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Managing Urinary Incontinence
in the Acute Care Setting
(An online continuing education activity)
An Online Continuing Education Activity
Sponsored By:
Grant Funds Provided By:
Managing Urinary
Incontinence in the Acute
Care Setting
(An Online Continuing Education Activity)
CONTINUING EDUCATION INSTRUCTIONS
This educational activity is being offered online and may be completed at any time.
Steps for Successful Course Completion
To earn continuing education credit, the participant must complete the following steps:
1. Read the overview and objectives to ensure consistency with your own
learning needs and objectives. At the end of the activity, you will be assessed
on the attainment of each objective.
2. Review the content of the activity, paying particular attention to those areas
that reflect the objectives.
3. Complete the Test Questions. Missed questions will offer the opportunity to reread the question and answer choices. You may also revisit relevant content.
4. For additional information on an issue or topic, consult the references.
5. To receive credit for this activity complete the evaluation and registration form.
6. A certificate of completion will be available for you to print at the conclusion.
Pfiedler Enterprises will maintain a record of your continuing education credits
and provide verification, if necessary, for 7 years. Requests for certificates
must be submitted in writing by the learner.
If you have any questions, please call: 720-748-6144.
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Pfiedler Enterprises, 2101 S. Blackhawk Street, Suite 220, Aurora, Colorado 80014
www.pfiedlerenterprises.com Phone: 720-748-6144 Fax: 720-748-6196
OVERVIEW
Urinary Incontinence (UI) is a stigmatized, underreported, under-diagnosed, under-treated
condition that is erroneously thought to be a normal part of aging. It is much more common
in women than men. It is so common among hospitalized older adults and those in long-term
care that it’s often seen as inevitable. People older than 65 constitute a growing hospital
population and studies have found that 20% to 42% of adult patients in acute care settings
are affected by UI. In addition, 20% to 35% of previously continent older adults admitted
to the hospital will go on to develop UI. Among its many complications, UI can lead to skin
irritation leading to pressure ulcers. Recent evidence indicates that 42.5% of incontinent
patients have some type of skin injury. Patients with incontinence are more likely to be
immobile and elderly, both of which have been demonstrated to be strongly associated with
pressure ulcer development. The financial costs of incontinence care in acute settings include
staff time for assessment and toileting assistance, clothing and linen changes, incontinence
products, catheter care, and laundry services. Nurses play a key role in the assessment
and management of UI and it is a daily challenge to maintain a healthy skin in patients with
incontinence.
Objectives
Upon completion of this continuing nursing education activity, the participant should be able
to:
1. Describe the causes and risk factors for urinary incontinence.
2. Explain the relationship of urinary incontinence to pressure ulcers.
3. Describe nursing interventions for managing incontinence in acute care settings.
4. Describe nursing interventions for preventing pressure ulcers in incontinent patients.
5. Discuss the role of skin-care protocols and absorbent products in managing patients
with urinary incontinence.
INTENDED AUDIENCE
This continuing education activity is intended for nurses who work in clinical setting that are
interested in learning about the care of patients who have urinary incontinence.
Credit/Credit Information
State Board Approval for Nurses
Pfiedler Enterprises is a provider approved by the California Board of Registered Nursing,
Provider Number CEP14944, for 2.0 contact hours.
Obtaining full credit for this offering depends upon attendance, regardless of circumstances,
from beginning to end. Licensees must provide their license numbers for record keeping
purposes.
The certificate of course completion issued at the conclusion of this course must be
retained in the participant’s records for at least four (4) years as proof of attendance.
1
IACET
Pfiedler Enterprises has been accredited as an Authorized Provider by the International
Association for Continuing Education and Training (IACET).
CEU Statements
• As an IACET Authorized Provider, Pfiedler Enterprises offers CEUs for its programs
that qualify under the ANSI/IACET Standard.
• Pfiedler Enterprises is authorized by IACET to offer 0.2 CEUs for this program.
Release and Expiration Date:
This continuing education activity was planned and provided in accordance with accreditation
criteria. This material was originally produced in April 2015 and can no longer be used after
April 2017 without being updated; therefore, this continuing education activity expires April
2017.
