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DEVELOPMENT OF A PRIMARYCARE ASSESSMENT: ' f ‘-

TOOL EOR URINARY INCONTINENCE IN THE — ;._:'-T'*

AMBULATORY ELDERLY

Schalaﬂy Project for the Degree Rf M S N
MICHIGAN STATE UNIVERSITY
BONNIE K OEIMAN ‘ "
1998

“WIS

 

 

LIBRARY W
Michigan State :
University

 

 

 

PLACE IN RETURN BOX to remove this checkout from your record.
TO AVOID FINES return on or before date due.
MAY BE RECALLED with earlier due date if requested.

 

DATE DUE DATE DUE DATE DUE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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DEVELOPMENT OF A PRIMARY CARE
ASSESSMENT TOOL
FOR URINARY INCONTINENCE
IN THE ANIBULATORY ELDERLY

By Bonnie K. Oetman

A SCHOLARLY PROJECT

Submitted to
Michigan State University
in partial ﬁilﬁllment of the requirements
for the degree of

MASTER OF SCIENCE
College of Nursing

1998

ABSTRACT
DEVELOPMENT OF A PRIMARY CARE ASSESSMENT TOOL
FOR URINARY INCONTINENCE
IN THE AMBULATORY ELDERLY
By

Bonnie K. Oetman

Urinary incontinence (UI) affects all age groups and is a particularly common
health problem in the elderly. Urinary incontinence is deﬁned as any involuntary loss of
urine sufﬁcient to be a problem. It is known to affect approximately 13 million Americans
in community and institutional settings. Many elders, as well as, health care professionals
do not view UI as abnormal, but rather as a normal part of the aging process. In order to
change views of U] in the elderly, health care providers must be educated about the
dimensions of U1. In the past, the practice toward UI has been focused on urine contain-
ment and skin protection rather than taking a proactive position toward assessment,
treatment oriented, therapeutic care as described by the AHCPR Clinical Practice
Guidelines on UI. Accurate assessment and diagnosis determine the success of treatment.

The purpose of this project was to develop a primary care assessment tool for UI
for the ambulatory elderly. This author presented a brief overview of the problem and
Signiﬁcance of U1 with the main emphasis is on the development of a provider based
assessment tool. As an outcome of the project, this assessment tool for U1 will serve as an
aid in the basic evaluation Of clients who present with UI in the primary care setting. This

tool will assist in detecting and conﬁrming U1 objectively.

Cepyright
199s

ACKNOWLEDGNIENT

To the one I love, my husband, Harvey
for his love, patience, understanding
and encouragement during the long hours and
countless weekends I worked on this project.
He’s my ﬁ'iend, I could never be happy without --

He truly is the wind beneath my wings!

iv

ACKNOWLEDGMENTS

I would like to thank my advisor and project chairperson, Louise Selanders, for her
continuous encouragement and support throughout my graduate study. She has truly been
a mentor and I appreciate her professionalism. I also appreciate the other project
members, Sharon King, for her great inspiration throughout this endeavor, whose untiring
support I have so much appreciated, and Laura Struble for all of her assistance and smiles
along the way to the accomplishment of this project.

I especially would like to thank Janice Kinsey and Dr. Lawrence Carey for their
editorial assistance during the writing of this project.

I would like to acknowledge the support I received from one special friend, Sandy,
who gave me so much of her time, and gave me the conﬁdence to sustain me throughout
my graduate studies. I would be amiss not to mention many other ﬁiends (Linda, Jan,
Van, Sheryl, Laima & Pam), who truly kept me going, through these past few years of

graduate school. Their encouragement is priceless. Thank you all for your friendship.

TABLE OF CONTENTS

LIST OF FIGURES ................................................... vii
Introduction ......................................................... 1
Background of the Problem ........................................ 1
Conceptual Deﬁnitions ............................................ 5
Purpose of the Project ............................................ 9
Conceptual Framework ................................................ 10
Conceptual Model ............................................... 16
Review of the Literature .......................................... 18
Pharmacologic Assessment for UI ............................ 18

Risk factors / medical history assessment of U1. .................. 20

Overview of UT .......................................... 24

Assessment of UT. ........................................ 26
Functional/environmental assessment .......................... 33

Physical assessment for U1 .................................. 33

Diagnostic assessment for UI ................................. 34

Tool Development .................................................... 36
Overview: .................................................... 37
Implementation ................................................ 38
Guidelines for assessment tool usage ................................ 38
Discussion .......................................................... 44
Implications for Advanced Practice ................................. 44
Evaluation .................................................... 48
Implications for Research ......................................... 50
Summary ..................................................... 52
Appendix A: Assessment Tool for Urinary Incontinence ....................... 53
Appendix B: Sample of a Voiding Diary ..................................... 55
List of References .................................................... 56

LIST OF FIGURES

Figure 1: Orem’s Basic Nursing Systems ................................... 13

Figure 2: Oetman’s Adaptation of Orem’s Basic Nursing Systems Model as Applied to
Urinary Incontinence ............................................ 16

vii

Primary Care Assessment Tool for Urinary Incontinence
In the Ambulatory Elderly

Chapter 1
medaction
Background of the Problem

Urinary incontinence (UI) affects all age groups and is a particularly common
health problem in the elderly. Urinary incontinence, deﬁned as any involuntary loss of
urine suﬁicient to be a problem for a person, is known to affect approximately 13 million
Americans in community and institutional settings (AHCPR, 1996). The incidence for U1
is estimated at 2.9% among 55 - 64 year old people with the more elderly individuals
having a higher prevalence of 14% to 18% of those elders living at home. Approximately
half of elders living in institutions have UI, ranging from 45% to 55% (Nazir, Khan, &
Barber, 1996).

Overall, there are 2.6 million elders with moderate to severe UI in the community
with 800,000 living in nursing homes (Bear, Dwyer, Benveneste, Jett, & Dougherty,
1997). Current estimates indicate that approximately 30% of the elderly population not
living in nursing homes, who are 60 years of age and older, are incontinent (Wozniak -
Petrofsky, 1993). Twice as many women as men are affected (approximately 39% of
women and 19% of men), with a signiﬁcant percentage (between 20% and 30%) having
frequent UI episodes, 'usually daily or weekly (Ham & Lekan-Rutledge, 1996; Catanzaro,
1996; Lagace, Hansen, & Hickner, 1993).

The cost of managing UI is enormous. In 1996 it was estimated at more than $15

2

billion (AHCPR, 1996). Most incontinent persons have tried alternative ways to manage
their urine leakage, most of which were self devised by use of sanitary napkins, paper
towels, adult diapers, and skin care products. According to a study done by J eter and
Wagner (1990), of the 1,670 respondents in the study, 19.3% were using adult diapers,
83% spent less than $15.00 per month managing their UI, while 6.6% spent $30.00 or
more per month for incontinence products. Ouslander and Kane (1984) estimate that care
cost of incontinent residents in nursing homes as being 2.5 times the cost of continent
residents. These costs include extra nursing time, laundering, incontinent pads, diapers,
and staff turnover caused by the Stress of caring for incontinent residents. The fact is the
cost of U1 alone can tip the balance between living independently versus assisted living,
given the enormous expense of nursing home care for the UI client.

Many people who are incontinent do not mention their problem to their health care
provider because they are not aware that help is available, or they are too embarrassed to
talk about it. About 50% of individuals with U1 have not reported their symptoms to a
physician or nurse (Ham & Lekan-Rutledge, 1997). According to Mitteness (1992),
elderly people resign themselves to having bladder control problems because no health
care professional has ever told them about treatment 'options. This ﬁnding is supported by
Branch, Walker, Wetle, DeBeau & Resnick (1994), who found that a majority of primary
care physicians had inquired about UI in approximately 25% of their older patients. When
individuals do seek assistance, evidence exists that primary care providers are either
hesitant or not prepared to discuss, diagnose, or treat the problem, or the provider

dismisses UI as a normal part of aging, and are not sympathetic to the problem

3
(AHCPR, 1996; Ham & Lekan-Rutledge, 1997).

Urinary incontinence is expected to continue as a signiﬁcant health care problem.
As the baby boomer generation ages, the incidence of UI will increase. The consequences
of UI are numerous; it affects everyday activities and the social interactions of elders with
other people. Some people may experience anxiety, depression, social isolation, and low
self-esteem related to their bladder problems. Often, UI causes the person to stop
working, traveling, or participating in social events. In addition, family members,
particularly Spouses, share the frustrations and limitations when the client refuses to leave
the house (Gallo, Fallon, & Staskin, 1997). According to Nazir, Khan & Barber (1996),
clients reported that their UI interfered with their living in the following ways: everyday
activities 34% of the time, performing household chores 24.5%, work life 11.8%, and
sport activities 10.7%. Thirteen percent of the clients with UI described it as being a
continuous problem.

At any age, continence depends on adequate mobility, mentation, motivation,
manual dexterity and intact lower urinary tract ﬁinction. According to Resnick (1995),
data ﬁ'om continent elderly is sparse. However, it is known that with aging, the bladder
capacity, contractility, and the ability to postpone voiding declines in both sexes. For
women, urethral closing pressure decreases, and in men the prostate enlarges which can
lead to UI.

Many elders accept their UT condition as part of the aging process and turn to
supportive aids without having their condition properly diagnosed and treated. A person

is more susceptible to UI with increasing age, but a loss of urinary control is not

4
necessarily a normal part of the aging process (Gallo, et al., 1997; AHCPR, 1996).

One of the biggest obstacles to effective management of UI has been the
perception that UI is inevitable and irreversible. This mis-perception is almost as common
among health care providers as it is with patients (Doughty, 1991; Mitteness, 1992).
Television has been one medium that has promoted this perception in the broadcasts of
advertisements for U1 products. Contrary to popular and some professional beliefs, UI is
a treatable problem and Should not be accepted as a normal part of the aging process.
Recognition of the problem must be combined with a thorough assessment to diagnose
and appropriately treat UI. The development of an assessment tool for use in the primary
care setting for the ambulatory elderly will aide the professional in appropriate care of the
UI client.

