The Role Nurses Can Play in Assessment and Rehabilitation - Coursework Example

Loss of urine control or urine incontinence is a functional disability related to toileting including difficulty is washing, difficulty in eating andcognitive impairment. It is not a disease but a symptom of other problems related with the body. It results from the weakening of the pelvic floor muscles especially in people suffering from muscular sclerosis, Alzheimer disease, Parkinsons, stroke and other neurological diseases. It can also be caused as a side effect of medication or surgery. Bates et al., (1979) define continence as “a condition in which involuntary loss of urine is a social or hygienic problem and is objectively demonstrated” (cited by Shirazi et al., 1999). This paper will discuss the management and rehabilitation of continence and the role nurses can play in assessment and rehabilitation. Burgio et al., (1994, cited by Shirazi et al.,) recognize four types of UI which include urge incontinence (bladder contractions are not inhibited), stress incontinence (urethra is not effectively closed during transient increases in pressure), overflow incontinence (bladder does not contract), and functional incontinence (inability or unwillingness of the person with normal bladder to reach the toilet in time). Urge incontinence occurs due to overactive detrusor muscle contacting and sending an urgent message to the brain to eliminate (Carr, 2004). Overflow incontinence is associated with storage due to an obstruction or a nervous system problem. Functional incontinence is found in people whose mobility or cognition is impaired. Stress incontinence occurs due to the deficiency in the urethral closure mechanism during episodes of raised intra-abdominal pressure such as coughing, sneezing, laughing (Dolman, 2003 cited by RNAO, 2006). Physiology and anatomy of the ageing While people of any age can be affected with incontinence, it becomes prominent in the elderly people as detrusor contractile function, bladder capacity, and urinary flow rates all decline with age (Wagg, n.d.). Prostrate enlarges with age in men and this tends to dominate the behaviour of the urinary outflow tract. The bladder requires a greater contractile effort as obstructions increases. The detrusor muscle and the urethral sphincter are essential for urinary continence and micturition (expulsion). These two act together for storage and expulsion of urine. Urine is stored when the detrusor muscle relaxes and the urethral sphincter closes while voiding occurs when detrusor contracts and sphincter relaxes (Yerkes, 1998). This process of storage and voiding depends on a complex neural control system. The detrusor muscle is innervated by the parasympathetic nervous system; the bladder and the urethra are innervated by the sympathetic nervous system. The somatic nervous system controls the urethral sphincter. Cerebral hemispheres, the spinal cord, and the local nervous system control micturition and any disruption at any of these loops can cause urinary dysfunction. As the bladder fills with urine, the signals reach the brain, which in turn sends messages to the urethral sphincter to relax and allow the flow of urine. Physiological changes with age increase the incidence of incontinence. The brain generally loses the ability to interpret the voiding stimulus and hence loses the ability to inhibit the urge to void. The inability to postpone voiding increases and the urethra is relaxed. In women, the urethral closure pressure and urethral length decline, and post-voiding residual (PVR) volume and uninhibited bladder contractions both appear and increase. As people age, they experience a decrease in thirst. When the body’s water loss equals 2% of the body weight, a person experiences thirst. Those with dehydration problems are more susceptible to urinary tract infections, pneumonia, pressure ulcers, confusion, and disorientation (RNAO). Normally adults produce two-thirds of the urine output during the day and one-third at night. In the elderly, renal concentrating ability falls and glomerular filtration rate increases in the supine position (Wagg). With age, the elderly may be suffering from other diseases and may be under medication. As a result, the kidneys work harder at night to produce greater quantities of more dilute urine, which is usually in excess of functional bladder capacity. Impact and attitude towards the older person and on the family Continence problems can restrict social activity of the elderly. The elderly people feel socially isolated, develop a low self-esteem, and feel loss of dignity and depression. Continence maintenance is burdensome and most incontinent people suffer in silence rather than seek help. The reasons for hiding could be embarrassment, limited information, fear of surgery or fear of confinement to an institution (PHAC, 2005). It is a significant healthcare problem in the elderly. Urinary incontinence (UI) generally increases with age and is higher in women. It has also been observed that it is more common among the acute and elderly in hospitals and nursing homes than among those living in the community. It is equally difficult for the individual and his family to cope with incontinence. The stench of urine becomes difficult to hide (Hamdy, 2002). Unable to cope, it forces the family to institutionalize the older people with incontinence. Both view this as a punishment – the patient feels rejected while the family feels guilty. Their guilt reflects in their attitude towards the nurses and the caregivers at the institution. The rift between the two isolates the patient even more. Lack of education on the part of the family leads them to institutionalize the patient. They believe that incontinence is a part of the ageing process and that little can be done about it. Role of Nurse in continence assessment The role of the nurse in continence assessment and primary continence management is significant. The nurse should be competent to identify the risk factors for urinary and fecal incontinence. An important factor for the nurse to remember in assessment is to consider all of the potential contributing factors and how each of these factors impact the person’s ability to control bladder control (RNAO, 2006). Patients should be asked to identify what they think started the problem. She should maintain a proper record of bladder and bowel elimination and incontinent episodes. This has to be recorded for both the day and the might. The specific symptoms of incontinence have to be collected, whether it is related to urge, stress, overflow, functional or a mixture. The cognitive awareness of the patient has to be assessed whether the brain receives and interprets the messages for voiding. Any obstruction or inability to relax the external sphincter has to be observed (RNAO, 2006). Care has to be taken to observe whether urine passed accidentally or purposefully, and the cause of the accident (Yerkes). Any incidence of infection, retention of urine, fecal impaction, perineal