21. Continence Management

The primary goals of a Continence Management Program are to assess a residents’ bowel and bladder functioning and level of continence upon admission and every quarter thereafter. The program will promote an individualized continence care and toileting care plan that meet the individual needs of each resident to maximize independence, comfort, and dignity while using the appropriate strategies and interventions. Some strategies that are developed to ensure this are:

  • Continence care products that are fitted and ordered as per individual needs
  • Constipation is monitored and treated
  • Enhancement of clinical knowledge incontinence management
  • Monitoring and evaluation of resident outcomes and continence care products considering feedback received from resident, families, and staff.

Management programs include prompted voiding, toileting routines based on individual patterns and to promote comfort for residents assessed as having to potential to promote continence. The Continence Assessment will be completed upon a resident’s admission, with deterioration incontinence level, and with any change in condition that may affect bladder and bowel continence.

Interventions Based on Urinary Incontinence Types

The interdisciplinary team will make an effort to follow the table below for interventions based on urinary incontinence types.

Stress UIUrge UIOverflow UIFunctional UI
CauseFailure to storeFailure to storeFailure to emptyFailure to store
Frequency20% of all cases50% of all cases10% of all cases20% of all cases
SymptomsSmall amount of urine loss frequently when resident coughs, laughs or changes position Wet during day Dry at night, no distensionLarge amounts of urine loss. Resident “can’t get to the bathroom in time.” Wet day and night No distension Known as overactive bladderSmall amounts of urine loss frequently (leakage) Wet day and night Distension Bladder is always full Associated with slow stream / difficulty urinatingBladder and sphincter are normal Wet day and night No distension
PathologyWeakness of sphincterResult of neurological and / or urological diseaseFemale: result of cystocele Male: result of enlarged prostate, fecal impactionOther factors cause incontinence are: environment, psychological, drugs Often a result of decreased mental or physical ability, unable to get to bathroom on time
PrevalenceMostly female, some men after prostate surgeryBoth male and femaleBoth male and femaleBoth male and female
Treatments / InterventionsMedications (i.e. Premarin, Entex-LA) Kegel exercises Prompted voidingMedications (i.e. Ditropan, antibiotics) Surgery Bladder retraining routines Toileting routines Prompted voidingMedications (i.e. Prazosin, Proscar) Surgery Double voiding Bowel maintenance program Dis impactionMedications Surgery Environment Mobility Psychological Prompted voiding

Interventions to Promote Urinary Continence

A. Prompted Voiding

The 3 primary techniques of prompted voiding are monitoring, prompting and praising

a) Monitoring involves asking the resident if they need to use the toilet at regular intervals. The caregiver needs to be aware of behavioral indicators and cannot rely only on the clock.
b) Prompting a resident to use the toilet at regular intervals encourages the maintenance of bladder control between prompted voiding sessions.
c) Praising is positive reinforcement given by the staff for dryness and maintaining bladder control.

The interdisciplinary team will utilize the appropriate interventions before initiating prompted voiding:

  1. Determine the resident’s bladder pattern using a 7-day voiding record (bladder monitoring record). To determine voiding pattern document the following:
    • I – if the resident is incontinent of bladder and product is required
    • D – when a resident is dry
    • T – if a resident is toileted ac or pc meals, and at hs
    • V – if the resident voided on the toilet, commode or urinal
    • CP – incontinent product is changed, peri care is provided
    • SL – if the resident is sleeping, undisturbed
    • F – all fluid intake on dietary, snack and hydration records (to establish patterns)
    • A – if the resident is agitated when toileted or changed
    • C – if the resident is calm when toileted or changed
    • R – if the resident refused to be provided care
  2. Address constipation and fecal impaction if required.
  3. Encourage fluid intake of 1500ml per day.
  4. Minimize caffeinated and alcoholic beverages where possible.
  5. Initiate an individualized prompted voiding schedule based on the resident toileting needs and as indicated by the 7-day voiding record (bladder monitoring record).
  6. Initiate another 7-day voiding record between 3 and 8 weeks after the prompted voiding schedule begins.
  7. Determine the success of the prompted voiding trail and develop the plan of care based on the results.
  8. Evaluate and document the resident outcome.