Incontinence is a common problem in the ambulatory elderly client presenting to
the primary care provider’s ofﬁce in daily practice. The primary care provider is the most
likely medical contact these clients will have and they should play an important role in
evaluation and treatment of UI. The primary health care provider today is becoming
increasingly aware of U1 because of the aging population. With an appropriate diagnosis
and proper management of this problem, an elder’s quality of life can be signiﬁcantly
improved. In caring for the client with UI, the goal may not necessarily be one of
absolute cure, but rather to improve the condition, prevent complications, and provide
comfort (Beckman, 1995). The initial approach by the health care provider is to begin
asking elderly clients if they are having any difﬁculty with UI and the degree to which it

causes a problem for them. The primary care provider can then take an active role in the

5

care of an incontinent client by becoming skilled in the assessment and evaluation of L1.
The use of an assessment tool is one way to make certain that a thorough history is
Obtained.

The advanced practice nurse (APN) is in a unique position both to provide care to
clients who experience UI problems, and to educate other health care providers about the
signs, symptoms, and appropriate interventions for UI (Beckman, 1995). A correcr
diagnosis can be made on the ﬁrst contact basis through the APN’s accurate assessment
skills and advanced knowledge. The use of an assessment tool will aide with the diagnosis
of the type of U1, so that an appropriate interventions can be instituted.

Cengptuel Deﬁnitions

Signiﬁcant terms used in this project will need speciﬁc deﬁnition.

Ineentinenee is deﬁned by the AHCPR (1996) guidelines as an involuntary loss of
urine that is sufﬁcient to be a problem. This loss of urine can be caused by factors
affecting either the anatomy or the physiology of the lower urinary tract, or both as well
as other factors. It is clinically useﬁrl to differentiate the four most common types of
chronic incontinence which include urge, stress, overﬂow, and ﬁmctional. However, some
people have mixed incontinence, with components of two or more of these urinary
incontinent conditions.

Urgenemugejmtjeenee is the urgent need to pass urine and the inability to
get to a toilet in time. This voiding dysfunction is related to detrusor (bladder) insrabiliry.
which may be due to problems with the bladder itself or to outlet obstruction (AHC PR

1996). Urge incontinence occurs when the bladder contracts at times other than during

6

intentional urination. The person experiences a sudden urge to void and subsequently
leaks urine before locating the toilet. This type of U1 occurs in 40% to 70% of the cases
in the elderly population (Chutka, D., Fleming, K., Evans, M., Evans, 1., Andrews, K..
1996). A more common cause of urge incontinence that increases detrusor instability is
an overactive bladder muscle that can be caused by diabetes, tumors, bladder diverticula.
inﬂammation, infection, dementia, stroke, multiple sclerosis, and prostatectomy (Yim 8;
Peterson, 1996).

W is characterized by the involuntary loss of urine from the
urethra during physical exertion; for example, during coughing, laughing, or lifting
(Newman, 1997). It is a failure to store urine that may result from problems associated
with the bladder or the urinary sphincter; this type of U1 results from either a loss of
structural support or from pelvic ﬂoor relaxation due to intrinsic sphincter dysfunction.
Stress incontinence occurs primarily as 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 & Peterson, 1996). It is also knovm as
outlet incompetence and is common in women. Although this type of incontinence can
occur in men, it is usually limited to those who have had internal sphincter damage from
urologic procedures (Chutka, et al., 1996). The most common causes for women and men
include weak pelvic ﬂoor, multi-parity, uterine prolapse, prostatectomy, and other pelxic
surgery or trauma (Yim & Peterson, 1996).

gnerﬂew ineentinenee is the involuntary loss of urine associated with over-

distention of the bladder, generally due to a bladder contractile dysfunction

7

(AHCPR,1996). Overﬂow incontinence occurs when the bladder contractions are
decreased or urethral resistance is increased, resulting in the bladder storing an increased
volume of urine until low-pressure dilatation is no longer possible, and leakage occurs
(Yim & Peterson, 1996). In other words, leakage of small amounts of urine occur usually
without the urge to void. Clients with overﬂow incontinence commonly have symptoms
of substantially reduced urinary stream, incomplete or unsuccessful voiding, and ﬁ'equent
or even continuous urinary dribbling. It is estimated to occur in 7% to 11% of incontinent
elderly clients (Chutka, et al, 1996). Some causes of this type of UI include diabetes,
spinal cord injury, fecal impaction, benign prostatic hypertrophy, and some medications,
including anticholinergic drugs (Yim & Peterson, 1996).

W is a physical or cognitive inability that inhibits urination.
This condition may be caused by medications, impaired cognition, or excessive distance to
the toilet. Functional incontinence occurs in people who have normal voiding systems but
have other physical or psychological impediments in reaching the toilet (Y im & Peterson,
1996). Some of the causes include inaccessible toilets, depression, anger or hostility,
impaired mobility, or inappropriate cognitive processing of information (Chutka, et al.,
1996; Thayer, 1994 ). Generally, clients with ﬁmctional UI have normally ﬁrnctioning
urinary systems; the UI is a result of some external factor, thus no typical ﬁnding will be
noted on physical examination.

Mixgﬁ ineentinenee is a loss of urine due to a combination of the above problems.
This term is used to describe storage problems with both stress and urge components.

Treatment is usually focused on altering whichever pathologic process can be changed.

8

Incontinence can be either acute or chronic. mm, also known as transient LT.
occurs abruptly and is usually associated with an acute illness and/or medications; it
subsides once the illness or medications are resolved (Beckman, 1995). Chmniﬂl can
be due to long-term changes in the bladder or urethra, or as a result of damaged pelxic
muscles and nerves (Newman, 1997). Chronic UI may last for indeﬁnite periods of time;
it may occur with gynecological, neuro-functional or psycho-behavioral disorders, and
surgical procedures. Beckman (1995) states that if a client’s condition cannot be traced to
any acute condition, it is probably chronic UI.

W is a Standard deﬁned documentation format that provides
for consistent recording of information about UI.

With a thorough medical history, physical examination and record keeping, the
identiﬁcation of UI can be improved (AHCPR, 1996). The clinical guidelines for III were
developed by the Agency for Health Care Policy and Research (AHCPR), an
interdisciplinary expert panel, who conducted an extensive review of the existing
knowledge base for practice about UI. This guideline provides helpful clinical information
about the initial assessment of UI and also provides an informed framework for selecting
appropriate behavioral, pharmacologic and surgical treatments, and supportive devices to
manage UI (AHCPR, 1996). These guidelines emphasize the need for clinicians to ask
about the presence of U1 in the initial assessment and to inform the client that treatments

are available to improve or “cure” the problem.

9

Perpese ef the Preject

The purpose of this project is to develop a primary care assessment tool for urinary
incontinence for the ambulatory elderly. The development of this tool will aide in the
basic evaluation of clients who present with symptoms of U] in the primary care setting.
Current research relative to UI will be used as the basis for developing the assessment
tool. The primary emphasis is on assessment strategies and not on treatment prorocols
for U1.

Several different types of U1 exist: urge, stress, overﬂow, ﬁrnctional. and mixed.
Therefore, assessment and history is usually the most important part of the evaluation for
U1 (Chutka, et al., 1996). Using an assessment tool for the elderly will set into morion
the process needed to begin early and appropriate management of U1. It “in increase the
awareness of the health care provider and provide consistent and effective documentation
of the assessment process. The goal of developing this research based assessment tool is
to assist the primary care provider in the assessment and diagnosis of U1 in the ambulatory
elderly client.

Dorothea Orem’s theory of nursing will be used as a guide for the development of
this project. Orem’s model of self care is applicable in most situations but is well suited
for the development and implementation of an assessment and diagnostic tool for III

because of her particular emphasis on the importance of self-care issues.

1 0
Chapter. 2
MW

Dorothea Orem’s theory of nursing will be used as a guide for development of this
project. Orem’s model of self care is well suited for the development of an assessment
tool for UI in the ambulatory elderly person. Her theory emphasizes the importance of the
individual and the individual’s ability to care for him/herself or perceived self-care deﬁcits.

Orem (1995) deﬁnes self-care as the practice of activities that individuals initiate
and perform on their own behalf in maintaining life, health, and well-being. Self-care
includes making choices, as well as acting on them. Thus, self-care involves control over
one’s life. In the ambulatory setting, once an individual has a self-care deﬁcit, in this case,
with UI, and seeks assistance from a health care provider, the health care provider can
utilize the assessment tool for U1 in the ambulatory elderly, to assist in the diagnosis of the
type of UT, which in turn, will aide the client to achieve self-care measures. It will then be
up to the elderly client to continue with self-care activities as outlined by the provider to
achieve a positive outcome of managing UI effectively.

Orem’s theory has been called a general theory of nursing; that is, one that is
descriptively explanatory of nursing in most types of practice situations. The speciﬁc
name for Orem’s general theory of nursing, however, is the Self-Care Deﬁcit Theory of
Nursing. Self-care is the voluntary regulation of one’s own human functioning and
development that is necessary for individuals to maintain life, health, and well-being
(Orem, 1995). Her conceptual model deﬁnes the concepts and interrelationships available

to practitioners for the development of self-care as a learned behavior and self-care as a

1 l

deliberate action (F awcett, 1995).

The central idea of Orem’s theory is that self-care is a human regulatory ﬁrnction.
With deliberation, individuals must perform for themselves or have performed for them,
the care needed to maintain life, while preserving physical and psychological functioning,
as well as developing norms compatible with conditions essential for life (Orem, 1995).
There are three interrelated components in Orem’s self-care deﬁcit theory: (1)self- care
(dependent care), (2) self-care deﬁcit, and (3) nursing systems (Hartweg, 1991).
The practitioner can select one or all components or concepts to guide his/her work.

There are six basic concepts within Orem’s self-care deﬁcit theory: self- care,
therapeutic self-care demand, self-care agency, self-care deﬁcit, nursing agency, and
nursing system (Parse, 1987). For the purpose of this project, the self-care deﬁcit and
nursing system theories will be discussed. The self-care deﬁcit part of Orem’s theory is a
patient-focused concept; there is potential for a self-care deﬁcit so a health care provider
would have a role in this area. The central idea in the self-care deﬁcit component is that
individuals are affected from time to time by limitations that do not allow them to meet
their self-care needs (Hartweg, 1991). For example, certain self-care limitations may
occur because of aging, thus placing the person in need of care by a primary care provider.