Disclaimer
Pfiedler Enterprises does not endorse or promote any commercial product that may be
discussed in this activity
Support
Funds to support this activity have been provided by CardinalHealth
Authors/Planning Committee/Reviewer
Julia A. Kneedler, RN, MS, EdD
Program Manager/Reviewer
Pfiedler Enterprises
Aurora, CO
Judith I. Pfister, RN, BSN, MBA
Program Manager/Planning Committee
Pfiedler Enterprises
Aurora, CO
Sue K. Purcell, MA
Medical Writer/Author
Englewood, CO
Kristine L. Winters, RN, BSN
Nurse Reviewer/Consultant
Aurora, CO
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ENTITIES FOR THOSE IN A POSITION TO CONTROL
CONTENT FOR THIS ACTIVITY
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for individuals who control content for an educational activity. Information listed below is
provided to the learner, so that a determination can be made if identified external interests
or influences pose a potential bias of content, recommendations or conclusions. The intent
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Disclosure includes relevant financial relationships with commercial interests related to
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distributing health care goods or services consumed by, or used on, patients.
Activity Planning Committee/Authors/Reviewers:
Julia A. Kneedler, RN, MS, EdD
Co-owner of company that receives grant funds from commercial entities
Judith I. Pfister, RN, BSN, MBA
Co-owner of company that receives grant funds from commercial entities
Sue K. Purcell, MA
No conflicts of interest
Kristine L. Winters, RN, BSN
No conflicts of interest
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contact us at:
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Introduction
Urinary Incontinence (UI), defined by the International Continence Society as “any
involuntary leakage of urine,” is a condition that is stigmatized, under-reported, underdiagnosed, and under-treated; it is also erroneously thought to be a normal part of aging.1, 2
It is much more common in women than men. About 25% of young women, 44% to 57% of
middle-aged and postmenopausal women, and about 75% of older women experience some
involuntary urine loss.3 Population-based studies report a prevalence of moderate to severe
urinary incontinence of more than 42% in women over the age of 60.4 In men living in the
community, the prevalence of UI is 5% to 15% and exhibits a more steady increase with age
than among women: 5% at younger than 45 years of age to 21% in men age 65 years or
older.5
People older than 65 constitute the greatest reason for a growing hospital population; this
age group has increased dramatically over the past 100 years and is expected to continue
to increase well into the 21st century. Furthermore, this segment of the population have
the greatest need for health care, those age 85 and older (the “oldest old” or “frail elderly”),
is predicted to undergo a rapid expansion from 10% to 19% by the year 2040. Urinary
dysfunction is reported to be the most prevalent problem in the geriatric population.6 For
example, a study of 577 general medical patients aged 70 and older admitted to three acute
hospitals in Australia indicated that the most frequently reported premorbid condition upon
admission was UI (44%). Furthermore, 13% of patients who did not enter the hospital with
bladder incontinence had developed it by discharge.7 Other studies of acute hospital settings
found that 20% to 42% of adult patients are affected by UI 8, 9 and that 20% to 35% of
previously continent older adults admitted to the hospital go on to develop UI.10, 11
Urinary incontinence is so common among hospitalized older adults and those in long-term
care that it is often seen as inevitable. UI can contribute to falls as patients attempt more
frequent trips to the bathroom and has been associated with depression and social isolation,
increased risk of nursing home placement, and increased strain on family caregivers. A
frequent complication is skin irritation leading to pressure ulcers or moisture lesions such
as incontinence-associated dermatitis (IAD). Recent evidence indicates that 42.5% of
incontinent patients have some type of skin injury.12 The financial costs of incontinence care
in acute settings include staff time for assessment and toileting assistance, clothing and linen
changes, incontinence products, catheter care, and laundry services.13 Nurses play a key
role in the assessment and management of UI 14 and face a daily challenge to maintain a
healthy skin in patients with incontinence.
Types of Incontinence
As defined in the Centers for Medicare & Medicaid Services (CMS) State Operations
Manual, there are six types of incontinence.15
• Urge Incontinence is associated with detrusor muscle overactivity (ie, excessive
contraction of the smooth muscle in the wall of the urinary bladder resulting in
a sudden, strong urge to expel moderate to large amounts of urine before the
bladder is full). Other symptoms include urinary frequency, nocturia, and enuresis.
Neurological conditions, such as stroke, suprasacral spinal cord lesions, and multiple
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sclerosis are associated with urge incontinence. Urge incontinence increases with
age for both men and women.16
• Stress Incontinence is associated with impaired urethral closure (ie, malfunction
of the urethral sphincter), which allows small amounts of urine leakage when
intra-abdominal pressure on the bladder is increased by activities such as
sneezing, coughing, laughing, lifting, standing from a sitting position, or climbing
stairs. The cause is pelvic muscular weakness or urethral hypermotility. Stress
incontinence decreases with age for both men and women.17
• Mixed Incontinence is a combination of two or more types of incontinence, most
often stress and urge incontinence together.