NOTE: To measure the success of the prompted voiding trial, utilize the formula provided by the RNAO best practice guidelines. Calculate the number of times toileting was successful and divide by the total number of toileting attempts and multiply by 100.

B. Toileting Routine

The purpose of a toileting routing is:

  • To restore a normal pattern of voiding and bowel elimination
  • To reduce incontinent episodes
  • To provide for resident comfort
  • Hygiene
  • Safety
  • To increases self-esteem
  • To prevent skin breakdown

The interdisciplinary team will:

  1. Ensure designated toilet times are clearly noted in the plan of care.
    a. The times the resident is to be toileted
    b. What equipment to use (bedpan, commode, etc.)
    c. What incontinent product to use if required
    d. Number of staff required to safety toilet resident
  2. Whenever skin breakdown is present, the registered staff will assess brief usage and advise the continence promotion team if a change is required.
  3. Any resident who cannot be left alone on the toilet will have this noted in their plan of care. Provide privacy while remaining in the immediate area to ensure safety.
  4. When toileting a resident ensure to inform them of what will be occurring and encourage them to attempt a BM each time they are toileted.
  5. Residents who require reminders to go to the washroom may require additional cues. Walk into the bathroom, be encouraging, etc.
  6. Residents requiring assistance to use the toilet must receive the appropriate level of assistance from staff.
  7. If a resident is resistive resulting in a toilet times being missed, take any opportunity he/she presents to help them use the toilet.
  8. Any resident who requests to be helped to the toilet is to be reported to the supervisor for further assessment.
  9. Any resident with repetitive requests to be helped to the toilet is to be reported to the supervisor for further assessment.
  10. Maintain nutrition, fluid levels and encourage exercise.
  11. Maintain bowel routines.
  12. Adaptive, supportive devices are to be used under the direction of rehab/restorative therapist.
  13. Assigned personal support worker must be alerted to changes of problems with elimination or behavior that can hamper success. Report this to the supervisor immediately.

C. Intractable Incontinence

Residents identified as having intractable incontinence are those who have been assessed and have had contributing factors identified, and for who attempts at regaining continence have not been successful and are no longer able to sit on the toilet.

The interdisciplinary team will:

  1. Assess the need for a continence care product, measure the resident to determine the appropriate size and evaluate the most effective category of the product according to the level of incontinence, ensure that the continence care products are appropriate for the time of day.
  2. Update the plan of care to reflect that the management program is now containment.
  3. Check the resident frequently and change based on product manufacturer’s recommendations. Provide peri care and skin care when changing the incontinence product.
  4. Monitor the perineum for redness and skin breakdown and report observations to the registered staff for further assessment and treatment.
  5. Document the bowel movements on the resident’s documentation record.
  6. Update the care plan quarterly and when there is a change in condition that affects continence.
  7. Maintain nutrition, fluids and encourage activity.
  8. Maintain bowel protocol.
  9. The assigned PSW/HCA must be alert to changes or problems with elimination and report these to a supervisor immediately.

D. Bowel Protocol

  1. On admission, each resident is assessed for bowel function. This assessment is done using the interdisciplinary approach and with involvement from the resident and/or substitute decision maker. The care plan is developed based on the individual’s assessed needs. The data collected from the 30-day bowel monitoring tool (used for 15 days) will be used to establish resident needs.
  2. Fluids are offered as per the home’s hydration protocol and residents are encouraged to consume fluids offered at meals and nourishment passes.
  3. Fiber is offered to each resident as part of the menu plan and based on nutrition evidence-based practices.
  4. Prune juice or stewed prunes to be offered to residents three times per week unless contraindicated (e.g., Low potassium diet which will be noted in the plan of care. Residents that require it more frequently will receive prune juice as requested.
  5. If a resident is prone to constipation, a dietary referral is made for further assessment. Nutritional interventions are implemented and documente4d in the president’s plan of care.
  6. When natural stimulants do not effectively maintain regular bowel elimination, further assessment by the physician takes place to determine the need to add to the bowel protocol stool softeners, and/or laxatives.