The nursing system is composed of those persons with education and training, who
can help others to meet or develop their self-care needs. Orem (1995) states that the
nursing system is all the actions and interactions of nurses and clients in nursing practice
situations. This nursing system would also include the advanced practice nurse (APN) and

his/her role. There are multiple roles the APN utilizes within the primary care setting. A

12

few of these roles include clinician, assessor, educator, collaborator, evaluator, and
advocate which will assist in the differing situations with clients who present with UI. A
couple of the most important roles in promoting self-care would be the assessor role and
the educator role. The assessor is one who utilizes a data base to identify health care. one
who forms diagnoses or problems and then updates data to validate and reyise initial
ﬁndings. The educator is one who teaches and assists clients in identifying and meeting
their health educational needs.

According to Orem’s theory (Orem, 1995), there are three basic variations of the
nursing system: (1) wholly compensatory, (2) partly compensatory, (3) supportive-
educative. Orem’s theory related to her basic nursing system concepts is illustrated in
Figure 1. In the wholly compensatory nursing system, the health care proxider has the
responsibility to meet all types of self-care requisites for the client. The second system
the partly compensatory nursing system, is for situations where both the health care
provider and client share the responsibility for certain self-care tasks.

The third system is called the supportive-educative system. This system is for
situations where the client is able to perform or can and should learn to perform required
measures of externally or internally oriented therapeutic self-care. Within this sysrem, the
client’s requirements for help are conﬁned to decision making, behavior control, and
acquiring knowledge and skills. The health care provider provides the information and
education for the support of the self-care skills (Hartweg, 1991). For the purpose of this

project, only Orem’s supportive-educative system will be utilized.

13

 

 

Wholly Compensatory System

 

Accomplishes patient’s
therapeutic self-care

N / Compensates for patient’s
urse > inability to engage

action in self-care

 

 

 

Supports and protects
patient

 

 

 

Partly Compensatory System

 

Performs some self-care
measures for patient

 

Compensates for self-care
limitations of patient

 

Assists patient as required

Nurse
action

 

 

Performs some self-care
measures

 

Regulates self-care agency patient

action

 

V

Accepts care and assistance
from nurse

 

 

 

Supportive-Educative System

 

Accomplishes self-care

Patient
action

 

 

Regulates the exercise and
development of
self-care aqencv

Nurse
action +

 

 

 

 

Figure 1. Orem’s Basic Nursing Systems.

SOURCE: Nursing Concepts of Practice, by D. Orem, 1995,
St. Louis, MO, Mosby-Year Book Inc.

 

 

14

The key to understanding the conceptual ﬁamework presented in this project is
through the theory of the nursing system, the supportive-educative system. It is within
this system that describes the role of the APN or health care provider in ambulatory
primary care. It is in this system the elderly client will need to perform some self-care
measures and also be willing to accept care and assistance from an APN or health care
provider in order to participate in activities of daily living with self-care. It is within this
system that the assessment tool for U1 in the ambulatory elderly will be utilized. The APN
may not have access to a continence clinic. He/she may be working in a general practice
setting, when he/she encounters someone with UI and it needs to be addressed.

Within the scope of this project, the elder person may become incontinent and
need some assistance to handle this problem. The APN or health care provider will assist
the elder by assessing the type of U1. This interaction may assist the elder to become
more aware of the strategies used for care of continent issues. The relationship
established between the client and the APN or health care provider can lead to the mutual
development of U1 interventions. The client’s implementation of these interventions can
then progress the client toward the ultimate goal of self care.

People with UI are just beginning to seek health care assistance with this problem.
The basic design of the nursing system within Orem’s theory is that of a helping system.
When the APN or health care provider uses a combination of helping methods in the care
of individuals, both providers and clients move from one role to another. In the
supportive-educative system, the goal is to help the client be as independent as possible

with the APN or health care provider providing information about UI depending upon the

15

assessment strategies, especially if there is a deﬁcit between therapeutic self-care and
current capabilities. The APN, using appropriate assessment strategies, will also provide
educational strategies that will address prevention protocols and be cost-effective and
promote health in the management of U1.

Orem’s conceptual model has been adapted so that assessment strategies are
provided to aide in the development of self-care strategies for the UI client. (See Figure 2
for the conceptual model presented in this project ). Figure 2, identiﬁes primary themes
found in the literature. The top box contains UI assessment strategies as a result of the
literature review, thus the APN can use these strategies to obtain information to aid in the
process of providing the educational strategies that are in the second box. Using these
two boxes of strategies the APN can empower the client to accomplish self—care outlined
in the third box. Thus the APN is providing supportive-educative strategy information as
applied to U1. The strategies outlined identiﬁes primary themes found in the current
literature. The APN or health care provider can help the client implement self-care
behaviors, or help an advocate or caregiver learn how to help the client with UI, by using
assessment strategies followed by identifying the type of UT, and providing educational
strategies to the client ultimately to promote self-care. Maintaining and promoting health
is the overall goal of any health care professional.

Self-care as described by Orem is regarded as a goal oriented activity that is
learned by the client. The focus of this project is the client and his/her self-care needs
while developing a provider based tool to assist in the management strategies of self-care.

Orem’s overriding umbrella is self-care. The self-care framework of Orem presents an

 

 

Figure 2.

l6

      

 

'N: . '

;_i§;';:t-:' TS} . 'I.

. Assess knowledge deﬁcit
. Risk factors

Screening of history, functional
8|. environmental status

. Medication review
. Physical exam
. Identiﬁcation of type of U1

‘29::-

 

. Management strategies for U1
. Health maintenance

. Health promotion

. Primary prevention

. Cost effectiveness

    
  

'-
4M. ﬁs'ix ' Esug".
1""

   
    
   

v '::‘.§I~ ~:"

   

asks ‘u'u‘u'ﬂn \n .

xv. .-. 3.
s... I s‘a‘ii’e‘sci‘

   

:n'u‘.‘ -

. Management of U1

. Minimalization/elimination of
symptoms

. Recognition of need for primary
care

  

Supportive-Educative System
for Urinary Incontinence

Oetman’s adaptation of Orem's Basic Nursing
System Model as applied to Urinary Incontinence.

 

 

17

optimistic view of the client’s contributions to his/her health care that is in keeping with
current evolving social values. Orem does not, however, address assessment strategies
within her ﬁ'amework. In order for self-care to be the ultimate focus, assessment becomes
the overriding concept. The client needs self-care strategies relative to UI. Assessment is
essential in helping the client deal effectively with UI. Even though Orem stresses a client
focused ﬁamework and the assessment tool is provider focused, the focus of this
theoretical framework is the ambulatory elderly population needing self-care strategies for
UI. The development of self-care measures with UI issues is the same concept that Orem
promotes throughout her framework of self-care.

Orem’s framework ﬁts this project because clients who have UI need to care for
themselves effectively. According to F awcett (1995), the unique focus of Orem’s
framework is the provider’s deliberate action to diagnose, design, plan, implement,
manage, and maintain the systems of therapeutic self-care for the individuals. Self-care is
the ultimate focus of this project. The desired outcome is the client’s ability to accomplish
self care measures with UI, and the intervention of the APN or health care provider using
assessment strategies to identify what is effective to help the client manage and participate
in self care. Elderly clients are viewed as having the right and responsibility to care for
themselves and maintain their own rational life and health. This conceptual framework
helps to guide and refocus the attention to a APN provider based tool that will begin with
assessment strategies and restructure the plan to have the outcome of self-care, which
includes educational strategies as part of the process. The APN can help facilitate the

client’s progression towards independent self care measures.

18

Chapter 3
Review ef the Literature

Intredugien; The purpose of the primary care assessment tool for U1 is to detect
and conﬁrm UT objectively, to recognize factors that may be contributing to or
precipitating UI and to identify clients who need ﬁrrther specialized evaluation before any
therapeutic interventions are initiated (AHCPR, 1996; Ham & Rutledge, 1997). The
cornerstone of assessment of U1 is the client history, including medications, physical
examination, simple diagnostics, such as urinalysis, and post-void determination. Initial
assessment and evaluation for UI can be done in the primary care setting. Clients with
complex neurological, urogynecological, or urological disorders should be referred for
more advanced evaluation and urodynamic testing by specialists.

The focus of this chapter is to evaluate the current research literature on
assessment strategies for UI in the primary care setting for the ambulatory elderly. There is
an abundance of information regarding UI in the gerontological literature; however, there
is little current research literature on assessment tools for U1. The majority of the
literature relates to clinical articles on the types and causes of UI and management issues.
Only a few articles in the literature actually address assessment strategies of U], which will

be discussed in this project.

Phatmeeelegie Assessment fer [ll

Wein (1990) states one of the assessment strategies is to look at the medication
proﬁle of the client, to note any drugs that may be causing or inhibiting continence. There

are medications available that decrease bladder hyperactivity and increase sphincter

l9

resistance. Medications that decrease bladder contractility include anticholinergic agents
such as: probantheline, musculotropic relaxants, or antispasmodics such as oxybutynin
(Ditropan), and dicyclomine hydrochlorise (Bentyl). Another class of medication, the
calcium channel blockers, such as Terodiline, are also known to decrease bladder
contractility and are sometimes used to control UI. Prostaglandin inhibitors which include
the non-steroidal anti-inﬂammatory drugs along with beta-adrenergic agonists such as
terbulaline, are also included because they decrease bladder contractility (W ein, 1995;
AHCPR, 1996).

The drugs that increase bladder outlet resistance include alpha adrenergic agonists,
such as imipramine, ephedrine and phenyl-propanolamine hydrochloride. Beta-adrenergic
antagonists and agonists, and estrogens are also included (W ein, 1995). Diuretics can
precipitate UI, but the more potent diuretics such as ﬁrrosemide can also precipitate
retention in men with prostatic enlargement (Ham & Lekan-Rutledge, 1997).

According to Gallo, Fallon and Staskin (1997), non-neurologic causes of UI are
predominately due to medications that directly affect the bladder smooth muscle. Gray &
Burns (1996) discuss the fact that transient UI is caused by multiple factors; one of those
factors is medications. They addressed speciﬁc certain drugs that are normally used for
acute problems that may also contribute to transient UI such as sedatives, hypnotics, and
diuretics. Thus it becomes imperative to obtain an accurate list of all medications that the
client is currently taking, whether over the counter or prescription medications, for

consideration of coexisting problems and UI.

20

Chutka, et al., (1996) reviewed pertinent articles in the literature and summarized
the types of UT and contributing factors. This study summarized the assessment of clients,
which included a thorough medical history, how frequently UI was a problem, how much
urine was lost with each UI episode and if there were any precipitating factors. The study
concluded that the physical examination should always include an abdominal exam with a
rectal and pelvic exam. Occasionally, various simple laboratory tests including urinalysis,
urine culture, complete blood count, serum creatinine and blood urea nitrogen are
necessary. The clients studied were questioned about whether and to what degree their UI
limited their lifestyle, and any degree of social isolation. Also reviewed in this assessment
were questions about use of protective, absorbent undergarments or pads. The limitation
identiﬁed in this study was that there was no actual tool for a clinician to follow.

