STRENGTHENING PELVIC FLOOR MUSCLES

Stress incontinence, the most common kind of urinary incontinence in women, usually results from weakening of the urethral sphincter. In men, it may sometimes occur after a radical prostatectomy.

You can help male and female patients prevent or minimize stress incontinence by teaching pelvic floor (Kegel) exercises to strengthen the pubococcygeal muscles. Here's how.

Learning Kegel exercises

First, explain how to locate the muscles of the pelvic floor. Instruct the patient to tense the muscles around the anus, as if to retain stools.

To identify this area initially, teach the patient to tighten the muscles of the pelvic floor to stop the flow of urine while urinating and then to release the muscles to restart the flow. Once learned, these exercises can be done anywhere. Although Kegel exercises shouldn't be done while urinating, they can be done at any other time.

, ,

Establishing a regimen

Explain to the patient that contraction and relaxation exercises are essential to muscle retraining. Suggest that the patient start out by contracting the pelvic floor muscles for 5 seconds, relax for 5 seconds, and then repeat the procedure as often as needed.

Typically, the patient starts with 10 contractions in the morning and 10 at night, gradually increasing the relaxation and contraction time.

Advise the patient not to use stomach, leg, or buttock muscles. Also discourage leg crossing or breath holding during these exercises.

Read More

Fecal Incontinence Management

Fecal incontinence, the involuntary passage of feces, may occur gradually (as in dementia) or suddenly (as in spinal cord injury). It usually results from fecal stasis and impaction secondary to reduced activity, inappropriate diet, or untreated painful anal conditions. It can also result from chronic laxative use; reduced fluid intake; neurologic deficit; pelvic, prostatic, or rectal surgery; and the use of certain medications, including antihistamines, psychotropics, and iron preparations. Not usually a sign of serious illness, fecal incontinence can seriously impair an elderly patient's physical and psychological well-being.

Patients with urinary or fecal incontinence should be carefully assessed for underlying disorders. Most can be treated; some can even be cured. Treatment aims to control the condition through bladder or bowel retraining or other behavior management techniques, diet modification, drug therapy, pessaries, and, possibly, surgery. Corrective surgery for urinary incontinence includes transurethral resection of the prostate in men, urethral collagen injections for men or women, repair of the anterior vaginal wall or retropelvic suspension of the bladder in women, urethral sling, and bladder augmentation.

Equipment

Bladder retraining record sheet • gloves • stethoscope (to assess bowel sounds) • lubricant • moisture barrier cream • antidiarrheal or laxative suppository • incontinence pads • bedpan • specimen container • label • laboratory request form • optional: stool collection kit, urinary catheter.

Implementation

Whether the patient reports urinary or fecal incontinence or both, you'll need to perform initial and continuing assessments to plan effective interventions.

For fecal incontinence

• Ask the patient with fecal incontinence to identify its onset, duration, severity, and pattern (for instance, determine whether it occurs at night or with diarrhea). Focus the history on GI, neurologic, and psychological disorders.
• Note the frequency, consistency, and volume of stools passed in the past 24 hours. Obtain a stool specimen if ordered. Protect the patient's bed with an incontinence pad.
• Assess for chronic constipation, GI and neurologic disorders, and laxative abuse. Inspect the abdomen for distention, and auscultate for bowel sounds. If not contraindicated,
  check for fecal impaction (a factor in overflow incontinence).
• Assess the patient's medication regimen. Check for drugs that affect bowel activity, such as aspirin, some anticholinergic antiparkinsonian agents, aluminum hydroxide, calcium carbonate antacids, diuretics, iron preparations, opiates, tranquilizers, tricyclic antidepressants, and phenothiazines.
• For the neurologically capable patient with chronic incontinence, provide bowel retraining.
• Advise the patient to consume a fiber-rich diet that includes lots of raw, leafy vegetables (such as carrots and lettuce), unpeeled fruits (such as apples), and whole grains (such as wheat or rye breads and cereals). If the patient has a lactase deficiency, suggest that he take calcium supplements to replace calcium lost by eliminating dairy products from the diet.
• Encourage adequate fluid intake.
• Teach the elderly patient to gradually eliminate laxative use. Point out that using laxatives to promote regular bowel movement may have the opposite effect, producing either constipation or incontinence over time. Suggest natural laxatives, such as prunes and prune juice, instead.
• Promote regular exercise by explaining how it helps to regulate bowel motility. Even a nonambulatory patient can perform some exercises while sitting or lying in bed.

Special considerations

• For fecal incontinence, maintain effective hygienic care to increase the patient's comfort and prevent skin breakdown and infection. Clean the perineal area frequently, and apply a moisture barrier cream. Control foul odors as well.
• Schedule extra time to provide encouragement and support for the patient, who may feel shame, embarrassment, and powerlessness from loss of control.

Complications

Skin breakdown and infection may result from incontinence. Psychological problems resulting from incontinence include social isolation, loss of independence, lowered self-esteem, and depression.

Documentation

Record all bladder and bowel retraining efforts, noting scheduled bathroom times, food and fluid intake, and elimination amounts, as appropriate. Document the duration of continent periods. Note any complications, including emotional problems and signs of skin breakdown and infection as well as the treatments given for them.