NOTE: For residents that are on narcotics and other regularly scheduled medications that increase the resident’s risk for constipation they may need to be placed on a daily stimulant ordered by the physician.

Medications That Cause Urinary Incontinence

In addition to medical problems, certain medications can cause or contribute to an incontinence problem. The urethra needs to be closed constantly to prevent leakage. Medicines such as alpha blockers that relax the urethral muscle will cause or worsen incontinence.

The detrusor bladder muscle that contracts to empty all urine can affect incontinence in two ways. It contracts too frequently and too strongly so the bladder pressure will overcome the closed urethra muscle and cause the urine to leak out. Medications can stimulate the detrusor muscle or cause spasms of that muscle will cause incontinence, also known as Urge Incontinence. If a drug blocks the bladder detrusor muscle from contracting, the bladder will continue to fill up and become over-distended. However, it will not rupture but cause a non-voluntary reflex mechanism to take over and strongly contract to empty the bladder and prevent overdistension and rupture. This contraction is so strong that it overcomes the muscle tone holding the urethra shut and a large volume of urine is voided, also known as Overflow Incontinence.

Excess urine production can also be associated with urinary leakage. It does not cause incontinence, but when there is already a weakened continence mechanism by muscle relaxation due to other medications or due to anatomical weaknesses, then the rapid production of the urine either by diuretic drugs (water pills) or even by just drinking excessive amounts of water, will overwhelm the impaired continence forces and results in urine leakage.

The following chart is some examples of medication that can affect urinary continence:

Diuretics (water pills)Diuresis induced by diuretics may cause incontinence. This is particularly relevant in older persons and/or those with already impaired continence.
Sedatives (sleeping pills), Hypnotics CNS DepressantsBenzodiazepines, especially long-acting agents such as flurazepam and diazepam (Valium), may build up in the bloodstream of an older person and cause confusion and alter the person’s ability to recognize the urge to void and lead to urinary incontinence.
Anticholinergic agents; Antihistamines, Antidepressants (TCA), Phenothiazines, Disopyramide, Opiates, Antispasmodics, Parkinson drugs, Alpha-adrenergic agentsPrescription as well as over-the-counter drugs with anticholinergic properties are taken commonly by persons with insomnia, pruritus (itchy skin), vertigo (dizziness), and other symptoms or conditions. Side effects include urinary retention with associated urinary frequency and overflow incontinence. Besides anticholinergic actions, antipsychotics such as thioridazine and haloperidol may cause sedation, stiffness, and immobility.
Alpha-adrenergic agents (high blood pressure meds) sympathomimetics, sympatholytics,Alpha-adrenergic stimulation increases urethral tone and alpha-agonists may cause urinary retention symptoms in older men. Stress incontinence may become symptomatic in women treated with alpha-antagonists as antihypertensive therapy. Older men with large prostate may develop acute urinary retention and overflow incontinence when taking multicomponent “cold” capsules that contain alphagonists and anticholinergic agents, especially if a nasal decongestant and a non-prescription hypnotic antihistamine are added.
Calcium channel blockers (heart and blood pressure medications)Calcium channel blockers can reduce smooth muscle contractility in the bladder and occasionally can cause urinary retention and overflow incontinence.

Medications That Cause Constipation

  • Narcotics
  • Aluminum Hydroxide Antacids
  • Anti-emetics
  • Antidepressants
  • Anticholinergics
  • Antihistamines
  • Anti-hypertensives
  • Anti-Parkinson Agents
  • Anti-psychotics
  • Bismuth
  • Calcium Channel Blockers
  • Diuretics
  • Histamine – 2 blockers
  • Hypnotics
  • Iron Supplements

Roles and Responsibilities

Registered Nurse:

  1. On admission, the registered nurse in collaboration with the resident, SDM and interdisciplinary team, will initiate the bowel and bladder continence assessment for all admissions in POC to determine individual continence patterns.
  2. Initiate a written plan of care within 24 hours of admission based on the resident pre-admission information and initial assessment including the resident and SDM input and review the residents assessed elimination patterns.
    a. Quantifiable, measurable objective with reassessment timeframes
    b. Resident choices and preferences in products and elimination patterns
    c. Outcomes of resident assessment
    d. Interventions with clear instructions to guide the provision of care, services and treatment
    e. Number of staff required to toilet safely
  3. The RN reviews, monitors and initials the bowel and bladder monitoring tool to determine any care plan adjustments to reflect the resident needs and individual preferences and/or medical referral requirements.
  4. With the assistance of the Continence Promotion Team, ensure that residents are provided with a range of continence care products that:
    a. Are based on their individual assessed needs
    b. Properly fit the residents
    c. Promotes resident comfort, ease of use, dignity and good skin integrity
    d. Promotes continued independence wherever possible
    e. Are appropriate for the time of day and for the individual resident’ type of incontinence.
  5. Complete the care plan within 21 days after admission in collaboration with an interdisciplinary team based on the RAI-MDS 2.0 assessments, the resident’s preferences and needs.
  6. Residents are reassessed for their continence status on a quarterly basis using the RAI-MDS. The plan of care is updated based on the triggered RAPs. If the interventions are not effective, initiate alternative approaches and update the care plan as necessary.
  7. Obtain informed consent for treatment from the resident and/or SDM at every stage of care planning and reflected in the care plan.
  8. Obtain feedback from the resident and/or SDM on the effectiveness of the continence care product.
  9. Makes referrals to other interdisciplinary team members as required.
  10. Provides education to the family and resident as well as other members of the team about the bowel and bladder management. Communicates education needs of resident and families to the Continence Management Coordinator for further education when required.
  11. Reviews bowel records and addresses constipation with the interdisciplinary team.
  12. Responds to concerns raised by other members of the interdisciplinary team on issues relating to bowel and bladder management.
  13. Evaluates the plan of care and updates as required.
  14. Communicates to the team and the resident and/or SDM whenever there is a significant change to the care plan regarding continence care and bowel management on an ongoing and annual basis.

Registered Practical Nurse:

  1. Carry out strategies to effectively manage incontinence and constipation (e.g., drug administration, intermittent catheterization, etc.).
  2. Document effectiveness of the interventions.
  3. Assist as required in the information gathering for the bowel and bladder assessment forms, bowel and bladder monitoring records.
  4. Report any changes in the resident’s bowel and bladder routines to the RN.
  5. Recognize and reports resident verbalizations and behaviors indicative of constipation.
  6. Receives education on continence care as required.
  7. Works with the Continence Promotion Team to meet the continence care needs and wishes of each resident.

Personal Support Worker / Health Care Aide:

  1. Offer privacy to the resident when toileting or changing.
  2. Encourage fluid and nutritional intake; notify the RPN/RN when decreased fluid and nutritional intake is observed.
  3. Follow the care plan interventions to promote continence.
  4. Ensures that continence care products are not used as an alternative to providing assistance to toileting.
  5. Assist residents when walking or transferring to the toilet.
  6. Maximize mobility and passive exercises.
  7. Toilet the residents prior to bathing and as per the plan of care.
  8. Use proper techniques in personal hygiene after toileting.
  9. Complete the voiding and bowel monitoring records and report concerns or changes to the RN/RPN.
  10. Do not use soap when providing care to the perineum, use peri care only (soap is used only in tub and bath).
  11. Report resident verbalizations, signs and symptoms of bladder and bowel discomfort to the RN/RPN. Document bladder and bowel function on flow sheets and report to the registered staff.
  12. Receives education on continence care as required.
  13. Works with the Continence Promotion Team to meet the continence care needs and wishes of each resident.
  14. Communicates requests or concerns regarding continence products directly to the Continence Promotion members of the resident’s unit via writing on the facility approved requisition forms and puts it in the unit communication binder for continence care.
  15. Stocks the resident’s personal products required for a 24-hour period only.

Bowel and Bladder Assessment

Residents are assessed for their continence status on admission, quarterly and whenever there is a change in health status that affects bowel and bladder function.