• Functional Incontinence refers to loss of urine that occurs in residents whose
urinary tract function is sufficiently intact that they should be able to maintain
continence, but who cannot remain continent because of external factors (eg,
inability to utilize the toilet facilities in time). It is caused by nongenitourinary
factors, such as cognitive or physical impairments that result in an inability for the
individual to be independent in voiding.
• Overflow Incontinence is the involuntary release of urine when the bladder
becomes overly full due to a blockage, but the individual would not feel the urge
to urinate. This is caused by low tone bladder muscle, or a bladder outlet or
urethral obstruction leading to overdistention and overflow. Patients describe
frequent, constant, or post-void dribbling, urinary retention with hesitancy or
an uncomfortable sensation of fullness, or pressure in the lower abdomen.
Conditions associated with overflow incontinence include drug side effects,
radical pelvic surgery, diabetic neuropathy, low spinal cord injury and benign
prostatic hyperplasia (BPH).
• Transient Incontinence refers to temporary episodes of urinary incontinence
that potentially are reversible once the cause(s) of the episode(s) is (are)
identified and treated. The causes of transient incontinence can be remembered
through the acronym, DIAPPERS.18
◦◦ Delirium-This can be caused by acute illness and may lead to dulling
awareness of the need to void and inability or unwillingness to reach the
toilet.
◦◦ Infection (eg, untreated Urinary Tract Infection -Urinary tract infections
are often seen in older women.
◦◦ Atrophic vaginitis or urethritis – This is a thinning of the skin around
the urethra and the vagina, which can be caused by a loss of estrogen.
Women will complain of burning, itching, frequency and incontinence.
◦◦ Pharmaceuticals-Many medications have secondary side effects or,
when used in conjunction with other medications, can exacerbate UI.
◦◦ Psychological – Depression can result in the loss of motivation to
maintain continence, which may be exacerbated by the side effects of
some antidepressants. Confusion and disorientation associated with
dementia may increase the episodes of UI.
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◦◦ Excess urine production – This is mainly associated with a large intake
of fluids containing caffeine or alcohol, which irritate the bladder causing
frequency, urgency, and urge incontinence.
◦◦ Restricted mobility/restraint -Due to surgery, illness or disability, use of
restraints or other reasons for restricted mobility can interfere or limit
one’s ability to reach the toilet.
◦◦ Stool impaction or constipation – This creates additional pressure on the
bladder, which can cause urinary urgency and frequency.
Urinary Incontinence and Pressure Ulcers
Causes and Risk Factors for Urinary Incontinence
A broad range of conditions and disorders can cause urinary incontinence, including birth
defects, postsurgical procedures of the bladder/pelvic floor, prostatectomy procedures,
injuries to the pelvic region or to the spinal cord, neurological diseases, multiple sclerosis,
poliomyelitis, infection, and degenerative changes associated with aging. It can also
occur as a result of pregnancy or childbirth.19 In addition to the causes of transient
incontinence listed previously, additional risk factors for urinary incontinence include
older age, female sex, and neurologic disease (including stroke). Increased body mass,
decreased physical activity, depression, and diabetes also may increase risk. 20, 21
Complications of Urinary Incontinence
Urinary incontinence can cause many complications, including the following:
• Skin problems. Urinary incontinence can lead to rashes, skin infections, and
ulcerations from constantly wet skin.22
• Urinary tract infections. Incontinence increases the risk of repeated urinary tract
infections.23
• Changes in activities, work life, and personal life. Individuals who are
incontinent may have an emotional burden of shame and embarrassment as well
as the physical discomfort and disruption of their lives that occur with episodes
of incontinence. Some persons may experience stresses in relationships, low
productivity at work, job difficulties, arranging daily activities by bathroom location,
and avoiding activities that provoke incontinence. Individuals who are incontinent
may experience anxiety about “accidents,” depression, social isolation, and social
exclusion.24
Urinary Incontinence and Skin Vulnerability to Pressure Ulcers
Incontinence and pressure ulcers often co-exist. Patients with incontinence are
more likely to be immobile and elderly, both of which have been demonstrated
to be strongly associated with pressure ulcer development.25, 26 Increased skin
moisture, especially when due to incontinence, has long been recognized as an
important risk factor for pressure ulcer development 27, 28, 29 and can have a significant
impact on skin integrity.
7
Skin contact with urine provides a strong, harmful stimulus stressing the epidermal
barrier.30 Urine is composed of 95% normal water and 5% organic solutes, which
primarily are urea. Normal skin has a pH of between 5.4 and 5.9, which is an acidic
environment; this has a bactericidal effect, limiting growth of pathogenic organisms.