Wozniak-Petrofsky (1993) reviewed the lower urinary tract ﬁrnction, the
pathophysiology, causes, types, and the impact of U1 in the elderly. There was much
discussion of age-related changes that affect normal ﬁrnctioning, but stressed that normal
aging is not the cause of UI. Dysfunctions are common among the elderly; for example,
urodynamic studies performed on two groups of 100 elderly persons complaining of U1
showed that 12 participants from one group and 16 from the other group had normal
bladder ﬁrnction. The remaining participants from each group were found to exhibit one
or two ﬁrnctional abnormalities. These abnormalities consisted of poor bladder
compliance, detrusor contraction, and urethral sphincter incompetence. This article noted

that assessment of the dysfunctions may indicate what abnormalities exist; then,

21

management can begin. The limitation of this study was there was no description of a
protocol for an assessment tool or assessment strategies used to evaluate the elder’s type
of U1.

The research done by Pearson & Kelber (1996) indicated that all adult clients
should be assessed comprehensively for their continence history. Their purpose was to
demonstrate how clinical outcomes are established using nursing research regarding
assessments linked with criteria for diagnoses based upon operational deﬁnitions and
interventions for urine control. Their central theme was the development of clinical
outcomes and interventions by the advanced practice nurse to enhance the quality of care
provided by other care givers. Published assessments were reviewed; the assessments
were based on questions asked to clients after they were incontinent. A literature search
was used to ﬁnd established criteria for 15 risk factors that are reported to inﬂuence the
ability to control urine. These 15 risk factors were: 1) inadequate liquid intake, 2) inability
to wait 10 minutes after urge to urinate, 3) lack of sensation of a full bladder, 4) inability
to recognize when urine began to ﬂow, 5) ﬁ'equency of urination greater than eight times
in 24 hours, 6) frequency of urination less than ﬁve times in 24 hours, 7) nocturia more
than once a night, 8) dribbling of urine, 9) inability to stop and restart urine ﬂow, 10)
smoking, 11) bunting sensation on urination, 12) bowel constipation, 13) bowel
incontinence, 14) dry vagina, and 15) involuntary loss of urine only once a month. The
literature revealed seven nursing interventions that could be linked individually or in
combination with each other to remedy the 15 risk factors; clinical nursing outcomes were

based on those seven nursing interventions. Included in this research article was a

22

condensed form for a continence history. The research results revealed that the
consequences of U1 include decreased excursions outside the home, as well as decreased
social interactions with ﬁiends and family. A desirable outcome mentioned in this research
was the quality of life, which could be expected to improve with the reduction of U1. This
quality of life outcome is one reason the incontinent person is seeking health care for U1
today. The limitation of this study was the fact that this condensed assessment tool would
have the client writing an answer for each question. This type of assessment tool could
become quite cumbersome for an elder and difﬁcult for the provider to evaluate on the
ﬁrst contact basis. This condensed assessment tool did not offer multiple responses from
which the client could choose, and this type of format does not lend itself to continuity,
since an elder could answer the questions in a short one word answer or use sentence
answers.

Another client history assessment tool was described by Jensen, Nielsen and
Ostergard (1994). This article analyzed the statement that the client history is found to be
highly accurate in diagnosing genuine stress incontinence and urge incontinence. A
literature search was performed for publications addressing the clinical evaluation of U1
between 1975 - 1992. Nineteen of the 29 articles during this period reported data in such
a manner as to allow statistical comparison of patient history to the diagnosis based on
urodynamic evaluation. The authors’ ﬁndings raised many questions about current
evaluation and management of clients with UI. Patient history is a less accurate predictor
of detrusor overactivity and mixed UI than of genuine stress UI. The report of urge loss

of urine had both a low sensitivity (0.735) and speciﬁcity (0.522), resulting in high false-

23
negative and false positive rates. Basing treatment of UI on a history of urge loss alone
resulted in a this-diagnosis in 45 % of the clients. This study concluded that the client
history should not be used as a diagnostic test, but rather as a screening device to identify
clients requiring further evaluation. The limitation of this study was there was no acrual
assessment tool other than the questions asked during the history taking. So history alone
cannot be used solely for diagnostic purposes, must identify multiple causes during the
assessment process.

The prevalence of U1 in persons with complex multiple problems for example in
Parkinson’s disease has been difﬁcult to determine according to DuBeau (1996), because
the complicating voiding dysfunction in these clients are subject to the same mechanical
sphincter problems as other persons without neurologic disease. Bladder outlet
Obstruction ﬁ'om benign prostatic hypertrophy (BHP) is found in 25% to 30% of men with
Parkinson’s disease. Parkinson’s related lower urinary tract dysﬁrnction mimics the
symptoms of both obstructive BHP and genuine stress UI, thus urodynamic evaluation is
necessary to establish the cause of the urinary dysﬁrnction in Parkinson’s disease. A high
incidence of constipation occurs in Parkinson’s disease, independent of mobility or
medications. Constipation may predispose to impaction with resultant UI. Incontinence
may also reﬂect functional status, arnbulation, and toileting Skills (DuBeau, 1996). With
Parkinson’s disease, potentially curable outlet abnormalities, such as stress U1 and outlet
obstruction such as BHP should not be overlooked.

Urinary incontinence associated with dementia is a signiﬁcant problem This

problem has been reviewed recently by Skelly & Flint (1995). Their research examined

24

the prevalence of U1 in individuals with a diagnosis of dementia. They reported that the
prevalence rates varied considerably; anywhere from 11% to 90% of individuals with
dementia had UI. They report the highest prevalence, 84%, was among those in
institutions. The rates for mixed institutional-community dwelling was at 47%: those
individuals attending outpatient clinics and living at home had a rate of 22%. Their
ﬁndings indicated that lower urinary tract pathophysiology in frail elders with dementia or
impaired mobility does not differ ﬁ'om those without such impairments. They emphasize
that U] in demented persons may not be causally related to dementia, but instead may have
multiple other etiologies with treatable causes. This research found that UI occurs with
equal or greater frequency in males than in females. Anticholinergic and antispasmodic
medications have not been shown to be effective in treating UI in demented persons.
However, prompted voiding regimens have been shown to reduce UI by an average of
32% and appear to be a useﬁrl approach in managing UI in the dementia population.

Warkentin (1992) states as Alzheimer’s disease progresses, UI develops and
worsens due to an absence of cortical control over bladder emptying. The person with
dementia forgets how to locate a bathroom, is unable to communicate the need to void,
and has an impaired central inhibition of elimination.
W

The AHCPR guidelines (1996) address the assessment process in a written format
with discussion of basic evaluation including history, physical examination, and
urinalysis. An algorithm was developed for the treatment options of U1. The diagnostic

tests are listed according to symptoms and conditions, and in table format according to the

25

type of incontinence. The guidelines include treatment options which include behavioral
modiﬁcations and surgical interventions. The limitations of the guidelines are that there
are no actual written assessment tools. The AHCPR guidelines were developed by an
expert panel of authors who have done the research of incontinence, but the clinician must
use this information to guide his/her practice and develop tools and assessment strategies
from this information. The guidelines contain in depth information on the assessment and
treatment of UI, but they do not address any speciﬁc assessment tool. The AHCPR
(1996) reports that if these clinical practice guidelines on UI are followed there will be a
deﬁnite cost savings and an impact on quality of life issues.

A few articles provided assessment forms which would aide the clinician with a
thorough assessment (Doughty, 1991; Ham & Lekan-Rudlegde, 1997). The clinical
literature from Doughty (1991) addressed that assessment of the client should start with a
history obtained by oral interview, using a checklist to facilitate adequate documentation.
This checklist included a voiding history, urologic history, neurologic history, related
medical conditions, reproductive system of the man and women, surgical history and
current medication.

Ham and Lekan-Rutledge (1997) describe an in-depth overview of U1. The
discussion identiﬁed that health care professionals should conduct initial screening and
basic evaluation of clients who present with symptoms of UI. The basic evaluation should
include history, a bladder diary, medication review, physical examination with additional
tests such as a urinalysis. The discussion detailed what Should be included in the history,

the physical, and the diagnostic test for the client. An algorithmic methodology was used

26

as a guide to the diagnostic reasoning process. Focused assessment Strategies need to be
addressed for each unique presentation and characteristic of each client.
Assesmtenmflﬂ.

Assessment is critical to appropriate management. Warkentin (1992) discussed
that the consensus panel sponsored by the National Institute on Aging applied the term
“ﬁmctional incontinence” to those people in whom the lower urinary tract is intact, but
other factors such as immobility or severe cognitive impairment result in UI. AS
Alzheimer’s disease progresses, UI develops and worsens due to an absence of cortical
control over bladder emptying. Also the client with dementia forgets how to locate the
bathroom, is unable to void, and has an impaired central inhibition of elimination. There
were no assessment tools used in this discussion.

Moore and Siu (1996) identiﬁed problems that commonly contribute to functional
disability, and focused on the following eight problems: malnutrition/weight loss, visual
impairment, hearing loss, cognitive impairment, urinary incontinence, depression, physical
disability, and reduced leg mobility. For all of the items identiﬁed, they modiﬁed a
screening measure appropriate for use in the ofﬁce setting. The study was performed with
a sample of 109 new clients in primary care. The prevalence rates in this population of
older persons ranged from 21% for malnutrition to 72% for physical disabilities. The
positive predictive values for ﬁrnctional UI varied between 0.60 for memory to 0.91 for
mobility. Negative predictive values in this population ranged between 0.77 for physical
disability to 0.96 for U1, which is highly negative. In conclusion, the screening measure

exhibited high positive and negative predictive power. Depending on the prevalence of

27

these conditions, clinicians using the screen should not be surprised by the need to
evaluate screen-positive clients who turn out to be false positives on the items. The
screening package may be a relatively inexpensive way to efficiently and effectively assess
problems that commonly adversely affect function in the elderly.