skin damage, neurological disorders have also to be identified (WOCN, 1996). The nurse should be adequately trained to evaluate prolapse and urethral hyper mobility, and performance of complex multi channel urodynamic studies with or without fluoroscopic imaging. The nurse also has to take into account history of urinary tract infection, environmental barriers, the patient’s awareness of the need to void and the behavior while voiding, medications and the motivation of the patient to become continent (RNAO). Medical and surgical history has to be taken into account as various factors can aggravate incontinence. Hartmann (2004) suggests a Continence Chart, which would help the nurse to make the right assessment to understand the client’s fluid intake, volume of urine voided, and the pattern of use of the toilet. This would also reveal if the patient has been using pads and the frequency of usage. Mid-stream urine specimen aids diagnose the cause of the bladder symptoms. Before assessment, the patient’s consent is necessary (NNAT, 2006). Information has to be collected from a variety of sources like older person, carers, friends, existing health and social care records, other professional staff. A ‘biography’ or the beliefs and values of the individual is also central to the assessment. Risk assessment and the stability and predictability of the health of the patient have to be considered. The assessment should finally be able to quantify the needs of the patient as well as determine how complex the care needs are. Health promotion and rehabilitation Nurses have an impact on the problem of incontinence in the community, acute-care, long-term care and chronic care settings (RNAO, 2005). There is also evidence to prove that staff attitude towards urinary incontinence was a barrier to treatment. In fact, their attitude could even promote incontinence. (Northwood, 2004 cited by RNAO). During rehabilitation and care planning, the patient’s needs, views, and wishes have to be of prime importance. Their strengths and abilities have to be considered and taken into account. The staff member stick to maintenance rather than encourage the patient to rehabilitation. Maintenance is to avoid change and pads are sufficient to maintain the status quo. Rehabilitation requires effort on the part of the nurse or the caregiver; it emphasizes development of potential. Toilet assistance should be provided according to the need. ‘Prompted voiding’ has been successful in reducing the number of incontinent episodes per day and increase the number of continent voids. This intervention is generally used with people with physical and mental impairments and find it difficult to cope with the situation. The nurse intervenes prior to the prior to the undesired bladder voiding. A schedule is determined using a 3-day record based on the person’s normal voiding record. Individualized toileting is more successful than routine toileting every two hours (RNAO, 2005). Apart from monitoring, the nurse should also prompt the person from using the toilet at regular intervals. Positive reinforcement of dryness and appropriate toileting motivates the patient. Behavioral techniques like pelvic muscles exercises, biofeedback, and bladder training help in controlling urination. These can help a person delay voiding until he or she can reach the toilet. Pelvic muscles exercises have reduced urinary incontinence in some cases upto 57% (Borrie et al., 2002). Pelvic floor exercises are equally effective in women with stress, urge, and mixed urinary incontinence. The goal of treatment is strengthening of the pelvic floor muscle. The Kegel exercises have met with success in helping patients to contract and release the right pelvic floor muscle. Decreasing caffeine intake also reduces incontinency. Research evidences that intervention by nurse consistence advisers reduce incontinence and pad use. Early intervention consisting of bladder training, and counseling about fluid and caffeine intake can contribute towards the rehabilitation of the elderly. Low fluid intake can result in concentrated urine leading to irritation and detrusor or sphincter irritability (Yerkes). Caffeine is a natural stimulant and can cause an urge within 15-20 minutes of consumption. Individuals have to be advised to decrease their intake of caffeine products and increase water consumption. Urge waves rise in the elderly, for which they need to be trained to recognize and respond accordingly. Those with urge continence have trained themselves to void at the height of the urge. Breathing relaxation techniques can help them to hold the urine as much as possible. Counseling has to be given regarding containment/absorptive devices and skin care. Rehabilitation program can include an educational on promoting continence using prompted voiding. The program should dispel the myths related to incontinence and ageing. The educational programs should be well-structured, organized, comprehensive, and directed at all levels of providers, patients and their families. It can thus be seen that assessment is as important as the rehabilitation and the maintenance of incontinence in the elderly. The care givers and the family have an equal role to play in rehabilitating the elderly with incontinence. This is not a disease but a dysfunction of the organs. If handled carefully, the patients can be supported to overcome the embarrassment and the inhibitions that they carry once detected. Nurse intervention is necessary to assess the type of incontinence and guide and motivate the patient accordingly. With regular pelvic control exercises and fluid intake, the older people can me taught and motivated to lead a life as normal as others. References: Borrie M J, Bawden M, Speechley M & Kloseck M (2002), Interventions led by nurse continence advisers in the management of urinary incontinence: a randomized controlled trial, CMAJ • May 14, 2002; 166 (10) http://www.cmaj.ca/cgi/content/full/166/10/1267> 31 July 2006 Carr M (2004), Continence Promotion and Management, 31 July 2006 Hamdy R C (2002), Urinary Incontinence, South Med J 95(2):175-176, 2002, 31 July 2006 Hartmann (2004), Continence Assessment and Treatment Programme, 31 July 2006 PHAC (2005), Incontinence: Silent No More, 31 July 2006 NNAT (2006), Department of Health, Social Services & Public Safety, 31 July 2006 RNAO (2005), Promoting Continence, 31 July 2006 RNAO (2006), Continence Care Education, 31 July 2006 Shirazi V, Fleishman R, Heilbrun G, Mandelson J (1999), Improving the quality of institutional care of urinary incontinence among the elderly: a challenge for governmental regulation, International Journal of Health, Care Quality Assurance 12/3 [1999] 105-119 Wagg A (n.d.), Continence, Incontinence and the Ageing Male, 31 July 2006 WOCN (1996), Role of Wound, Ostomy and Continence Nurses in Continence Management, 31 July 2006 Yerkes A M (1998), Urinary Incontinence in Individuals With Diabetes Mellitus, Diabetes Spectrum, Volume 11 Number 4, 1998, Pages 241-247 31 July 2006 Read More