  1. Screening resident for continence level occurs on admission and quarterly using the RAI-MDS assessment, upon a significant change in status relating to continence.
  2. Resident voiding and bowel patterns are assessed on admission using the Continence Assessment Form.
  3. The registered staff completes the continence assessment on residents on admission.
  4. All residents will be assessed on admission through the bowel and bladder monitoring tools to determine the ability to participate in toileting program promoting continence and prevent constipation.
  5. The continence promotion team will identify the residents who can participate in a toileting program promoting continence.
  6. The registered staff will use the RAI-MDS to assess resident able to participate in toileting programs in conjunction with the Bladder Monitoring Record and Bowel Monitoring Record.
  7. The quarterly RAI-MDS assessment captures bowel and bladder continence.
  8. The registered staff based on data gathered from the assessment updates the plan of care and documents the data in the electronic progress notes.
  9. The plan of care for bladder and bowel management is communicated to the interdisciplinary care team.
  10. The care plan will include measures to reduce risks of constipation and prevent occurrences.
  11. The care plan will identify measures to promote comfort, maintain skin integrity and prevent infections associated with incontinence.
  12. Any significant change in status is communicated to the SDM for personal care.
  13. If an incontinent product is required, a request for the resident’s product is filled out and sent to the Continence Promotion Member to that unit or designate.

Fecal Incontinence Assessment

Identify factors that are contributing to the incontinence and the factors that may affect treatment. The objective of the assessment is to identify the following:

  • Cause or causes of incontinence
  • Component of the incontinence mechanism that is effective (sensory, motor, reservoir)
  • Degree/severity of the incontinence
  • Effect of the incontinence on the resident’s quality of life
  • Factors that affect management (the resident motivation, mobility, etc.)

Ask the resident about their history in regards to:

  • Past and present bowel function
  • Current problems with bowel control (if any)
  • The onset of incontinence and duration
  • Current patterns of defecation and soiling
  • Inability to control flatus or leakage of small amounts (smear on underwear)
  • Awareness of impending leakage and or inability to prevent the usual consistency of the stool
  • Description of the consistency of the stool (watery, runny, soft, formed, etc.)
  • History of diarrhea and constipation
  • Dietary habits
  • Average fluid intake
  • Use of laxatives or enemas
  • Medications that cause constipation or diarrhea
  • Physical activity level
  • Emotional status
  • Recent changes to daily routines
  • Previous medical conditions such as anorectal, trauma to the perineum, neurological disease, gastrointestinal surgery, trauma to the spinal cord, diabetes or radiation therapy.

Constipation Assessment

Constipation is one of the greatest problems for the elderly. Laxatives need to be chosen carefully, considering the specific action of the medication and the cause of constipation.

Causes include:

  • Inactivity or decreased activity
  • Poor bowel habits – not establishing regular pattern or time and ignoring signal for elimination
  • Poor nutrition – an inadequate intake of bulk related to limited ability to purchase and prepare proper foods and self-imposed fluid restrictions related to concern about the urinary frequency
  • Emotional problems – depression can reduce food intake, promote inactivity, boredom, withdrawal or isolation
  • Anorexia which may be physical or emotional in origin.
  • Medication such as iron preparations, antihypertensives, analgesics, tranquilizers, anticholinergics, antacids containing calcium carbonate, laxatives (excessive use can cause muscle atrophy and decreased awareness of the presence of a stool.)
  • Organic problems such as hypothyroidism, tumors, diabetic neuropathy, hypokalemia, hemorrhoids, ischemia of the colon, decreased motility of the GI tract, dementia, fissures, colon stricture, volvulus

Clinical manifestations include the following:

  • Difficult passage of hard dry stool
  • Decreased frequency of bowel movements
  • Abdominal fullness, discomfort, flatulence
  • Hard stool in the rectum on palpation
  • Nausea, vomiting, anorexia

Nursing assessment:

  • Find out what is the client’s definition of constipation (many adults sometimes interpret the lack of daily bowel movement as constipation, despite the absence of clinical signs).
  • Keep a diary of food and fluid intake, bowel movements and activity.
  • Take a thorough drug history, including the use of over the counter medications.
  • Palpate abdomen, auscultate bowel sounds. Note the character and frequency of stools.
  • Note presence of other symptoms that when associated with constipation could indicate larger problems. Consult the dietician if required.