The majority of the literature on UI is focused on the clinical aspects of the
pathophysiology, types and causes, the management and treatment of U1 (Gallo, Fallon &
Staskin, 1997; Chutka, et al., 1996; Yin & Peterson, 1996; AHCPR, 1996; Davila, 1994;
Thayer, 1994; Wozniak - Petrofsky, 1993; Resnick, 1990). Within the body of these
articles, there are some references to assessment and evaluation of the client.

According to Gallo, et al., (1997) a consultation visit for a client with UI may
include, but is not limited to, diagnosis, evaluation, and treatment with a cost effective
evaluation tool and treatment options for the ofﬁce setting. It is the clinician’s
responsibility to ask the client in a sensitive manner during an annual exam about bladder
control and voiding habits. This article focused on history taking, physiology,
medications, physical examination, types of UT, and treatments. A UI
questionnaire/assessment tool found in this article, was described as a simple tool for
obtaining UI information. This tool would provide information for the clinician to review
once the client had completed the questionnaire prior to the initial visit. The assessment
was in question and answer form with the client either circling the answer or being asked
for a written short answer. This questionnaire is useful to diagnose the type of UI and
hence to expedite a treatment plan. Another positive aspect about this tool is that the

client just needs to circle the answers to the questions which makes answering the

28

questionnaire easy and is usually the best format for the elderly to answer. The client has
the responsibility to remember to bring the questionnaire to the initial visit.

Yim and Peterson (1996) stressed the need for greater awareness of the UI
problem and describe basic types of U1, diagnostic studies, and treatment options that can
improve the quality of life for affected patients. After diagnosing UI it was emphasized
that most patients with UI can be treated with behavior modiﬁcation, muscle exercises,
and medications. This article states with the current guidelines for evaluation and
management; a thorough history, physical examination, and limited laboratory work-up
can be accomplished for most patients with UI in the clinic setting. The assessment was
limited in that it did not address the assessment Skills needed to make a diagnosis of UI on
a ﬁrst contact basis.

Thayer (1994) discussed the fact that evaluation of U1 begins with a complete
history and physical. It was emphasized that questions about urine leakage are important,
and how attention to the client’s ability to process information and answer questions
should be assessed. The practitioner must observe for impaired cognitive function. Thayer
(1994) suggests objective assessment of the problem, and a voiding dairy. Then, the
practitioner may consider a series of diagnostic studies that will provide answers for a
more complex history. The limitation of this article is the fact that no general assessment
questions were addressed.

In the article by Resnick (1990) an accurate clinical evaluation of U1 include:
urinary history of the patient, the type of U1, ﬁ'equency, pattern, associated symptoms,

alteration in bowel habits, other relevant factors, medications, ﬁrnctional assessment, and a

29

self reported incontinence chart. Along with the history, a physical examination should be
conducted which would include a pelvic, rectal, and neurologic exam. Followed by
clinical tests such as: metabolic survey, measurement of post void residual volume, urine
analysis and culture, renal ultrasound, urine cytology, uroﬂowmeter, and cytoscopy. This
in depth assessment of the client was followed by certain tests to indicate type of UI.
However, not all primary care settings are set up to do extensive diagnostics testing this
article called important in making the evaluation of the client. This article alluded to the
fact that the diagnosis of UI was already in place. The history of the client should
augment the ﬁndings of U1. There was no actual tool used for the assessment of the
client.

Many articles found in the literature outline a systematic approach to the
evaluation, diagnosis, and treatment of U1; some authors mention an assessment tool
within the scope of their articles (AHCPR,1996; Colling, 1996; Pearson & Kelber, 1996;
Beckman, 1995).

The assessment tool described by Coiling (1996) included focus on the health
history as well as a listing of medications and a ﬂuid intake proﬁle; also involves are a
history of the UI and a voiding diary. A focused physical examination involved both
cognitive and ﬁrnctional assessments, urinalysis, and an environmental assessment. In
long-tenn care facilities, initial UI detection usually occurs through the use of the
Minimum Data Set, a standardized, comprehensive screening tool currently mandatory in
all long-term care facilities. There is no standardized instrument for the detection of U]

among community-dwelling dependent elderly persons. Questions about incontinent

30

episodes may need to be initiated. Health care providers can perform speciﬁc assessment
to help determine appropriate strategies to determine the cause of UT in the elderly.

Beckman (1995) identiﬁed that the goal in caring for a client with UI may not
necessarily be one of absolute cure, but rather to improve the condition, prevent
complications, and provide comfort. This article has the assessment process listed in two
tables; one table was the history taking, including past conditions, genitourinary, bowel
proﬁle, medication, dietary, and environmental. The other table included physical
examination: general, abdominal, rectal, and pelvic. Also included in the assessment table
were the diagnostic tests which include urinalysis, dipstick, post-void residual, provocative
stress test, and bedside cystometrograrn. The history focused on characteristics of the
client’s incontinence and accompanying symptoms, while also assessing for factors that
may contribute to U1. The author stated that an assessment could be performed by an
advanced nurse clinician in an outpatient setting by using the information in the tables.
These ﬁndings were also supported by AHCPR (1996) and Pearson and Kelber (1996),
who found that all clients should be assessed comprehensively for their continence history
and that each client should complete a 24-hour voiding or bladder diary for a complete
assessment.

Haab, Zimmern and Leach (1996) performed an extensive literature search related
to the diagnosis, management and treatment of intrinsic sphincteric deﬁciency; this type of
U1 is commonly described as type II stress UI. Of the 414 women with stress UI who
never had an operation only 13% had documented intrinsic sphincteric deﬁciency as the

only factor for the U1. Estrogen deﬁciency in postmenopausal women is responsible for

31

atrophic urethral mucosa] changes. The relationship between the appearance of intrinsic
sphincteric deﬁciency and the onset of menopause suggest that the lack of estrogen may
be an important contributing factor in compromising urethra ﬁrnction. This study
indicated that intrinsic sphincteric deﬁciency should be suspected based on the history and
severity of the UI. By history the risk factors need to be identiﬁed, such as UI persisting
or worsening after bladder neck suspension, radiotherapy, and extensive pelvic surgery.
The conclusions made from the study indicated that documentation and diagnosis of stress
UI secondary to intrinsic sphincteric deﬁciency are essential before treatment. Accurate
diagnosis can be achieved for most clients with an appropriately focused evaluation.

In a prospective randomized Study, Bergman, Ballard and Koonings (1989)
studied the effects of three different surgical procedures for stress UI: the anterior
colporrhaphy, modiﬁed Pereyra, and Burch retropubic urethropexy. There were 127
women in the study, with a mean age of 55 years. Evaluation included history and
physical with clinical and urodynamic evaluation. These evaluations were repeated at a
three-month postoperative time and again at one year after surgery. The three groups of
women were comparable in mean age, parity, and menopausal status. The results
indicated that the cure rate at three-month postoperative evaluation among the three
procedures were insigniﬁcant ( 82%, 84% and 92% for the anterior colporrhaphy,
Pereyra, and Burch respectively) but became statistically signiﬁcant at the one year
postoperative evaluation (cure rates of 65%, 72%, and 91% for the anterior colporrhaphy,
Pereyra, and Burch respectively, p< 0.05). There were no differences between subjective

and objective cure rates among the three groups. Using strict criteria, short—term

32

evaluation at three-months after operation demonstrated no signiﬁcant differences in cure
rate among the three groups. The differences among the three groups become obvious
only at the 12-month postoperative evaluation. Conclusions indicated that a long term
study, between 3-5 years after surgery, be conducted on these women to examine the rate
of long-term cure as one of the treatments for stress UI. The limitation of the study was
that no assessment tool was identiﬁed for use with the client who presented with stress U1.
The assessment included an in depth history and physical, but treatment was done
randomly, thus the importance of an assessment process.

Other methods used to assess and manage UI by older adults in the community
was a study done by Herzog, Fultz, Norrnolle, Brock, and Diokno (1989). This study
data came from 1,956 self-reported incontinent respondents, in how they dealt with
involuntary urine loss. Thirty percent of respondents reported urine loss within the last 12
months, with the prevalence for men at 19% and for women at 38%. The 19% incontinent
men can be ﬁrrther differentiated into 7% urge, 2% Stress, 5% mixed, and 5% other. The
38% incontinent women can be divided into 4% urge type, 10% stress type, 21%
combined urge and stress, and 3% other. Women were signiﬁcantly more likely than men
to be using a method to control urine loss; about 69% of the women respondents reported

using some type of method to control urine, compared to about 55% of the men. For
those who attempted to manage their UI, absorbent products such as sanitary napkins,
toilet tissue, and absorbent garments were the most popular means. About 55% of the

women used absorbent products; only about 20% of the men used them. The next most

33

common means of controlling UI was to locate a toilet upon arrival at an unfamiliar place.
F orty-two percent of the respondents used this method, and there were no signiﬁcant sex
differences. The conclusion of this study indicated that about two-thirds of all
respondents classiﬁed as incontinent do attempt to manage their UI. The most common
strategies are the use of absorbent products, the location of toilets before the need to

urinate arises, and the manipulation of voiding patterns. Only abOut one-quarter have
sought formal health care regarding the condition; only about half have ever sought such
care, and very few were taking any medication for the condition.
F n i n 'r n S m

Appleby (1995) states that within the home care setting, a ﬁrnctional assessment
should be completed because clients ﬁnd comfort in their own homes, and most are more
relaxed in that environment. This evaluation includes the client’s physical abilities,
including mobility, transfer ability, balance, strength, and visual acuity. According to this
article, environmental factors, including the general safety features of the home and access
to the toilet and other areas, are evaluated. The article stated that it is best to observe the
client in the process of toileting to adequately assess the need for environmental change.
thsicaLassessmanfQLUI

Gray (1990) stated that assessment of the UI client should include a basic physical
examination, with emphasis on genitourinary and neurologic systems. Careful inspection
of the client will reveal much about the general state of health, mobility, and mental state.
The female genital area should be inspected for altered skin integrity or signs of estrogen

deﬁciency. The male genitalia should be examined for signs of altered skin integrity; a

34

digital rectal examination should be performed if fecal impaction or prostatic enlargement
is suspected.
Di ic s m n f r UI

There are assessment tools that discuss simple voiding records as an assessment.

A voiding dairy, which is a record kept by the client and used to help determine the
frequency, timing, and amount of voiding, as well as other factors associated with UI.
This diary must be included in the assessment process, but cannot be used alone in making
a U1 diagnosis. This record may provide clues about the underlying cause of U1 as well as
information on ﬂuid intake and voiding patterns that may be helpful for behavioral
interventions, and can serve as a baseline to gauge severity and treatment efﬁcacy
(Colling, 1996; AHCPR Treatment Guidelines, 1996; Doughty 1991).

