Continuing care - Incontinence - Essay Example

Continuing care – Incontinence Introduction Incontinence is one of the many problems which often afflict those who are elderly. This incontinence often causes more psychological and social problems among elderly citizens, sometimes causing them to retreat away from society. There is therefore a need to come up with a clear plan for these patients in order to effectively address their incontinence. This paper shall discuss the case of a patient with incontinence, generally describing his other continuing care needs. It shall select two of the continuing care needs identified and through the holistic approach shall briefly outline how they have impacted on the life of the patient and his family. It shall analyse how care was planned and delivered in order to meet the identified continuing needs in relation to evidence gathered from literature. It shall then reflect on the outcomes of care delivery for the continuing care needs identified. The patient, for this paper, shall be referred to with the pseudonym John Wilson. He is 82 years and was admitted into the Accidents and Emergency Unit after suffering a fall. He was later transferred to the medical ward to help him recover from his fall. He had a previous history of prostatectomy and was having problems with incontinence. He showed early signs of dementia, which however did not interfere with the nurse’s communication with the patient. The patient’s wife Barbara also assisted in answering questions about the patient. He lives with his wife and is often visited by his daughter and son-in-law. He needs continuing care because his mobility is compromised and cannot easily make it to and from the bathroom to relieve himself during urinary urgencies. He needs continuing care in order to help manage his urination, in order to prevent him from withdrawing from society, and eventually to keep him from being depressed. The continuing needs of the patient were assessed by the nurse and the other members of the multidisciplinary team (MDT). The nurse and the members of the multidisciplinary team (physiotherapist, occupational therapist, and the attending physician) assessed his risk for experiencing another fall. His previous fall broke his right hip; and he underwent hip replacement surgery soon after. He is now undergoing physical and rehabilitative therapy in order to gradually regain his mobility. He could get himself independently out of bed, but he has to use a walker in order to move about. He also needs assistance with his activities of daily living, but he is slowly gaining independence in carrying out these activities. With therapy and rehabilitation, he is slowly and gradually regaining his mobility without the use of the walker. His attending physician and the nurse then assessed incontinence. John leaked urine frequently, and every time he had to exert effort in getting up, when he sneezed or laughed he would also leak urine. When his bladder is full, he also experienced incontinence. He is frustrated and embarrassed with his condition because he would sometimes wet his bed and his underclothes due to his incontinence. This has already been a problem even before he fell and now it has been made worse by the fact that he had limited mobility. He was also assessed through the Waterlow pressure prevention chart and the continuance chart. Based on the pressure prevention chart, he is at risk for developing pressure ulcers because of his limited mobility. There were reddish areas seen at the bony protrusions at his back and hip area. The social worker also assessed the patient’s emotional, social, and psychological well-being in order to determine how best to address the needs in relation to his incontinence. John felt helpless because of his condition and his limited mobility. He is also feeling depressed because of his incontinence. The assessment tools used above were valid and reliable assessment tools. The Waterlow chart helped determine his risk for pressure ulcers which would be expected based on his limited mobility. The MDT was also there to determine his health risks based on their medical expertise, making the assessment process holistic and comprehensive. Incontinence Incontinence is basically about the loss of bladder control (Mayo Clinic Staff, 2009). Physical impact Rashes at John’s perineal area Poor skin integrity and skin infection in relation to his pressure ulcers. This was exacerbated by the fact that his perineal area and hip area sometimes got wet due to his incontinence Psychological impact John felt anxiety and shame Feelings of low self-worth and helplessness Depression Helplessness on part of family Social impact Reduced social activities Reduced interaction with family members Depression on part of wife because of reduced interaction with husband Care Plan and Interventions 1. Bladder training: involves following strict schedules for bathroom visits. It usually starts with 2 hour intervals, followed by longer intervals to increase bladder control (Gericare Online, n.d, p. 1) Rationale: in order to re-learn control of urination. It also helps to increase time between urinations and to increase the ability of muscles to control urination, long enough to make it to the toilet (Wallace, et.al., 2000, p. 1). 