FHA - ACUTE CARE CLINICAL PRACTICE GUIDELINES
Promotion and Maintenance of Urinary Continence in the Hospitalized Elderly
(FINAL September 2002)
INTRODUCTION

All patients are to be considered continent unless assessed and diagnosed
otherwise.

No patient will have an incontinence product applied for "accidental" wetting
unless assessed for cause and a plan initiated on continence care.
1.0
PURPOSE
2.0
1.1
To maintain urinary continence in the acutely ill patient in hospital.
1.2
To promote the restoration of urinary continence.
1.3
To promote the attainment of a patient-centered achievable level of
continence for the chronically incontinent patient.
BACKGROUND
Seven percent of community dwelling adults in Canada experienced urinary
incontinence during the previous year. (Angus Reid Group 1997) Women are
twice as likely to experience UI than men (12% versus 2.5%). Up to 35% of
community-dwelling people over the age of 60 and 50% of institutionalized
residents experience UI. (AHCPR UI Guidelines 1996) In addition to being
inconvenient and embarrassing, urinary incontinence (UI) can be the precursor
to serious health problems. Some of these problems include UTI, renal failure,
depression, and falls.
The cost to manage UI is estimated to be about 2.6 billion per year in Canada.
(M. Shaw 1998)
A hospitalized patient whose mobility and functional status has been altered due
to their current acute illness is at a high risk for developing urinary incontinence.
If assessed and treated promptly, UI can be effectively reversed or appropriately
managed. (BC Medical Journal 1996)
3.0
DEFINITIONS AND CLASS DISTINCTION

Urinary Incontinence (UI): Involuntary urine loss which is a social or
hygienic problem. (AHCPR, 1996)

Urge Incontinence: A result of detrusor instability and the bladder
contracts at times other than during intentional voiding. The person is
unable to get to the toilet in time after receiving the urge to void. (Yim,
1996)

Overflow Incontinence: The sensation of fullness is impaired and the
bladder becomes distended resulting in leakage of urine when the intraabdominal pressure exceeds urethral pressure. This is due to an
underactive bladder, or to bladder outlet or urethral obstruction leading to
overdistention and overflow. (AHCPR, 1996)

Stress Incontinence: A result of reduced sphincter resistance, which
allows urine leakage, especially when intra-abdominal pressure is
increased by such activity as coughing, laughing, or lifting. (Yim, 1996)

Mixed Incontinence: A combination of urge and stress incontinence. (L.
Loughrey, Nursing 99)

Functional Incontinence: The person has normal voiding systems, but
has other physical, environmental or psychological impediments to
reaching the toilet. Factors to consider are accessible toilets, depression,
impaired mobility or dexterity, suboptimal response of caregivers. (Yim,
1996)
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
Transient Incontinence: A temporary, reversible loss of bladder control.
This type of UI commonly occurs with UTI, vaginitis, certain medications
and excessive urine production. (Loughrey, Nursing 1999) It is often seen
with functional incontinence.
Causes of Transient Urinary Incontinence:
Pneumonic = DISAPPEAR (Whytock, S. 2002 unpublished)

4.0
D=
Delirium ("Drugs and Bugs")
I=
Infection (e.g. urinary tract infection, pneumonia, hypoxia)
S=
Stool impaction, constipation
A=
Atrophic vaginitis or urethritis
P=
Pharmaceuticals - (e.g sedatives, hypnotics, anticholinergics,
diuretics, calcium channel blockers, anesthesia) (see list in
Appendix E)
P=
Psychological (depression or psychosis)
E=
Excess urine (endocrine e.g. diabetes, thyroid dysfunction,
edema)
A=
Abnormal lab values (e.g. high calcium or glucose, vitamin B 12
deficiency, fluid and electrolyte imbalance)
R=
Restricted mobility (bed rails up, restraints, hemiparesis, pain)
Unconscious Incontinence: Occurs without the patient's awareness. Is
common with paraplegic patients or patients with a bladder fistula, ectopic
ureter or multisystem organ failure. Total incontinence also falls into this
category. (L. Loughrey, Nursing 99)
STANDARDS
4.1.
On admission the nurse will identify the patient's continence status prior to
the acute episode of illness and current continence status.
4.2.
The patient who has a pre-existing history of UI will be assessed for
increasing severity and current management. The interdisciplinary team
will complete a continence assessment and treatment plan. (Appendix B)
4.3.
If the patient has just developed UI, the interdisciplinary team will assess
and complete a continence assessment and treatment plan. (Appendix B)
4.4.
The least intrusive care measures will be used to assist the patient's return
to continence. (Regular toileting being the least intrusive and application
of containment product or insertion of indwelling foley catheter being the
most intrusive.)
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4.5.
5.0
Continence counselling and teaching will be included as part of home
discharge teaching. This may include referral to community resources for
followup. Incontinence should not be a reason to delay discharge.
GUIDELINES
5.1
Assessment
5.1.1 Patient's History

Duration

Characteristics (to determine type)

ability to recognize the need to void

ability to hold

associated to an activity such as coughing, lifting,
exercise

number of voids per day/per night voiding
times/amount

normal flow: dribble, hesitancy, double void voiding
position

pads or other means of protection; what and how
many

Contributing factors:

constipation

caffeine

alcohol

medication

mobility

Other relevant history

chronic illness(es)

radiation

previous UTIs, urodynamic testing

previous treatment (including surgeries)
5.1.2 Observation

Note colour, consistency, concentratIon, clarity and odour of
urine and stool. If UTI suspected the nurse can proceed
(under physician order or with GOP) including in/out
catheterization, urinalysis and/or C&S. Positive WBC and
nitrite requires C&S follow-up.

