implement a screening process for urinary incontinence because it helps implement the prevention and the early detection of the disorder. And among high-risk populations, it also helps manage and prevent escalation of symptoms. It is important to identify at-risk patients which include those who suffer from: “immobility, impaired cognition, medications, morbid obesity, smoking, faecal impaction, delirium, low fluid intake, environmental barriers, high-impact physical activities, diabetes, stroke, oestrogen depletion, and pelvic muscle weakness” (Dowling-Castronovo, 2004). By assessing these high-risk groups, it is possible to detect the impairment early and to prevent further distress on the patient’s part. Assessment tools can also be used to evaluate the impact of the incontinence on a person’s life. The impact of the incontinence may actually vary based on the type of incontinence – with the more uncontrollable forms of incontinence often causing the most impact on a person’s life. The assessment process should then actually be based on how the patient feels about his situation and how he feels his situation is being handled by his health provider (Dowling-Castronovo, 2004). In order to make possible an engaged assessment on the part of the client, assessment tools which measure the impact of incontinence should be self-administered in order to minimize embarrassment and sensitivity during the process of answering, and in order to provide a modicum of cultural sensitivity to the process of assessment (Dowling-Castronovo, 2004). The assessment process must also include a patient’s complete medical history in order to determine possible causes of incontinence and the patterns of behaviour leading to incontinence (Fillit & Picariello, 1998, p. 72). In case urinary incontinence is revealed by the patient as a problem, then the essential follow-up screening questions should be asked of the patient. A review of all the drugs being taken by the patient must also be conducted because this will help identify drugs which trigger incontinence (Fillit & Picariello, 1998, p. 72). The physical exam of the patient which includes the palpation and the percussion of the abdomen, rectal, and pelvic areas must also be undertaken because this will help identify possible inflammation and enlargement of the bladder and the pelvic area (Fillit & Picariello, 1998, p. 72). Finally, the assessment process must also include the laboratory tests on the patient which include tests on BUN, creatinine, electrolytes, glucose, and urine; and an ultrasound which would also help complete the initial diagnostic process (Fillit & Picariello, 1998, p. 72). These assessment tools must all be applied to the patient to identify early and high-risk patients, and to implement early interventions for the affliction. Implications for practice The voiding diary can help improve patient outcomes. In a study undertaken by Nygaard & Holcomb (2000, p. 1433), they sought to evaluate the reproducibility of using the 7-day voiding diary in women with stress incontinence. The authors compared two 7-day voiding diaries which were accomplished at 4-week gaps by about 130 women who had stress incontinence and who were enrolled in an interventional trial (Nygaard & Holcomb, 2000, p. 1433). The paper revealed that “the number of incontinence episodes, as recorded on a 7-day voiding diary, is a reproducible outcome measure in women with stress urinary incontinence” (Nygaard & Holcomb, 2000, p. 1433). The study also revealed that the 3-day diary is already an appropriate outcome measure for assessing clinical treatments for stress incontinence (Nygaard & Holcomb, 2000, p. 1433). It is also important to implement comprehensive assessment techniques on patients who are high-risk for incontinence, especially the elderly because urinary incontinence is very much prevalent for this population. Moreover, assessment plays a major role in determining whether a person can actually function independently in the community or whether or not he needs to be placed in a nursing home (Chutka, et.al., 1996, p. 93). Since urinary incontinence takes on different types and has different causes, the assessment process can help establish the cause and the type of incontinence which afflicts the elderly patient. By accurately classifying the patient’s incontinence, the physicians will know the possible cause of the affliction and the proper medications they would be prescribing (Chutka, et.al., 1996, p. 93). In some instances, physicians do not ask the patients about the particulars of their incontinence, and this often leads to untreated or undiagnosed incontinence. However, the assessment process must be undertaken no matter how embarrassing the questions may be because they ultimately help in the process of alleviating patient suffering (Chutka, et.al., 1996, p. 93). The importance of assessment for urinary incontinence was once more emphasized in a study conducted by Ouslander, et.al., (1989, p. 715) when they designed a prospective evaluation in order to assess geriatric urinary incontinence in primary care settings. The study revealed that limited risks were manifested in treatment plans based on clinical assessments undertaken on patients. And although more refinement and testing is needed for the study, “the data presented documentation that a substantial proportion of elderly patients with a treatable and often ignored problem can be appropriately managed based on a relatively simple and inexpensive assessment, which can be carried out in primary care settings” (Ouslander, et.al., 1989, p. 715). Impact of incontinence based on physical, psychological, social, economic, and cultural factors Physical factors In terms of physical impact, urinary incontinence can cause rashes, poor skin integrity and skin infection because the perennial area may always be wet