Davila (1994) stated that the key to managing UI is identifying the cause. Office
tests, including cystometry, can pinpoint the cause in about 80% of the patients. New
non-surgical treatment options are effective in at least 70% of clients. This article covered
the causes of UI, as well as evaluation by history, physical examination, urine cultures,
measurement of postvoid residual, and cystometrogram. It discussed management options
that may help clients avoid surgical interventions. The assessment tool used was totally by
experience of the clinician. The assessment tool was not in a written format. It stated that
diagnostic tools, including the cystometry can help identify the cause of U1. However not
all primary care settings are set up with cystometrograrn equipment to be able to diagnose
UI in this manner.

In conclusion, there is little empirical research demonstrating the true effectiveness

35

of assessment strategies for UI to quantify importance of clinician skill regarding
diagnosing UI on the ﬁrst contact basis. According to Branch, Walker, Wetle, DeBeau,
Resnick (1994) appropriate symptom interpretation and reporting is closely related to
accurate knowledge and information. For all aspects of incontinence, levels of knowledge
among clients and health care providers must be increased to ensure that appropriate
treatment and management of U1 are achieved. The literature in general does not
document the assessment process for U1. There is adequate clinical literature recognizing
the assessment process, but there are no adequate assessment tools to aide the APN in this
process. This concern provides the incentive and rationale for the development of a
standard assessment tool to provide consistency for accurate diagnosis and appropriate

interventions.

36

Chapter 4
mm

The purpose of developing an UI assessment tool for the ambulatory elderly was
that current empirical literature did not identify any written assessment tools for use in the
primary care setting. The clinical literature described several assessment tools but none
were developed based on empirical data. Through the review of literature, a variety of
assessment aids was found. These include: descriptions of nursing assessments for UI
(AHCPR, 1996 ); simple voiding records (Colling, 1996, AHCPR, 1996); and assessment
forms which help guide a thorough assessment (Doughty, 1991, Ham & Lekan-Rutledge,
1997). These tools are helpﬁrl in collecting appropriate data, but do not directly interpret
the results to diagnose a speciﬁc types of UT. The development of an UI assessment tool
follows the recommendations from the AHCPR guidelines, that addresses medications,
risk factors, types of U1, functional and environmental issues, the physical exam, and
diagnostic tests.

There were many limitations in currently available literature noted from the
literature review. Some of the tools found in the literature were written in a general
format. They did not directly assist the practitioner to diagnose a speciﬁc type of UI.
Many articles in the literature review focused attention on the types of UI,
pathophysiology, and management of various incontinent problems; however assessment
of U1 was implied and not explained. Many authors did not provide a tool for assessment
and most important, a tool for assessment that was appropriate for the primary care

setting.

37

The development of this assessment tool will provide needed strategies to promore
self-care measures for the client who presents with UI. Orem’s ﬁ'amework that focuses or.
self-care presents an Optimistic view of the client’s contributions to his/her health care.

An accurate assessment tool of U1 conducted by an APN or health care provider becomes
the overriding concept within the scope of this paper; thus, the motivation for the
development of an assessment tool for U] in the primary care setting.

May; The reason for the development of an assessment tool for U1 is to
provide an easy, understandable tool that will simplify identiﬁcation of UT on a ﬁrst
contact basis in the primary care setting. This tool doesn’t require expensive invasive tesrs
and is an easy tool for the APN and/or the primary care provider to use in the primary care
setting. None of the assessment tools in the literature was in a format that was easy to use
for the client or the health care provider who may have limited knowledge about UI.
Elderly clients should be asked about symptoms of UT because appropriate assessment and
treatment can usually provide solutions to the problem. Health care providers want clients
to be independent in activities of daily living. Maintaining self-care in the performance of
activities of daily living for the elderly is an important quality of life issue. Self-care
involves control over one’s life, which includes making choices, as well as acting upon
them. According to Orem (1995), self-care is the practice of activities that individuals
initiate and perform on their own. The use of this assessment tool will provide the
opportunity for the APN to provide direct care and enhance self-care believes in older

clients who experience UI problems.

38

Implementatien; The assessment tool is designed to be used by any health care
provider when there is a question about UI. It is a short one page, two sided assessment
tool that uses an interview format. Most of the questions requires the APN provider to
circle the appropriate response or ﬁll in the blank with short responses. This is a
comprehensive assessment tool which collects data in a progressive and systematic way.
It will guide the health care provider to assess broadly, and help determine the probable
type of UI on the ﬁrst contact basis in the primary care setting. The assessment tool
identiﬁes medications, allergies, risk factors, including medical conditions and lifestyle
behaviors, along with urinary history, and the UI proﬁle of urge, stress, overﬂow, and
ﬁrnctional UI. Additional assessment includes ﬁrnctional status, and environmental
assessment. The physical examination includes abdominal and pelvic exams. Simple
diagnostic tests can be conducted right in the primary care setting such as an evaluation of
urine using dipstick, culture if indicated, and a post-void residual urine evaluation. A
voiding diary is also included in the assessment analysis, but this diary must be given to the
client, to be completed over a course of three to ﬁve days to help complete the urinary
history.

Assessmentjeet; The Urinary Incontinence Assessment Tool for the Ambulatory
Elderly, Oetman Assessment Tool, to be used in the primary care setting is available in
Appendix A.

W: The assessment tool is designed as an aide
for the practicing health care provider to evaluate and diagnose UI, that can lead to

appropriate evaluation and management of U1. This assessment can be implemented

39

across all ages but is particularly important in the elderly population, because the elderly
have the highest prevalence of UT. The tool is intended to be used with clinical judgment
and individual circumstances. The goal of the assessment tool is to provide an easy
assessment of the elderly client when UI is suspected. A thorough assessment can result
in correct diagnosis and appropriate management of U1. It will help the clinician identify
the type of U1 so as to implement appropriate intervention. This assessment tool should
be easy to use and assist in decreasing the dollars spent in providing supportive
care for U1.

The tool begins with demographics, then lists the current medications. This
allows the practitioner to review the medications that may adversely affect continence.
Keeping in mind the medications that affect UI will include: alpha blockers, alpha
stimulators, antispasmodics, anticholinergics, antihistamines, calcium channel blockers,
diuretics, hypnotics, narcotics, and sedatives (Wein, 1995, AHCPR, 1996). Following
the list of medications, allergies are listed, to help identify any medications that may cause
a reaction if taken. Any drug a client is taking should be recorded because many drugs
have a subtle or direct inﬂuence on bladder function. This will draw attention for the APN
health care provider to evaluate medications that may be a problem for the individual
client relative to incontinence.

The assessment of risk factors include any medical condition that may provide
important information about the neurologic, musculoskeletal, metabolic, urologic, and
gynecologic condition of the client. Within this section on the assessment form, the

clinician needs to circle the appropriate response or ﬁll in the blanks with short responses.

40

The U1 risk factors will guide the APN to discuss health promotion education, and
lifestyle changes with the older client. Gray (1990) found that multiple aspects of a
client’s medical history affects UI and should be noted.

The urinary history provides an area for the client to state in his/her own words
how and to what degree UI is a problem. The history area helps to determine more
information about the frequency of urination, the amount of leakage, and what kind of
management program the client has tried or is currently trying. This will give the APN a
quick look at what actually has been happening to the client. Chutka, et al. (1996) stated
that the history is the most important part of the evaluation of U1. Jensen, et al. (1994)
found client history Should not be used as a diagnostic test, but rather as a screening
device to identify clients requiring ﬁrrther evaluation. '

The next section includes questions about speciﬁc types of incontinence. If one
area has more circled responses, the assessment would indicate that type of incontinent
problem. In some instances, clients may present with a combination of symptoms that may
lead the clinician to make a diagnosis of mixed incontinence. In this case, treatment would
need to be adjusted accordingly. Gray (1990) found that UT symptoms provides clues to a
possible diagnosis, and when combined with a comprehensive history and thorough
examination, allows for a provisional diagnosis of voiding dysﬁrnction.

The functional assessment addresses the client’s access to a toilet, whether or not
he/she have the ability to void, the time it takes to reach a toilet, and if the client is
cognitively intact to comprehend the voiding function. The respOnses need to be circled

or a short answer ﬁlled in the blank.

41

The environmental assessment identiﬁes the accessibility of toilets, bed pan or-
bedside commode, and if they are close at hand. Also considered is safety in the bathroom
area, such as does the bathroom have enough light; does it have any loose rugs; orare
there any other things the client is not aware of, that may be causing some difﬁculties,
such as excessive time to remove clothing. Gray (1990) states that an assessment of a
client’s environment should focus on bathroom facilities in the home; the assessment
includes that of poor lighting, stairs, long distance to the toilet, and chairs or beds that
obstruct walkways. The need of any mobility aids must be assessed, such as wheelchairs,
walkers, crutches, canes, and eyeglasses.

A complete, physical examination should be performed on all clients that present
with UI. Careﬁrl inspection of the client will reveal much about the general state of health,
mobility, and mental state (Gray, 1990). Examination of the abdomen will evaluate
bladder distension, because a distended bladder is Often palpable especially in clients with
overﬂow incontinence (Chutka, et al. 1996). Upon examination of the abdomen, palpation
for masses Should be included to rule out any type of abnormality. Also checking for
CVA tenderness to rule out any renal dysfunction needs to be included.

Included in the physical examination is the pelvic examination. The female genital
area in inspected for altered skin integrity or signs of estrogen deﬁciency. This exam
allows the practitioner to observe the external genitalia, assess for local inﬂammation,
vaginal atrophy, and evidence of weak pelvic support. Weak pelvic support, such as
cystocele, rectocele, or prolapse may be observed by asking the client to bear down or

cough vigorously, thus noting the organs that may protrude. The male genitalia are

42

examined for signs of altered Skin integrity and a digital rectal examination is performed if
fecal impaction or prostatic enlargement is suspected (Gray, 1990).

The rectal examination should be completed on both male and female clients. It
starts with inspection of the perianal area, checking for lesions or other skin alterations.
Chutka, et al. (1996) stated that the assessment of the anal wink reﬂex and a rectal
examination Should be done to disclose any neurologic deﬁciency, prostate abnormalities,
fecal impaction, or pelvic pathologic conditions. The anal sphincter tone must be assessed
for integrity and sensations. The internal sphincter tone can be assessed by the client
coughing while lying supine on the exam table, leakage of urine in this position is
suggestive of an outlet incompetence. Assessment of fecal impaction, prostate
enlargement, or other pelvic pathologic conditions must be considered.

