|Although incontinence has always been an area of regulatory scrutiny since other quality indicators have been held to stricter guideline compliance standards and penalties, incontinence management has been largely ignored-reduced to a weak, rarely enforced blip on surveyors' radars. But not anymore. Last June, CMS issued its revamped F315, Urinary Incontinence and Catheters. Now it is a whole new endeavor.|
Not that the new F315, a combination of the old F315 and F316, changed what nursing staff were always expected to do. Nursing staff have always been required to do a Resident Assessment Protocol (RAP) on episodes of incontinence, followed by an individualized plan of care. But since January 2006, surveyors are taking a closer look at urinary incontinence (UI), and they have the power to impose financial consequences for noncompliance in detail.
First, though, what is meant by the term "urinary incontinence," or UI? As defined by the International Continence Society, UI is "involuntary loss of urine which is objectively demonstrable and a social or hygienic problem." It is not a disease, but rather a symptom that corresponds to various social and pathophysiological factors. It is not an inevitable part of aging and is often curable and always manageable.
Urinary Assessment and Management
Perhaps a resident's assessment suggests primary urge incontinence. In such a case, I would first order a cystometrogram to determine the bladder's capacity and stability. One case I consulted on involved an 84-year-old cognitively alert woman with diabetes and Parkinson's disease. She took nearly 20 different medications a day and complained that she "leaks all the time." To investigate the possible cause, a post-void residual was taken that measured nearly 400 cc-a sign of incomplete bladder emptying. If she had just been put on a bladder control drug, she would've gotten worse, not better. Unfortunately, these symptoms also manifest in a distal colon packed with stool, requiring an obviously different treatment. In that case, once the stool is removed, pressure on the bladder is relieved and normal function resumes. This illustrates the ultimate goal of F315: to guarantee that people with incontinence are accurately evaluated and treated.
Urinary Tract Infections
Maintaining normal pH and normal discharge actually helps to prevent UTIs. One recommendation is to restore the vaginal lining by giving the patient vaginal estrogen in cream or ring application form. Chronic antibiotic treatment should be avoided because of the risk of antibiotic resistance developing.
Sometimes the care plan isn't medically complex. It may be as simple as recognizing that a patient has chronic constipation. The resulting laxative treatment could produce diarrhea, with the frail resident remaining unclean for a significant period and bacteria gaining easy access to the bladder. Cases like these are the basis for the F-tag's insistence on a focused assessment.
In executing a RAP for incontinence, the most important things to do are to take a post-void residual and monitor for UTI. Nursing needs to start the resident on a trial toileting program-in other words, a restorative program for incontinence. A restorative program is not just keeping records. It's keeping bladder records for a few days, and then reviewing them to see if the resident is still incontinent. If so, the nurse must go back to see if everything medically involved has been addressed. Is the post-void normal? Is there chronic constipation? Does the resident have a chronic UTI? If all those answers are negative, the resident could possibly benefit from a trial on a mild agent controlling an overactive bladder.
If the post-void is normal, perhaps a simple toileting program can address the problem. Not all residents need to be medicated. Bladders work 24 hours a day, and most people over age 75 go to the bathroom twice a night. This means that a toileting program, to be successful, needs to be in effect on all shifts. This doesn't mean that that a resident should be awakened at night. But if the resident is awake at midnight, he or she should be offered a bedpan or commode. The same should occur at 5 a.m. if the resident is awake.
Staffing for Success
Diane A. Smith, MSN, CRNP, is a geriatric nurse practitioner with 20 years of experience in managing incontinence. She has a private practice that includes consultation to nursing homes to implement incontinence programs. For further information, call (610) 353-4391. To send your comments to the author and editors, please send e-mail to firstname.lastname@example.org.
|Incontinence Management System|
SCA has introduced the TENA« InstaDri Skin-Caring SystemÖ, employing wicking technology that keeps residents drier to help maintain skin integrity. The InstaDri Skin-Caring System promotes good skin health through better incontinence management.
The system's technology consists of three components designed specifically to keep residents' skin drier and more comfortable: A transfer layer allows fluid to almost instantly enter the dual core, helping to promote skin dryness; the Dry-Fast Dual CoreÖ rapidly wicks fluid away from the skin, trapping it in the lower core; and strategic placement of superabsorbent polymers improves fluid absorption.
Available from Direct Supply, the BladderScan BVI« aids in compliance with F-tag 315 revisions. The noninvasive BladderScan measures post-void residuals. Incorporating ultrasound technology in an easy-to-use system, the BladderScan allows staff to accurately diagnose the type of urinary incontinence and develop customized treatment schedules for each resident based on bladder volume.
|3-in-1 Wash Cream|
GOJO Industries' PROVON« 3-in-1 Wash Cream is a single product that is used for complete perineal care and bed bathing. Designed to help LTC facilities deliver effective and efficient incontinence care, the new wash cream helps maintain skin integrity, increases skin moisture, and leaves a fresh, clean fragrance after use. No rinsing, soaps, or additional creams are necessary.
3-in-1 Wash Cream is available in 12-fl.-oz. pump bottles with the available PLACESÖ holder and PROVON 1,000-ml dispensers.
DawnMist Barrier Cream from Donovan Industries protects the skin by using an effective yet gentle formula that allows the skin to breathe naturally. Formulated with aloe, lanolin, and petrolatum, it allows the air transmission to the dermal layer, unlike other zinc-based formulas.
|Spray-On Moisture Barrier|
Touchless Care Systems' Rash Relief« protects skin with its concentrated 25% zinc oxide and 20% dimethicone formula. Spray-on, no rub-in application only takes a few seconds, saving nursing time. Additional savings are achieved by eliminating the residual waste and cleanup expense of traditional products. Each 4.5-oz bottle delivers more than 100 adult applications.
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