2. Wearing pads: use of disposable diapers including reusable incontinence garments which keep the moisture away from the skin (cheaper for the patient to utilize) (Brazzelli, Shiran, & Vale, 2002, p. 45) Rationale: in order to catch leaks and prevent soiling of clothes and linens (Bishoff, et.al., 1998, p. 454). 3. Managing diet and fluid intake: eating less fatty foods (Dallosso, et.al., 2004, p. 920); drinking less coffee and drinking more water (Norton, 2010) Rationale: decreased coffee or caffeine intake and increased water intake was able to decrease incontinence based on a study by Tomlinson (1999, p. 22). managing diet can help person lose weight and improve abdominal muscle control (Norton, 2010) increasing fluid intake – decreased fluid intake can irritate lining of bladder causing leakage; lower fluid intake makes urine more pungent and less odorous, therefore less embarrassing for John (About.com, 2010). 4. Scheduled toilet trips: scheduled trips to the toilet, preferably every two hours is advisable (McBride, 1996, p. 27). Rationale: to adjust voiding patterns in order to reduce full bladders and reduce unscheduled leakage of urine (Ouslander & Schnelle, 1995, p. 438). to motivate the patient in delaying and resisting the urge to urinate; more importantly to pre-empt involuntary urination (Ministry of Health, 2003). 5. Habit training: otherwise known as void training. This uses the scheduling of voiding hours without changing such schedule (Hoeman, p. 354). Rationale: in order to match the patient’s voiding patterns with his habits to allow less interference with his regular activities (Wyman, et.al., 1997) 6. Pelvic floor exercises: can be done by stopping the flow of urine midflow when going to the toilet; sitting and squeezing abdominal muscles by tightening stomach, buttocks, thigh muscles at the same time (National Health Services, 2010) Rationale: in order to strengthen the pelvic muscles and improve bladder control (Wilson & Herbison, 1998, p. 257). 7. Indwelling urinary catheterization: tube placed in the body to facilitate passage of urine (Liou, 2009). Rationale: in order to monitor fluid balance; to prevent bed wetting; reduce frequent changes in bed spread and clothes; reduce disruption to patient; maintain dryness and reduce pressure ulcers (Malmsten, 1997). This is advisable and preferred for John because of his limited mobility; to minimize bathroom visits; to keep him dry and consequently prevent pressure ulcers. 8. Administer drugs like Imipramine and anticholinergics as advised and as ordered by doctors (Ouslander, 2004, p. 786). Nurse has to ensure that the patient knows when to take, how much, and how often these drugs can be taken. The nurse also has to note any adverse reactions that the patient may experience after taking the drugs. She also has to educate the patient about the drugs and what to expect after taking in these drugs. Rationale: Anticholinergics calm overactive bladders; the imipramine drug treats stress and urge incontinence and helping to manage the incontinence (Andersson, 1999, p. 923). Outcomes of care delivery The outcomes of the different care delivery methods identified above can be measured through improved bladder control, longer intervals between toilet visits, elimination of rashes, elimination of soiling and bed wetting, decreased or diminished feelings of shame and embarrassment, improved relationships with members of the family, and improved emotional disposition as seen in less depressed feelings. More specifically, the success of the measures implemented for John would be on improved bladder control and decreased soiling and wetting of clothes and linens. Due to his immobility, it is important to prevent him from wetting his garments because moisture would add to his risks of developing pressure ulcers. Improving his pelvic muscle control would help him independently control his bladder and his urination – long enough for him to visit the toilet. The success of the interventions and plans for his continuing care would be seen on how well he is able to control his bladder and how well he is able to adjust emotionally to the psychological impact and implications of his incontinence. As regards the medications, the patient should be able to express what the drugs are for; and how much and how often he is to take them. He must also be able to express the possible adverse effects he may experience from the intake of these drugs. 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(1998) A randomized controlled trial of pelvic floor muscle exercises to treat postnatal urinary incontinence, International Urogynecology Journal, volume 9 (5), pp. 257-264 Wyman, J., Fantl, J., McClish, D., Harkins, S., Uebersax, J., & Ory, M., (1997) Quality of life following bladder training in older women with urinary incontinence, International Urogynecology Journal, volume 8(4), pp. 223-229 Read More