In the event of incontinence, urinary urea decomposes on the skin to form ammonium
hydroxide, an alkaline substance that raises the skin pH and favors bacterial
proliferation.31 Occasional exposure to urine alone may not be deleterious, but repeated
exposure, especially in the presence of occlusion of fecal material, puts the skin at
higher risk.32 If the skin becomes overhydrated - this can be due to urine and/or washing
methods, such as overwashing; the skin barrier is disturbed, hence making it more
permeable to irritants, at greater risk of breakdown, and more vulnerable to bacterial
growth and fungal invasion.33
During ageing, genetic factors, metabolic reactions, and hormonal changes lead to
structural changes in the skin. There is a decline in the level of sex hormones (estrogen,
testosterone, dehydroepiandrosterone sulfate), and growth hormone; declining hormonal
levels accelerate skin deterioration. For women, the change in hormone levels, estrogen
in particular, during menopause is accompanied by significant changes within the skin as
skin cellular renewal becomes sluggish, resulting in thinning of the epidermal and dermal
layers. Ageing skin is less resilient and more vulnerable to damage than is younger skin
because it is generally thinner, structurally weaker and drier.34 Dry skin has reduced
lipid levels, water content, tensile strength, flexibility and junctional integrity between the
dermis and the epidermis. Excessive moisture on the skin surface is thought to contribute
to increased risk for the development of pressure ulceration by compromising the skin’s
barrier function and weakening the skin. Moisture can weaken the crosslinks between
the collagen in the dermis, soften the stratum corneum,35 and increase the exposure
of underlying blood vessels to the effects of pressure and shear stresses. In addition,
excessive moisture can significantly increase the skin’s coefficient of friction,36 leading
to increased likelihood of skin damage from friction and shear stresses.37 When skin
exposed to urine is also exposed to mechanical forces such as friction and shear (eg,
friction during the cleaning process, rubbing of perineal skin on containment devices,
clothing, bed, or chair surfaces), the skin can break down more quickly.38
Risk of Infection Associated with Incontinence and Pressure Ulcers
The same areas of the body exposed to UI are also very prone to pressure ulcers. The
hip and buttock regions account for 67% of all pressure ulcers, with ischial tuberosity,
trochanteric, and sacral locations being most common. Infection is the most common
major complication of pressure ulcers and bacterial contamination from improper
skin care or urinary incontinence is an important factor to consider in the treatment of
pressure ulcers as such contamination can delay wound healing.39
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Incontinence and Pressure Ulcer Prevention
General Considerations
Those caring for patients with incontinence and limited mobility have great challenges
since indwelling urinary catheters are strongly discouraged due to the risk of catheterassociated urinary tract infections (CAUTI).40 Beginning in 2008, the CMS stopped
reimbursing hospitals for costs attributable to CAUTIs. A priority recommendation of the
CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC) is to avoid
use of urinary catheters in patients for management of incontinence.41
Interestingly, in a survey of patients with short-term indwelling urinary catheters, 47%
were aware that catheters cause urinary tract infections, 89% believed that catheters
were not overused, and 68% preferred catheter placement rather than use of a bedside
commode, bedpan, or diaper. Patient education is needed regarding the risks of urinary
catheters.42
Some alternatives to indwelling urinary catheters include:
• Establish a voiding program: develop a toileting routine/schedule and offer
frequent reminders to toilet and assistance with toileting, if necessary.
• Modify hospital environment:43
◦◦ Place nurse call bells within easy reach.
◦◦ If mobility is limited, consider using a commode near the bed, an
elevated toilet seat, urinal, or bedpan.
◦◦ Avoid restraints, including side rails.
◦◦ Encourage and assist to void before leaving the unit for tests.
◦◦ Enhance bathroom lighting.
◦◦ Obtain referrals to include physical and occupational therapists for
ambulation aides, gait training, further assessment of ADLs with
continence, and improved muscle strength.
• Use containment products for individuals where bladder control is not possible:
◦◦ Condom catheters/penile sheaths for males.
◦◦ Body-worn pads/diapers: these disposable pads come in various sizes
depending on the volume of fluid expected. They are made of superabsorbent material, which turns to a gel when it comes into contact
with fluid, helping to lock the fluid away from the skin. It is essential to
change soiled products on a regular basis.