with urine. It can also cause sore pressures especially among older patients who are bedridden (Elderly Health Service, 2006). Psychological factors In terms of psychological impact, urinary incontinence can create feelings of anxiety, insecurity, shame and embarrassment (Elderly Health Service, 2006). It can also create feelings of low-self esteem and helplessness. It can also cause a person to be depressed. Social factors In relation to psychological factors, a person’s social activities may be decreased because of the shame and the embarrassment caused by incontinence. It may also lead to weak interpersonal relationships due to the patient’s social withdrawal (Roach, p. 151). Many sufferers also tend to shy away from sexual relationships because they do not want to risk being embarrassed by their incontinence (Elderly Health Service, 2006). Economic factors The economic impact of urinary incontinence is measured in terms of its overall cost on the health care industry. In the United States alone, costs for the treatment of urinary incontinence already amount to $12.6 billion annual expenses (Onukwugha, et.al., 2009, p. S090). Expenditure for this affliction is mostly for costs of diagnostics, pharmacological and other treatment, routine care, treatment for related diseases like falls, fractures, and UTI (causes); and skin infections and depression (effects) (Onukwugha, et.al., 2009, p. S090). Cultural effects Urinary incontinence is an unacceptable condition in almost all cultures. This is patent in the perceptions of the different cultural groupings as regards children who wet their bed or who are unable to control their bladder (Landau, et.al., 1996, p. 151). Hence for individuals who manifest with urinary incontinence, their condition may still be a source of embarrassment and shame within their culture. Holistic assessment Holistic assessment is basically the process of evaluating all the aspects of a patient’s life. It is an assessment which is based on the premise that the body, mind, and the spirit are interconnected with one another (Potter & Frisch, 2007, p. 213). It is a practice which uses knowledge, intuition and creativity in order to provide a caring process which combines theory and practice and documenting them in standard formats (Potter & Frisch, 2007, p. 213). Through this holistic process, all aspects of a person’s life are considered as contributory to his physiological condition. In the process, the interventions and planning process also create holistic interventions. The holistic assessment as applied in urinary incontinence will also consider all possible causes and symptoms for urinary incontinence. There is a need to conduct a holistic assessment for patients with urinary incontinence because in most cases, their symptoms or causes do not occur in isolation from each other (Baessler, 1994, p. 221). Some women “may present with coexisting urological symptoms, such as urge incontinence, frequency, elevated post void residual urine, or urinary tract infection” ( Baessler, 1994, p. 221). Through the standard and the usual physical assessment which can be conducted on the patient, the holistic assessment would include the pain assessment of the pelvis, the lower back, the pelvic floor because these symptoms may indicate some other conditions which may cause the incontinence (Baessler, 1994, p. 221). Based on this holistic assessment, the interventions which would now be applied would also necessarily be more holistic, covering all possible aspects contributory to the incontinence. Works Cited Baessler, K., 1994, Pelvic Floor Re-education: Principles and Practice, London: Springer Limited Chutka, D., Fleming, K., Evans, M., Evans, J., & Andrews, K., 1996, Urinary incontinence in the elderly population, Mayo Clinic Proceedings, volume 71, number 1, pp. 93-101 Dowling-Castronovo, A., 22 April 2004, Urinary Incontinence Assessment, Dermatology Nursing, volume 16, number 1 Fillit, H. & Picariello, G. 1998, Practical geriatric assessment, UK: Oxford University Press Health Problems of the Elderly, 1 October 2006, Government Information Centre, viewed 03 March 2010 from http://www.info.gov.hk/elderly/english/healthinfo/healthproblems/urinary-e.htm Landau, R., Last, U., Aldor, R., & Hartman, M., 2001, Sex and Sociocultural Correlates of Urinary Incontinence in Israeli Preschool Children, Journal of General Psychology, volume 123 Nygaard, N., & Holcomb, R., January 2000, Reproducibility of the Seven-Day Voiding Diary in Women with Stress Urinary Incontinence, International Urogynecology Journal, volume 11, number 1, pp. 1433-3023 Onukwugha, E., Zuckerman, I., McNally, D., Coyne, K., Vasundha, V., & Mullins, D., 24 March 2009, The Total Economic Burden of Overactive Bladder in the United States: A Disease-Specific Approach, American Journal of Managed Care, viewed 03 March 2010 from http://www.ajmc.com/supplement/managed-care/2009/A220_09mar_OAB/A220_09mar_OnukS90toS97 Ouslander, J., October 2007, Urinary Incontinence, Merck.com, viewed 03 March 2010 from http://www.merck.com/mmhe/sec11/ch147/ch147a.html Ouslander, J., Leach, G., Staskin, D., Blaustein, J., Morishita, L., & Raz, S., 1989, Prospective evaluation of an assessment strategy for geriatric urinary incontinence, Journal of American Geriatric Society, volume 37, number 8, pp. 715-724 Potter, P. & Frisch, N., 2007, Holistic assessment and care: presence in the process, Nursing Clinics of North America, volume 42, number 2, pp. 213-228 Physiology of Urination, University of Oklahoma, viewed 03 March 2010 from http://www.ouhsc.edu/geriatricmedicine/Education/Incontinence/INCONTPhysiology_of_Urination.htm Roach, S., 2001, Introductory Gerontological Nursing, Philadelphia: Lippincott Williams & Wilkinson Wylie, L., 2000, Essential anatomy and physiology in maternity care, Philadelphia: Elsevier Health Sciences Read More