Diagnostic tests include obtaining a clean catch urine specimen and testing it with a
dipstick. This dipstick is used to detect conditions such as hematuria, suggestive of
infection, cancer, or stones. It is also used to detect glucosuria, pyuria, and bacteriuria.
Urine cultures are obtained when the dipstick indicates infection or when the symptoms
suggest infection (AHCPR, 1996). The estimation of post void residual (PVR) urine will
help to rule out a bladder emptying problem. This test is measured by urethral
catheterization. It is generally accepted that a PVR of less than 50 ml means the bladder is
adequately emptying, and volumes greater than 200 ml may indicate a urinary obstruction
(Appleby, 1995).

Another diagnostic tool is the voiding diary which is a vital part of the client’s

overall bladder habits. The diary helps the client to self report accurate urinary symptoms

43

rather than trying to have the client recall what incontinent episodes have occurred at
home. The voiding diary is a valuable tool to assess voiding patterns, including diurinal
and nocturnal voiding. The voiding diary should be simple to use and provide pertinent
information to assist in the assessment of U1 (Appleby, 1995). A sample of a voiding
diary is available in Appendix B.

The last part of the assessment tool is the impression the clinician Obtains based
upon the clinical information from the tool. This information should yield the diagnosis of
urge, stress, overﬂow, ﬁmctional, or mixed. Once this diagnosis has been made,
treatment can be initiated. If the clinician needs further information, or if more in depth
urodynamic testing is indicated, then a referral would be made to a specialist for
follow up.

This assessment tool is then signed and dated. Once the initial assessment has been
completed, treatment options can be presented. The treatment of UI would be based or.
an algorithm for management such as those provided in the AHCPR guidelines. .\fosr

cases of UI can be evaluated by the APN or primary health care provider by using this

type of assessment tool.

44

ChapterS
Di i n
m l' i n fr P i

The advanced practice nurse (APN) who provides primary care to the elderly is in
a unique position to impact the elderly with UI by accurately assessing and using
educational strategies to inform clients about the speciﬁc self-care interventions available
to them. The assessment tool described in this paper is intended to aide the APN in the
assessment process, evaluate, and initiate an impression of the type of UI on a ﬁrst contact
basis for those clients presenting with UI. As stated previously, an individual assessment
of each client, in conjunction with the assessment tool for the ambulatory elderly, will aide
in a correct diagnosis and initiation of treatment. Multiple risk factors must be assessed
before implementing any type of intervention. The APN can provide educational
strategies that will be cost effective with positive outcomes in the area of U1. Another
positive outcome from using the UI assessment tool is that the APN can become proﬁcient
in assessing U] in the primary care setting.

In the conceptual model based on Orem’s self-care deﬁcit theory, the goal of
Orem’s assessment is client focused self-care. The theoretical ﬁ'amework for the UI
assessment tool is to refocus the attention to a provider based tool. It is speculated that
during the assessment time, effective communication can occur between the APN and the
client, and realistic expectations for self-care activities can be developed. Thus, the goal is
to help the client be as independent as possible, using self-care strategies as outlined by the

APN. These strategies occur through the clinical knowledge and judgement skill of the

45
APN provider and the use of the assessment tool.

There are several aspects of the medical system that contribute to health care
professionals who under evaluate and under treat UI among the elderly. One of those
aspects may be inadequate instruction or education. Health care providers without
training in geriatrics do not always know how to respond to the elderly UI patient, and
assume it’s part of the aging process. The APN must acknowledge the taboos and belief s
of many individuals that U1 is a normal part of aging. Reassuring the client becomes vital-
discussing the fact that UI is not a normal part of the aging process is important. Another
area of concern is adequate assessment of the UI client. The assessment skill is time
consuming; many primary care providers have limited time to spend with each UI client.
Another area of concern is the reimbursement issues. The reimbursement mechanisms of
the American private health insurance and Medicare systems strongly discourage adequaze
responses to incontinent people (Mitteness, 1992). For example, Medicare will
reimburse for the ongoing cost of indwelling catheters but will not reimburse for the cosr
of incontinence pads, pants, or diapers (Mitteness, 1992). APNs can provide services
that have traditionally been provided by physicians. These services are more within the
realm of nursing practice, such as education, client advocacy, assessing, care coordinaticr.
and collaboration with other care providers.

The roles of the APN with UI expertise are several fold: an assessor. educator,
advocate, consultant, and a collaborator. As an assessor, the APN utilizes the data from
the assessment tool to identify health care needs. This data base helps to formulate

impressions about initial ﬁndings about U1. The APN begins to interpret and makes

46

clinical judgments ﬁom the objective and subjective data. The assessor systematically and
continuously collects information and updates that data to validate and revise initial
ﬁndings.

As an educator, the APN is in a unique position to educate other nurses, APN
students, other nursing Students, health care providers, clients and the community at large.
The APN can provide education to the elder client about speciﬁc UI problems through
Community Education inservices, through newspaper articles, and in one to one
interviews. Education for the elders and the community provided by inservices can be
done on a contractual basis, whether contracted by the individual or a facility. Education
for nursing students, APN students, health care providers can be done more formally,
done in a classroom setting or by videotaping. According to AHCPR (1996) information
about UI should be included in the curricula of undergraduate and graduate health care
professionals. Also included should be schools of nursing and physical therapy and
physician assistants. Specialists of incontinence care can be expert advisors to other health
care providers, in teaching hospitals and nursing homes.

The APN educator can provide information regarding risks factors, lifestyle
behaviors, and treatment options for the client with UI. The educational strategy may
include behavioral therapies, such as Kegel exercises, scheduled toileting or any other
supportive information. Health promotion and prevention Strategies for U1 must always
be considered by the APN. As baby boomers age and become more aware of the problems
of UI, demands for programs and education will increase.

Another area the APN should be involved with as an educator is continuing

47

education programs for health care professionals. Assessments and treatments are
effective only if the health care providers are aware of them and are skilled in
implementing them (Mitteness, 1992; Newman, 1996). No longer can the APN be
prepared for the future as they have been in the past. The APN must integrate many skills
that will create an effective, meaningful role. They need to address the standard of
practice, processes, policy and parameter of practice. They must also prove the value of
their practice in the delivery of health care services (Porter-O’Grady, 1997).

The advocate role promotes a transfer of responsibility to the client by creating a
climate of mutuality where the APN can empower the client to take over their health care
and improve their self-care abilities. Self-care is so important when it comes to the
management and treatment of U1. Maintaining self-care in the activities of daily living for
the elderly in so important for the elder’s quality of life.

AS a consultant, the APN would be available to advise other health care providers
on UI assessment skills. This would occur in such settings as private practice, extended
care facilities, acute care agencies and home care settings. The APN is in a unique
position both in providing direct care to the elders who experience UI problems, and to
assist and educate other health care providers on appropriate assessment Skills and
interventions available (Beckman, 1995).

The APN is also a collaborator, one who can assist others with the management of
U1 by providing expertise and leadership in innovation in the area of U1. This may include
communicating with nursing homes, foster care homes, and families to ensure continuity

of care in managing U1. The APN can share the knowledge gained from assessments of

48

clients with physicians and other health care providers to advocate for continuity of care
and to improve the quality of life for each client.

Positive roles identiﬁed for the APN include: providing comprehensive, cost
effective care, acting as an assessor, an advocate and an educational resource to staff and
clients, being available for consultation to peers, and assisting others with the management
of the client. Serving in these roles, the nurse in advanced practice can improve
primary care.

Eduction

Evaluation of the assessment tool for the ambulatory elderly will be on going, and
changes may be made as the tool usage increases. As the health care providers begin to
identify the positive outcomes and beneﬁts from identifying the type of U1 on the ﬁrst
contact basis, the assessment tool will become part of their everyday use for their elderly
clients presenting with U1. The expected outcome of this project is with increased
knowledge about assessment skills, health care providers will expertly question and offer
suggestions of alternative treatment options for the elderly client who presents with UI.

As health care providers become more aware of the misconceptions that many
people have about U], they will use a more matter of fact approach and be sympathetic to
the client’s embarrassment. Reassuring the client is vital. The health care provider must
be careﬁrl not to dismiss UI as an un-treatable fact of aging.

The speciﬁc evaluation plan for this assessment tool would be to have the tool
available in the family practice and internal medicine offices with a short inservice on

usage. Follow up in one month to the individual sites would include a retrospective chart

49

review for: (1) those clients who presented with complaints of U1, (2) to look for the
number of times UI was identiﬁed, (3) to check for the number of times the assessment
tool was actually used, (4) monitor the amount of time involved in using the tool,

(5) whether the provider actually used the tool for the assessment process, (6) identify the
number of referrals made to a specialist, and (7) whether the provider was satisﬁed with
the tool.

Part of the evaluation would include identifying the client outcomes. Some of
those outcome measures would consist of the client’s ability to recognize their urge to
void, whether their underclothing was dry during the day, or were they wet or their
bedding was wet during the night. Was the client able to manage their clothing
independently and were they able to toilet independently. Is there some predictable
pattern to the client’s passage of urine. Does the client still have incontinent issues after
the initial visit and what other educational strategy needs to be initiated for a positive
outcome for the individual client.

Another important area that needs to be addressed and not overlooked is client
satisfaction with the outcome. Has the social and psychological consequences that often
accompany UI been improved. Has the client’s quality of life been improved by the
implementation of the outlined educational strategies. Identifying the level of self-esteem
and activities of daily living, will be predictors of client satisfaction and quality of life
issues. A section on the evaluation form should include whether the client was satisﬁed,
unsatisﬁed and why, or not applicable. Older people are healthier, living longer, and living

better with more chronic issues. The provision of services to essentially healthy aging

50

peOple will be an increasing focus of advanced practice (Porter-O’Grady, 1997).

During the evaluation, the author would be available to answer questions, Offer
guidance in usage of the tool, and Obtain feedback ﬁ'om the practitioners regarding the
usefulness of the tool to APN’S and physicians. Frequent contact via the phone or with
ofﬁce visits is needed to provide support and positive reinforcements for use of the tool.