◦◦ Bed pads where body-worn pads are inappropriate
The National Pressure Ulcer Advisory Panel (NPUAP) and European Pressure Ulcer
Advisory Panel (EPUAP) recommend the following strategies for preventing pressure
ulcers: 44
1. Identify all individual risk factors (eg, decreased mental status, exposure to
moisture, incontinence, device-related pressure, friction, shear, immobility,
9
inactivity, nutritional deficits) to guide specific preventive treatments. Modify care
according to the individual factors.
2. Establish a bowel and bladder program for patients with incontinence. When
incontinence cannot be controlled, cleanse skin at time of soiling and use a
topical barrier to protect the skin.
3. Select under-pads or briefs that are absorbent and provide a quick drying surface
to the skin. Make sure they are smooth and have no ridges.
4. Use moisturizers for dry skin. Minimize environmental factors leading to dry skin
such as low humidity and cold air.
5. Avoid massage over bony prominences.
Guidelines for Assessing and Treating Urinary Incontinence in Acute Care
Settings
The National Guideline Clearinghouse (NGC) is an initiative of the Agency for
Healthcare Research and Quality (AHRQ). Its mission is to provide physicians and
other health professionals, health care providers, health plans, integrated delivery
systems, purchasers, and others an accessible mechanism for obtaining objective,
detailed information on clinical practice guidelines and to further their dissemination,
implementation, and use.
NGC-6726, updated in 2008: Urinary incontinence (UI) in older adults admitted
to acute care. Found in: Evidence-Based Geriatric Nursing Protocols for Best
Practice.45
Major Recommendations
Parameters of Assessment
• Document the presence/absence of urinary incontinence (UI) for all patients on
admission.
• Document the presence/absence of an indwelling urinary catheter.
◦◦ Determine appropriate indwelling catheter use: severely ill patients,
patient with Stage III to IV pressure ulcers of the trunk, urinary retention
unresolved by other interventions.
• For patients with presence of UI:
The nurse collaborates with interdisciplinary team members to:
◦◦ Determine whether the problem is transient, established (stress/urge/
mixed/overflow/functional), or both and document.
◦◦ Identify and document the possible etiologies of the UI.
Nursing Care Strategies
• General principles that apply to prevention and management of all forms of UI:
◦◦ Identify and treat causes of transient UI.
◦◦ Identify and continue successful pre-hospital management strategies for
established UI.
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◦◦ Develop an individualized plan of care using data obtained from the
history and physical examination, and in collaboration with other team
members.
◦◦ Avoid medications that may contribute to UI.
◦◦ Avoid indwelling urinary catheters whenever possible to avoid risk for
urinary tract infection (UTI).
◦◦ Monitor fluid intake and maintain an appropriate hydration schedule.
◦◦ Limit dietary bladder irritants.
◦◦ Consider adding weight loss as a long-term goal in discharge planning
for those with a body mass index (BMI) greater than 27.
◦◦ Modify the environment to facilitate continence.
◦◦ Provide patients with usual undergarments in expectation of continence,
if possible.
◦◦ Prevent skin breakdown by providing immediate cleansing after an
incontinent episode and utilizing barrier ointments.
◦◦ Pilot-test absorbent products to best meet patient, staff, and institutional
preferences, bearing in mind that diapers have been associated with
UTIs.
• Strategies for specific problems:
Stress UI
◦◦ Teach pelvic floor muscle exercises (PFMEs).
◦◦ Provide toileting assistance and bladder training as needed.
◦◦ Consider referral to other team members if pharmacologic or surgical
therapies are warranted.
Urge UI
◦◦ Implement bladder training (retraining).
◦◦ If patient is cognitively intact and is motivated, provide information on
urge inhibition.
◦◦ Teach PFMEs to be used in conjunction with bladder training or
retraining.
◦◦ Collaborate with prescribing team members if pharmacologic therapy is
warranted.
◦◦ Initiate referrals for those patients who do not respond to the above.
Overflow UI
◦◦ Allow sufficient time for voiding.
◦◦ Discuss with interdisciplinary team the need for determining a post-void
residual test (PVR).
◦◦ Instruct patients in double-voiding and Crede’s maneuver.
◦◦ Sterile intermittent catheter irrigation as needed is preferred over
indwelling catheterization as needed.
◦◦ Initiate referrals to other team members for those patients requiring
pharmacologic or surgical intervention.
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Functional UI
◦◦ Provide individualized, scheduled toileting or prompted voiding.
◦◦ Provide adequate fluid intake.
◦◦ Refer for physical and occupational therapy as needed.
◦◦ Modify environment to be conducive to maintaining independence with
continence.