Post void residual (PVR) if retention is suspected (either
catheter or bladder scanner). A PVR greater than 100 - 150
mL requires follow up.
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5.2

Intake/output (balance, hydration, retention).

Abdominal palpation (distension, mass).

GU examination for discharge, inflammation, abnormalities
(e.g. prolapse, atrophic vaginitis, urethritis).

Rectal examination prn for impaction. (Note: Liquid stool
may indicate bypassing an impaction.)

Frequency of voiding and bowel movements.

As needed for assessment, complete Voiding Record (see
Appendix A) for three (3) days. For the cognitively or
functionally impaired patients, staff will need to complete.
For the cognitively well, have the patient complete.
Management
5.2.1 Based upon the continence care assessment and treatment plan
(Appendix B), the nurse will determine the type(s) of UI being
experienced by the patient. In collaboration with the patient/family
and interdisciplinary team, continence care goals will be
established.
5.2.2 Notify physician immediately if PVR is greater than 300 cc as
retention needs to be investigated. (See Appendix G)
5.2.3 Patient will be positioned upright for males (standing or sitting for
females) to maximize anatomical and physiological elimination
function.
5.2.4 All patients will be instructed on the use of the call bell system. The
call bell will always be within reach of the patient.
5.2.5 Patients on diuretics, IVs and/or push fluids will be checked
minimally q 2 h for toileting need. (NB! Cognitively impaired will be
toileted q 2 h.)
5.2.6 Patients will be encouraged to drink 1500-2000 ml glasses (1 glass
= 250 ml) of fluid per day, unless on restricted fluid intake.
5.2.7 Patients who normally have nocturia will have a commode and nonskid mat at the bedside with facilitative access to self-toilet or call
for assistance. (See: Least Restraints re: side rails)
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5.2.8 Based on the assessment, ongoing reassessment and type of UI,
the interdisciplinary team will:

Determine the need for a regular toileting schedule
(prompted or scheduled voiding).

Provide functional and mobility assistive devices (e.g.
accessible clothing, equipment).

Request a physician or specialist assessment and/or referral
as needed and appropriate.
5.2.9 If patient is unable to sit to void or defecate, a regular bedpan
rather than slipper pan will be used whenever feasible.
5.2.10 If patient is unable to be mobilized to the toilet, a commode at the
bedside will be used.
5.2.11 Interventions for Incontinence (see Appendices C and D for specific
instructions on basic pelvic floor muscle exercise).
5.2.12 Behavioural approaches (see Appendix F).
Note: Skin care, selection of appropriate pads and teaching for all types.
Type
Urge
What to Look For
Overwhelming sensation
present, unable to reach
bathroom in time, voids
large amounts.
How to Intervene









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Scheduled or prompted
voiding. (bladder
training)
Pelvic floor muscle
Rehabilitation.
Giving fluids evenly
throughout day.
Bowel hygiene.
Teach urge
suppression.
Eliminate bladder
irritants.
Teach about bladder
irritants.
Assure clothing is easy
to remove.
Refer to physician re:
treatment.
6
Type
Stress
What to Look For
Loss of urine during activity
that increases abdominal
pressure. Aware of need to
void.
How to Intervene





Mixed
Combination of urge and
stress incontinence
symptoms.




Pelvic floor muscle
rehabilitation.
Scheduled voiding.
Bowel hygiene.
Observe/assess
perineum.
Teach about
estrogen/progesterone
for females.
See Urge and Stress.
Scheduled or prompted
voiding if voiding
interval is less than 3
hr. (bladder training)
Pelvic floor muscle
rehabilitation.
Bowel hygiene.
Loss of urine with
overdistension of the
bladder, no sensation,
frequent or constant
dribbling, daytime small
amount voids with nighttime
flooding, positive (postresidual) bladder scan or
catheterization.

Functional
Functional deficit (usually
cognitive impairment or
immobility) related indirectly
to urinary tract problems.




Scheduled voiding.
Bowel hygiene.
OT and physiotherapy.
Adapt environment and
clothing.
Transient
Temporary loss of bladder
control; common in urinary
tract infections, vaginitis.

Treatment of underlying
cause.
Hydration.
See "Functional".
Overflow
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





Intermittent
catheterization.
Double voiding (having
patient attempt to void,
relax, then attempt to
void again or stand and
retry.
Prompted voiding.
Bowel hygiene.
Refer to physician
immediately.
7
Type
What to Look For
Unconscious Complete absence of
bladder mechanisms;
unpredictable and constant
leakage of urine.
How to Intervene



6.0
7.0
DOCUMENTATION
6.1
On admission the nurse will document in nursing history, the patient's
continence status prior to admission and current status.
6.2
Based on assessment, the nurse will complete continence care
assessment and treatment plan (Appendix B), if needed. Special actions
or observations are to be recorded on the back of this form.
6.3
The continence care assessment and treatment plan will be noted in
progress notes. It will be placed in the kardex.
6.4
The interdisciplinary team will reassess patient's continence status, goal
and continence care plan daily or as needed due to changing continence
status. Alterations will be documented on the kardex and patient's health
record.
PATIENT/FAMILY/CAREGIVER EDUCATION
7.1
8.0
Use of incontinence
products.
Routine skin care and
odor prevention.
Bowel hygiene.
Educational materials and resources will be given to the
patient/family/caregiver on continence and/or incontinence care. (see
Appendix C)
EVALUATIONS
8.1
Standard Review to be completed annually.
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9.0
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