Read More

Urinary Incontinence Management

In elderly patients, incontinence commonly follows any loss or impairment of urinary or anal sphincter control. The incontinence may be transient or permanent. In all, about 10 million adults experience some form of urinary incontinence; this includes about 50% of the 1.5 million people in extended-care facilities. Fecal incontinence affects up to 10% of the patients in such facilities.

Contrary to popular opinion, urinary incontinence is neither a disease nor a part of normal aging. Incontinence may be caused by confusion, dehydration, fecal impaction, or restricted mobility. It's also a sign of various disorders, such as prostatic hyperplasia, bladder calculus, bladder cancer,

urinary tract infection (UTI), stroke, diabetic neuropathy, Guillain-Barrè syndrome, multiple sclerosis, prostatic cancer, prostatitis, spinal cord injury, and urethral stricture. It may also result from urethral sphincter damage after prostatectomy. In addition, certain drugs, including diuretics, hypnotics, sedatives, anticholinergics, antihypertensives, and alpha antagonists, may trigger urinary incontinence.

Urinary incontinence is classified as acute or chronic. Acute urinary incontinence results from disorders that are potentially reversible, such as delirium, dehydration, urine retention, restricted mobility, fecal impaction, infection or inflammation, drug reactions, and polyuria. Chronic urinary incontinence occurs as four distinct types: stress, overflow, urge, and functional incontinence.

In stress incontinence, leakage results from a sudden physical strain, such as a sneeze, cough, or quick movement. In overflow incontinence, urine retention causes dribbling because the distended bladder can't contract strongly enough to force a urine stream. In urge incontinence, the patient can't control the impulse to urinate. Finally, in functional (total) incontinence, urine leakage occurs despite the fact that the bladder and urethra are functioning normally. This condition is usually related to cognitive or mobility factors.

Equipment

Bladder retraining record sheet ; gloves; stethoscope (to assess bowel sounds) ; lubricant ; moisture barrier cream ; antidiarrheal or laxative suppository ; incontinence pads ; bedpan ; specimen container ; label ; laboratory request form ; optional: stool collection kit, urinary catheter.

Implementation

Whether the patient reports urinary or fecal incontinence or both, you'll need to perform initial and continuing assessments to plan effective interventions.

For urinary incontinence

• Ask the patient when he first noticed urine leakage and whether it began suddenly or gradually. Have him describe his typical urinary pattern: Does he usually experience incontinence during the day or at night? Does he get the urge to go again immediately after emptying the bladder? Does he get strong urges to go? Ask him to rate his urinary control: Does he have moderate control, or is he completely incontinent? If he sometimes urinates with control, ask him to identify when and how much he usually urinates.
• Evaluate related problems, such as urinary hesitancy, frequency, urgency, nocturia, and decreased force or interrupted urine stream. Ask the patient to describe any previous treatment he has had for incontinence or measures he has performed by himself. Ask about medications, including nonprescription drugs.
• Assess the patient's environment. Is a toilet or commode readily available, and how long does the patient take to reach it? After the patient is in the bathroom, assess his manual dexterity; for example, how easily does he manipulate his clothes?
• Evaluate the patient's mental status and cognitive function.
• Quantify the patient's normal daily fluid intake.
• Review the patient's medication and diet history for drugs and foods that affect digestion and elimination.
• Review or obtain the patient's medical history, noting especially the number and route of births, hysterectomy (in women), and any incidence of UTI, prostate disorders, diabetes, spinal injury or tumor, stroke, and bladder, prostate, or pelvic surgery. Assess for such disorders as delirium, dehydration, urine retention, restricted mobility, fecal impaction, infection, inflammation, and polyuria.
• Inspect the urethral meatus for obvious inflammation or anatomic defects. Have the female patient bear down while you note any urine leakage. Gently palpate the abdomen for bladder distention, which signals urine retention. Assess for costovertebral angle tenderness. If possible, have the patient examined by a urologist.

• Obtain specimens for appropriate laboratory tests as ordered. Label each specimen container, and send it to the laboratory with a request form.
• Begin incontinence management by implementing an appropriate bladder retraining program.
• Nursing alert Obtain a 24- to 48-hour bladder diary before implementing bladder retraining.
• To ensure healthful hydration and to prevent UTI, make sure the patient maintains an adequate daily intake of fluids (six to eight 8-oz glasses). Restrict fluid intake after 6 p.m.
• To manage stress incontinence, begin an exercise program to help strengthen the pelvic floor muscles. (See Strengthening pelvic floor muscles.)
• To manage functional incontinence, frequently assess the patient's mental and functional status. Regularly remind him to void. Respond to his calls promptly, and help him get to the bathroom quickly. Provide positive reinforcement.
   

Complications

Skin breakdown and infection may result from incontinence. Psychological problems resulting from incontinence include social isolation, loss of independence, lowered self-esteem, and depression.

Documentation

Record all bladder and bowel retraining efforts, noting scheduled bathroom times, food and fluid intake, and elimination amounts, as appropriate. Document the duration of continent periods. Note any complications, including emotional problems and signs of skin breakdown and infection as well as the treatments given for them.

Read More