Guidelines for the Prevention of Pressure Ulcers
Two guidelines regarding prevention of pressure ulcers are in the NGC. When more than
one guideline is accepted by NGC, the NGC will compare them and create a synthesis
document.
NGC Guideline Synthesis: Prevention of Pressure Ulcers46
Guidelines Being Compared:
1. Hartford Institute for Geriatric Nursing (HIGN). Preventing pressure ulcers and
skin tears. In: Capezuti E, Zwicker D, Mezey M, Fulmer T, eds. Evidence-Based
Geriatric Nursing Protocols for Best Practice. 3rd ed. New York (NY): Springer
Publishing Company, Inc.; 2008: 403-429.
2. Wound, Ostomy, and Continence Nurses Society (WOCN). Guideline for
prevention and management of pressure ulcers. Mount Laurel (NJ): Wound,
Ostomy, and Continence Nurses Society (WOCN); 2010.
3. Areas of Difference: There are no significant areas of differences between the
guidelines.
Areas of Agreement
Skin Care and Protection
There is overall agreement that keeping the skin clean, dry and moisturized is
an important preventive step. The groups further agree that massage over bony
prominences should be avoided, and that dry lubricants or other protective dressings (eg,
transparent films, hydrocolloids) should be used to avoid skin injury from friction/shear
during transferring and turning. Both groups recommend use of moisturizers on dry skin.
The groups agree that incontinence-related skin moisture can be a risk factor for
pressure ulcer development, and that the etiology of the incontinence should be identified
and eliminated, if possible. Both groups recommend that skin be cleansed and dried
as soon as possible after each incontinent episode, and that hot water, drying bar
soaps, and irritating cleansing agents (eg, products with fragrance or alcohol) should
be avoided. If skin damage is present, clinicians should avoid products containing
chlorhexidine gluconate because it can be absorbed by damaged skin.47 The use of skin
protectants/incontinence skin barriers is recommended by both groups, with the Wound,
Ostomy, and Continence Nurses Society (WOCN) noting that products with humectants
should be avoided. There is further agreement that absorbent underpads/undergarments
that wick moisture away from the skin should be used. WOCN also recommends a
bowel/bladder management retraining program be established, and consideration of
12
a pouching system or a bowel or fecal containment device to contain excessive stool
output and to protect the skin from the effluence. They add that an indwelling catheter
may be indicated in situations where the severity of urinary incontinence has contributed
to or may contaminate the pressure ulcer. The Hartford Institute for Geriatric Nursing
(HIGN) recommends a bedpan or urinal be offered in conjunction with turning schedules.
Positioning and Pressure-Relieving Devices
Both groups recommend the following be implemented to aid in the prevention of
pressure ulcers: elevation of the head of the bed to no more than 30 degrees (or at
the lowest degree of elevation consistent with the patient’s medical condition); use of a
30-degree lateral lying position; avoidance of placement of the patient directly on his/
her trochanter; use of lift sheets/equipment to reposition or transfer patients rather than
dragging or pulling; employment of trapeze bars to facilitate the patient who is able to
assist with mobility; protection of high-risk areas such as the elbows, heels and sacrum;
and use of pillows or wedges to reduce pressure over bony prominences and to keep
them from rubbing together. There is further agreement that donut-type devices should
not be used for pressure redistribution; WOCN also recommends against foam rings,
foam cut-outs, and synthetic sheepskin.
There is further agreement that support surfaces should be used on beds and chairs
to redistribute pressure. HIGN cites static air, alternating air, gel, and water mattresses
as options. WOCN notes that there is insufficient evidence to support the choice of one
specific pressure redistribution surface/device over another, adding, however, that it has
been reported that at-risk patients should not be placed on an ordinary, standard hospital
mattress. WOCN continues to note that compared with standard hospital mattresses,
alternating or dynamic mattresses and oscillating air-flotation beds have been associated
with a lower incidence of pressure ulcers. They add that high specification foam has been
shown to be effective in decreasing the incidence of pressure ulcers in high-risk patients.
When choosing a support surface, WOCN states that factors to consider other than
interface pressure include skin surface tension, shear force, temperature, humidity, the
magnitude and duration of interface pressure, pressure and blood flow distribution, and
adult versus pediatric patients.
With regard to heel pressure ulcers, the groups agree that heel protection devices should
completely offload (float) the heel. WOCN notes that no specific support surface or heel
product has proven superior overall in decreasing pressure at the heel. They recommend
against the use of synthetic sheep skin, bunny boots, rigid splints, IV bags, and rolled
towels or sheets. WOCN adds that pillows under calves decrease heel interface
pressures as well as foam cushions under calves, and that the recommended method is
to place the pillow longitudinally underneath the calf with the heel suspended in air.