This author plans on having the tool available for use in family practice and internal
medicine offices which have high volumes of elder clients in the Lansing area. It can be
used with very little in-service, as it is self explanatory. This author will be available for
questions that may arise upon usage of the tool, and will provide follow up with the
primary care offices after one month of usage of the assessment tool in their elderly
population.

ImplicationsfoLResearch

The need to promote and maintain health for as long as possible will intensify with
the ever-increasing number of elderly; measures to enhance or maintain physical, mental,
and social ﬁrnction will also need emphasis (Strumpf & Paier, 1993). The research
component cannot be overlooked. Research is needed to understand the natural
development and remission of UI, to identify risk factors and to match affected clients to
the most appropriate and effective treatment (Beckman, 1995). Nursing research Should
be on-going to evaluate the effectiveness of interventions, but this clinician suggests more
research Should focus on assessment tools and their eﬁicacy for U1 clients.

Adequate assessment of U] in the elderly usually does not require complex, highly

technological skills, but it is time consuming and requires skilled history taking and

51

repeated contact with clients (Mitteness, 1992). Research is needed to keep track of the
number of clients being seen for U1 and whether the assessment tools helped with the
diagnosing of U1. Researchers must continue to assess for client outcome studies in the
area of UI.

Further research is needed to examine the assessment strategies used for the
elderly client in the primary care setting. Clients who are reluctant to initiate conversation
about their U1 may welcome the opportunity to discuss the problem with a provider who
is genuinely interested and who can convey accurate information and potentially assist the
client’s as to what type of UI they are dealing with, so treatment can be initiated. Focused
assessment and treatment strategies can be individualized to address the unique
presentation and characteristics of the older client.

Further research is indicated to evaluate differences in reimbursement issues that
may affect clinical decisions. Medicare will reimburse for the ongoing cost of indwelling
catheters for a management strategy for U1, but will not cover the cost of incontinence
pads, pants, or diapers. Also other technological diagnostic procedures are reimbursed
more fairly than long clinical interviews and non-technical management strategies
(Mitteness, 1992). The APN is in an excellent position to be instrumental in implementing
current research, to seek and clarify reimbursement issues for future plan of care.

From this author’s perspective, this assessment tool for UI will provide data for
further research when used consistently. It is far easier to abstract information from this

standardized format than from traditional notes. Data gathered would be more

52

meaningﬁrl as the client information is documented. The data regarding UI would be
more consistent, more reliable, and be meaningﬁrl research for the future plan of care.
ngmety

After evaluating the current research relating to UI, there are several conclusions
that can be made. Urinary incontinence is a common condition in the elderly population,
both in the community and in long term care settings (Chutka et al., 1996). Many elders
with U1 would beneﬁt from an assessment, but most do not seek medical evaluation for
various reasons. Health care providers need to begin to ask about UI on the ﬁrst contact
basis. By using this new assessment tool, diagnosis of U1 can be identiﬁed quickly, and
management can begin earlier. This process will improve the quality of life for U1 elder’s
as they are assessed for UI and how it has affected their lifestyle. Understanding the
process of U1 in the elderly population, the healthcare provider can treat UI successﬁrlly.

Urinary incontinence is both a community health problem and a personal crisis
(Newman, 1997). According to Mitteness (1992), U] does not have to be a destructive
force in the lives of elderly people. It is, therefore, the leadership expectation that APN’s
invest themselves in ensuring that the valuable and signiﬁcant contribution of nursing and
the design and ﬁrture of health care are in evidence in every place where decisions are
made (Porter-O’Grady, 1997). The challenge is for the APN to incorporate this
knowledge, so they can provide more therapeutic care in the area of UI. The goal for
clients with UI may not necessarily be one of absolute cure, but rather to improve their

quality of life, prevent complications, and provide comfort (Beckman, 1995).

APPENDIX A

APPENDIX A

Urinary Incontinence Assessment for the Ambulatory Elderly

Practitioner ﬁll out with client:
Name: Date:

Current Medications:

Date of Birth/Age: Sex:

 

 

Allergies:

 

For each question, circle the appropriate response or ﬁll in the blanks.

URINARY HISTORY:

Do you have a problem holding your urine: (Describe in their own words)

 

Qnset ef Preelems: 1. recent within last six months, 2. within past year, 3. problem

for more than one year.

Fre uen of Leaka e Fre uen of Ac idents: 1. once a day, 2. twice a day,

3. three times or more per day, 4. at nighttime.

Amount of Leakage: 1. small (pants are damp), 2. moderate (pants are wet),

3. large (pants are soaked).

Management: 1. catheters, 2. medications, 3. pads, 4. skin care, 5. toileting program.

RISK FACTORS:

Medical Conditions: 1. arthritis, 2. back injury/surgery, 3. cancer, 4. chronic constipation,
5. dementia, 6. diabetes, 7. eye/sight problems, 8. hypothyroidism,

9. multiple sclerosis, 10. multiparity,

11. parkinson’s disease,

12. pelvic surgeries (including prostatic surgery), 13. restrictive mobility,
14. stroke, 15. urinary tract infections, kidney disease, stones,
16. any other active major medical condition:

Lifestyle Behaviors:

 

1. alcohol, 2. caffeine intake, 3. inadequate ﬂuid intake, 4. obesity, 5. smoking.

Medieetions Affecting U1:

1. Alpha BLockers, 2. Alpha Stimulants, 3. Anticholinergies, 4. Antihistamines,
5. Antispasmodics, 6. Calcium Channel Blockers, 7. Diurectics, 8. Hypnotics,

9. Narcotics/Sedatives.

INCONTINENCE PROFILE: Circle the appropriate response. Diagnosis of U! will be
indicated by the increased number of responses a‘rcled.

Urge UI:

Leak urine on the way to the toilet.
Frequency or urgency of urination.
Leakage in moderate to large amounts.
Leakage during the night.

Strong uncontrolled urge to void.

tress UI:
Leakage with cough, laugh, exercises or
physical activity.
Leakage in small amounts.
No leakage during the nighttime.
Sudden onset.

rm wewwr

app

Oetman Assessment Tool

Overflow UI:

WPPPI‘

Difﬁculty starting the urination.

Weak or interrrupted stream.

Post voiding dribbling.

Prolonged voiding.

Voiding in small amounts or dribbling.

Functional UI:

1.

9195“

Mobility or manual dexterity
impairments.

Lack of toileting facilities/excessive
distance to toilet.

Depression, delirium, or dementia.
Pain.

Medication use.

Urinary Incontinence Assessment for the Ambulatory Elderly Page Two

Circle the appropriate response or ﬁll in the blank.

FUNCTIONAL ASSESSMENT:

1.
2.
3.

Meeility: a) independent, b) assistance needed, c) wheelchair use,

d) transfer assistance.

Voiding ability: a) able to urinate on own, b) difﬁculty starting urination,
c) refuses to urinate when assistance offered.

Cognitive function: a) intact, b) impaired.

Check Mini Mental State Exam (score) (<24 abnormal).

ENVIRONMENTAL ASSESSMENT:

:55” N”

Is bathroom area well lit: a) Yes, D) No.

Are there any physical barriers on the way to the bathroom, such as:

a) stairs, b) loose rugs, c) doors to open, d) furniture.

Difﬁculty in removing clothing: a) Yes, b) No.

Are the toilet facilities large enough to accommodate any assistive devices, such as:
a) wheelchairs, b) walkers.

PHYSICAL EXAM:

 

 

 

 

 

 

 

 

 

 

 

 

1. Abdominal Exam:
a) palpate for distended bladder, b) massess, c) CVA tenderness, d) normal.
2. Pelvic Exam: Check all that apply.
Genitelie: BEE
a) atrophic mucosa a) perenial sensation
b) cystocele b) anal sphincter tone
c) rectocele c) prostate enlargement (male)
d) uterine prolapse (female)__ d) fecal impaction
DIAGNOSTICS:
1. Uﬁne:
Dipstick: leukocytes , blood , protein , glucose
Culture, if ordered, date: . results:
Post-void residual urine measurement
2. Voiding Dianr: Give to the client to complete. For 3-5 days, record the number of

 

urinary accidents, reason for the accidents, and review at next visit.

Impression (type of incontinence)

 

 

 

Refer to Algorithm for Management of Urinary Incontinence.

 

 

Signature Date

Oetman Assessment Tool

(A

APPENDIX B

APPENDIX 8

Appendix B: Sample of a Voiding Diary

NAME:

 

DATE:

 

INSTRUCTIONS: Place a check in the appropriate column next to the time you urinat-
ed In the toilet or when an incontinence episode occurred. Note the reason for the
incontinence and describe your liquid intake (for example, coffee, water) and estimate

the amount (for example. one cup).

 

Time interval

Urinated in
toilet

incontinence

Had a small

episode

incontinence

Had a large
episode

Reason for
incontinence
episode

Type/amount

of liquid
intake

 

6—8 am.

 

8—1 0 am.

 

1 O—noon

 

Noon-2 p.m.

 

2-4 pm.

 

4—6 pm.

 

6—8 pm.

 

8-10 pm.

 

IO—midnight

 

Overnight

 

 

 

 

 

 

 

No. of pads used today:

 

No. of episodes:

 

 

Comments:

 

55

 

LIST OF REFERENCES

56

REF N

Appleby, S., (1995). A home health perspective on the management of urinary
incontinence. JWQCN, 22, (3), 145-152.

Bear, M., Dwyer, J., Benveneste, D., Jett, K., Dougherty, M., (1997). Home-
based management of urinary incontinence: a pilot study with both frail and independent

elders. JWQQN, 24, 163 - 171.

Beckman, N., (1995). An overview of urinary incontinence in adults: assessments

and behavioral interventions. WW 241-274.

Bergman, A., Ballard, C., & Koonings, P., (1989). Comparison of three different
surgical procedures for genuine stress incontinence: prospective randomized study.
Arncrjcanloumalcmbstetricsandﬁmmw (5). 1102-1106-

Branch, L., Walker, L., Wetle, T., DuBeau, C., & Resnick, N., (1994). Urinary
incontinence knowledge among community-dwelling people 65 years of age and older.
IoumalotAmerjcanﬁedamLSQcienrAuu), 1257- 1262.

Catanzaro, J., (1996). Managing incontinence, an update. M 39-45.

Chutka, D., Fleming, K., Evans, M., Evans, J ., & Andrews, K., (1996). Urinary
incontinence in the elderly population. WWW 93-101.

Colling, J ., (1996). Noninvasive techniques to manage urinary incontinence among

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