continence - what are we aiming for?!!
DESCRIPTION
Continence - What are we aiming for?!!. Dr Tammy Angel. Why is it important?. INCONTINENCE. Curable!. IS NOT. A NORMAL. PART OF AGEING. QOL. Occupational Physical Social Psychological Sexual Domestic. Topics for today. What’s normal? - PowerPoint PPT PresentationTRANSCRIPT
Continence - What are we aiming for?!!
Dr Tammy Angel
Why is it important?
Curable!Curable!
QOL
• Occupational• Physical• Social• Psychological• Sexual• Domestic
Topics for today..
What’s normal?What are the NICE guidelines for each
types of incontinence?Local services and National initiativesWorking example..
Normal?
Bladder stores and voids
Usually sense ‘urge’ to PU at 2-300mls
At socially convenient time and place
Reflex relaxation of external sphincter
Bladder muscle contracts
Types of incontinence
• Stress
• Urge
• Overflow
• Functional
• Cognitive/neurological/psychiatric
• Mixed
NICE Rx UI
• At initial ax-SUI/UUI/ Mixed
• Hx is suffficient to inform non invasive 1st line Rx options
• (3 day) bladder diaries
• Invasive Ix NOT recommended before conservative Rx
Stress incontinence..
• Pelvic floor exercises .. ‘of at least 3 months duration’– Digital ax PFM contraction- at least 8 contractions tds - consider electrical
stimulation/ biofeedback for pts unable to actively contract PF
• Duloxetine : ‘Not be routinely used 2nd line, may be offered as alternative to surgical Rx’
• Urodynamics +/- surgical intervention (TVT TOT; injectables colposuspension)
Stress Urinary Incontinence care Plan
Additional instruction/information Stress urinary incontinence occurs when
the (pelvic floor) muscles which usuallysupport the bladder have becomeweakened, such that urine leaks when apatient coughs sneezes picks up heavyobjects, runs jumps or laughs
The most common cause of weak pelvicfloor muscles is pregnancy and childbirth,being overweight, suffering fromconstipation or a prolonged cough
Pelvic floor exercises are the best way toimprove stress incontinence (see separateleaflert), there are drug and surgicaloptions
Comments section to be used to recordnursing actions on care plan
Patient label / details
Name:_____________________________
D.O.B:_____________________________
Hosp No:___________________________
Consultant:__________________________
Aims of Care / Goal: To reduce / cure symptoms of stress incontinence by providing appropriate
advice and specialist attention whenever necessary
Nursing Actions
1. Condition has been explained to the patient
2. Patients with chronic cough and or severe constipation should bereferred to junior doctor
3. Patient given pelvic floor exercise leaflet and instructions explained
4. Daily reinforcement of pelvic floor exercises
5 Patient should be offered continence assessment/ further investigation
6 Before discharge ask patient Ôbothersome ratingÕ of symptoms ofstress incontinence1 = not bothersome 10 = very troublesome and affecting quality of life
7 Follow up to be arranged with continence team on ext 2396
Urge incontinence
• Rx UTI’s and stop unnecessary diuretics• OAB : Caffeine reduction and Bladder retraining .. ‘at least 6 weeks’• Anticholinergics ‘ non-proprietary oxybutynin due to cost effectiveness rather
efficacy - if not tolerated tolterodine; solifenacin, trospium• Intravaginal oestrogens for atrophy• Botulinium toxin A (willing to self catheterise); sacral nerve stimulation;
augmentation cystoplasty; urinary diversion • intravesical oxybutynin,
Overflow incontinence
• Clear bowels• Alphablockers eg tamsulosin• Stop anticholinergics• Intermittent self catheterisation• ?prostatic surgery
Functional incontinence
• Physiotherapy• Move closer to toilet
Neuropsych REGULAR TOILETTINGREGULAR TOILETTING
How should we assess pts - history?
MOBILITY
DRUGS
BOWELS
COGNITION
INFECTION
MEDICALCOMORBITIES
PSxH
Continence Assessment
Examination:
Abdomen/ Pelvis
Perineal/ cough
Rectal
Post micturition bladder scan
+/- Neuro/ Gait
• Investigation• Fluid volume charts• Urinalysis/ MSU• Creatinine• PSA• AXR
+/- USS Renal tracts
Hemel initiatives..
Weekly ward round : “the dry, the wet and the catheterised”!Rolling Educational Programme for AllAssessment of patients in Day Hospital and RAUManagement Algorithims and care planParticipation in National Continence AuditLocal Catheter Audit
+ Identify HCA + Trained on each ward+ Weekly screening--> see referrals + rationalise pad usage
Bleep 17251725
Shape of new service
Monday Tuesday Wednesday Thursday Friday
Hemel
F/U
Watford
Wards
SACH
RAU/OPD
Watford
F/U
Hemel
Clinic/
WR
Wards TA/ AC
WR
? Community
Admin/
Audit
Service Objectives..
Patients identified, comprehensively assessed, and appropriately managed
Patients receive written information about their condition
Better follow up for patients
Improve transfer of information into community
Promote education
My interpretation..
Gynaecologisteg post partum SUI
Urologisteg enlarged prostate +LUTS
GeriatricsComorbidities + UI
GP AssessmentTRIAGE
CommunityContinenceAdvisors
Working example
• 70 yr old woman;
• C/O: severe urgency, UI, nocturnal frequency..needs radioactive iodine!
• PMH : ‘CCF’, HT, OA awaiting THR
• DH: BFZ, Frusemide, Diltiazem, doxazosin tramadol
• PSH: N and no previous ix
Further hx and ix
• O/E: well in self , mild SOA,
abdo NAD, PV N, PR loaded
• Urinalysis = clear
• Bladder scan when ‘desperate’ = 60 mls and PMRV = 0 mls
• WHAT NEXT?…
Assessment..
1. Overactive bladder with small capacity
2. Exacerbated by diuretics,
3. Reduced mobility due to OA,
4. SOA ? Diltiazem/Gravity/RVF
5. Constipation
Plan and outcome
• Stopped BFZ, doxazosin• Frusemide at 5pm then fluid restrict• Detrusitol XL 4 mg od• Bladder retraining exercises – holding on• Senna and docusate• Leg elevation during the day
DRY!!.. Rx radioiodine
Conclusions
Dispel 2 urban myths:
1. Incontinence is not normal for age
2. It is curable…
A continence nurse specialist will dramatically improve quality of service and community integration!
Any questions ?