The groups agree that chair-bound individuals have unique repositioning and pressure
redistribution needs. There is agreement that for those who can reposition themselves
while sitting, pressure relief using weight shifts or activities (e.g., chair push-ups, standing
and re-sitting, elevating the legs or placing the feet on a stool) should be encouraged
every 15 minutes. There is further agreement that those who are incapable of performing
13
position changes while sitting should be repositioned at least every hour by a caregiver.
The use of a pressure-reducing device (not a donut) is recommended by both groups for
chair-bound clients. According to WOCN, selection of appropriate pressure redistributing
chair cushions should be done by trained health care professionals who have specific
knowledge and expertise in this area; chair cushions have not been adequately
evaluated to recommend one over another.
Nutrition
The groups agree that individuals with suspected or identified nutritional deficiencies
should be referred to a registered dietician. HIGN recommends protein and calorie intake
be increased and A, C, or E vitamin supplements be administered as needed. WOCN
recommends maintenance of adequate nutrition that it is compatible with the individual’s
wishes or condition, and that individuals with nutritional and pressure ulcer risks be
offered a minimum of 30-35 kcal per kg body weight per day with 1.25-1.5 g/kg/day
protein and 1 ml of fluid intake per kcal per day. HIGN recommends offering a glass of
water with turning schedules to keep the patient hydrated.
Skin-Care Protocols
Although it is best to treat incontinence so that the skin does not come into contact
with urine in the first place, that isn’t always possible. When continence isn’t possible,
barrier creams and sprays can be useful in protecting moist skin from further damage,
especially from urine.48, 49 Clinicians have access to a robust range of skin-care products,
variously labeled as cleansers, moisturizers, moisture barriers, skin protectants, moisture
barrier pastes, and antifungals. Whichever products are selected should be kept readily
available at the patient’s bedside to encourage regular skin care. Skin-care products
include:
• Skin cleansers: soap and water cleansing using a washcloth and bath basin
are associated with multiple infection control issues as well as increased risk of
skin damage. Studies indicate that no-rinse cleansers are just as effective as
soap and water in reducing bacterial counts on the skin, and clinical consensus
now supports no-rinse nonionic “pH-balanced” cleansers and soft disposable
washcloths as a preferred approach to cleansing following an incontinent episode.
However, after cleansing, a protectant product must be applied. The WOCN
Society thus recommends the use of a disposable cloth impregnated with both
acidic no-rinse cleansers and with a protectant such as dimethicone.50
• Moisturizers: products labeled as moisturizers typically contain emollients, which
are designed to promote moisture-barrier function by replacing intercellular lipids
and slowing water loss from the skin. Moisturizers are available as stand-alone
products, but they also are incorporated as ingredients in most perineal and
incontinence cleansers and disposable cleansing wipes. Since studies indicate
that stand-alone moisturizers may not be used consistently, a combination
cleaning/moisturizing product should be used.
• Skin protectants: also referred to as moisture barriers or occlusive moisturizers,
skin protectants provide a film that protects the skin against penetration by
chemical irritants and pathogens contained in stool and urine. These combination
14
products are available either as stand-alone products or as an ingredient in
disposable cleansing wipes. Evidence suggests that a disposable wipe that
combines a cleanser, moisturizing agent, and skin protectant is more effective for
prevention of skin breakdown than a skin-care regimen combining neutral soap
and water.51, 52
A limited number of studies have demonstrated both cost benefits and improved clinical
outcomes related to simplified protocols with fewer steps and product decisions.
• Warshaw and colleagues53 compared a two-step skin-care procedure (cleansing
with either soap and water or an incontinence cleanser followed by application
of a protective barrier) to a one-step procedure using a cleanser-protectant
combination product. The one-step procedure was associated with a reduction in
nursing time and product costs as well as a reduction in skin pain and erythema.
• Clever and colleagues54 found an 89% reduction in incidence of skin breakdown
and an estimated annual savings of $3700 with the use of a one-step skin
protection program as opposed to a “multistep” intervention program.
• Several studies have addressed the economic and clinical efficacy of a prevention
protocol incorporating the use of a spray acrylate clear barrier film applied 3 times
weekly as the moisture barrier, as opposed to petroleum-or zinc oxide-based
ointments applied after each incontinent episode. The barrier film was found to
be as clinically effective and more cost-effective in all studies, due in part to the
significant difference in frequency of application.55, 56
Use of Absorbent Products
There is a strong association between poor mobility and continence problems in
patients, and between poor mobility and pressure ulcers. Hence, patients using pressure
management products are therefore also likely to be using absorbent pads.57 For patients
who are incontinent and require the use of absorbent underpads/undergarments,
use of breathable pads/undergarments that allow transmission of moisture vapor is
preferable. Care is required to ensure that their use does not interfere with the pressure
redistribution or microclimate management properties of any support surface in use for
preventing pressure ulcers.58 It is important to remember that incontinence pads should
be smoothed prior to application to reduce ridges and creases. Equally important, the
pad with the most suitable absorbency and shape should be chosen on an individual
basis. The use of multiple pads and pads that have been stretched over support
surfaces are not recommended as they are likely to reduce the efficacy of any pressure
redistribution.59
Prolonged use of absorbent pads/adult diapers is to be discouraged as the use
of absorbent pads is associated with an increased risk of developing urinary tract
infections.60 Interestingly, a study of 325 patients in Israel indicated that in previously
continent adults aged 70 or older, the use of continence aids like urinary catheters or
diapers while in the hospital increased the risk of new urinary incontinence in 17% of the
patients.61 Commenting on the study, McLaffery notes that the authors did not mention
15
why patients were given pads if continent but conjectures that once patients start using
pads, it is very difficult to withdraw them again as they feel a sense of security when they
are wearing them.62
Summary
Urinary Incontinence (UI), much more common in women than in men, is very common
among hospitalized older adults, affecting 20% to 42% of patients in acute care
settings. Moreover, it is estimated that 20% to 35% of previously continent older adults
admitted to the hospital go on to develop UI. For the patient, UI can contribute to
falls and to skin irritation leading to pressure ulcers or other moisture lesions such as
incontinence-associated dermatitis (IAD); it also has been associated with depression
and social isolation, increased risk of nursing home placement, and increased strain
on family caregivers. Recent evidence indicates that 42.5% of incontinent patients
have some type of skin injury. The financial costs of incontinence care in acute settings
include staff time for assessment and toileting assistance, clothing and linen changes,
incontinence products, catheter care, and laundry services. Nurses play a key role in the
assessment and management of UI. Strategies for managing UI include assessing and
treating causes of transient UI, establishing a voiding program, modifying the hospital
environment to facilitate continence and attempting techniques to address specific
types of chronic UI, when possible. If UI persists, then best practices are to implement
good skin-care protocols, use absorbent pads if necessary, and take precautions to
prevent pressure ulcers. It is a daily challenge to maintain healthy skin in patients with
incontinence.
16
Glossary
Dimethicone
A topical emollient that is commonly used to treat
and prevent dry, rough skin and minor irritations
such as diaper rash. Emollients are medicinal
substances that soften and moisturize the skin.
Emollients work by creating an oily layer over the
skin, trapping water underneath the surface.
EnuresisBedwetting.
Functional Incontinence
Incontinence caused by nongenitourinary factors
such as cognitive or physical impairments that
result in an inability for the individual to be
independent in voiding.
Incontinence-Associated An inflammation of the skin caused by prolonged
Dermatitis (IAD) exposure to urine and/or feces. It is superficial
erosion of the epidermal layer of the skin along
with a wet macerated appearance. Skin is
damaged from the “top down” as opposed to
pressure ulcers where skin damage is “bottom
up.”
Mixed Incontinence
Combination of two or more types of incontinence,
most often stress and urge incontinence together.
Nocturia
Frequent awakening at night to use the bathroom.
Overflow Incontinence
Involuntary release of urine associated with
bladder due to a blockage, but the individual does
not feel the urge to urinate.
Pressure ulcer
Localized injury to the skin and/or underlying
tissue usually over a bony prominence, as a result
of pressure, or pressure in combination with shear
and/or friction. Skin is damaged from “bottom up”
as opposed to IAD where skin damage is “top
down.”
Shear
The folding of underlying tissue when the
skeletal structure moved, while the skin remains
stationary.
17
Stress Incontinence
Involuntary loss of urine when pressure is put
on the abdomen by activities such as sneezing,
coughing, laughing, lifting, standing from a sitting
position, or climbing stairs.
Transient Incontinence
Temporary episodes of urinary incontinence that
potentially are reversible once the cause(s) of the
episode(s) is (are) identified and treated.
Urge Incontinence
A strong sudden need to urinate due to bladder
spasms or contractions.
Urinary Incontinence
Any involuntary leakage of urine.
18
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