NURSE-UN 1243 Adult and Elder Nursing 3 WEEK 9 – Urinary Incontinence,100% CORRECT

NURSE-UN 1243 Adult and Elder Nursing 3 WEEK 9 – Urinary Incontinence Learning Objectives By the end of this week, the learners will be able to : • Differentiate types of urinary incontinence. • Implement collaborative management (assessment and treatment) of urinary incontinence in the older adult. • Discuss sexual health and sexually transmitted infection risk in the older adult population. • Describe the components of a sexual health assessment for an older adult. Urinary Incontinence (UI) - viewed as a social and hygienic problem but it is not; it does affect the quality of life. ● Involuntary leakage of urine o More prevalent with older adults (women more than men) but not a natural consequence of aging. o Gender differences ▪ Men—common with BPH (Benign prostatic hyperplasia - also called prostate gland enlargement) or prostate cancer; overflow incontinence from urinary retention related to BPH - urine can back up into the ureters → Hydronephrosis - the swelling of a kidney due to a build-up of urine ▪ Women—stress and urge incontinence o Transient or “new onset” o Chronic o occurs when the bladder pressure is greater than sphincter control o DRIP - causes of UI ▪ D - dehydration, delirium, depression ▪ R - restricted mobility, rectal impaction ▪ I - infection, inflammation, impaction ▪ P - polyuria (pee a lot), polypharmacy Incontinence ● Types of Incontinence o Stress o Urge o Overflow o Functional o Mixed o (May have more than 1 type) ● Risk Factors o Weak bladder muscles o Overactive bladder muscles o Weak pelvic floor muscles - teach pt kegel exercises - ▪ to perform exercise; Make sure your bladder is empty, then sit or lie down. ▪ Tighten your pelvic floor muscles. Hold tight and count 3 to 5 seconds. ▪ Relax the muscles and count 3 to 5 seconds. ▪ Repeat 10 times, 3 times a day (morning, afternoon, and night). o Debility - physical weakness, especially as a result of illness. o Arthritis o Pelvic organ prolapse - happens when the muscles or connective tissues of the pelvis do not work as they should. The most common risk factors are: Vaginal childbirth, which can stretch and strain the pelvic floor. Multiple vaginal childbirths raise your risk for pelvic organ prolapse later in life. o BPH/Prostatitis o Infection New Onset Incontinence: What to do? ● Always a nursing priority - same as DRIP - look for the underlying causes ○ Delirium - new onset of confusion - there is always a reason**** ○ Infection--urinary (symptomatic) - UTI: urge/ frequency ○ Atrophic urethritis (urethra vulvar tissue thinning) and vaginitis (an inflammation of the vagina) ○ Pharmaceuticals - antihypertensive, diuretics ○ Psychologic disorders, especially depression - causing not to want to get out of bed ○ Excessive urine output (e.g., heart failure or hyperglycemia (polyuria, polydipsia, polyphagia - big with a new onset of diabetes)) ○ Restricted mobility - Pt may have arthritis, causing them to move slowly - this is a functional problem; pt cant get to the bathroom fast enough, end up dribbling. ○ Stool impaction (1) Stress Incontinence Stress incontinence, also known as stress urinary incontinence (SUI) or effort incontinence is a form of urinary incontinence. It is due to inadequate closure of the bladder outlet by the urethral sphincter. ● Weakened external sphincter/pelvic floor (common after birth), increased intra-abdominal pressure ● Small urine loss during sneezing, laughing, exercise ● Most common in women under age 60, men after prostate surgery o Structures starts to atrophy as estrogen decreases - this is one reasons why women start to have this problem ● Interventions -- Look in the book for charts (causes, intervention) o Journaling, behavioral interventions, diet modification, pelvic floor (Kegel) exercises - is it related to their diabetes, hypertension, meds? o Diet therapy ● Drug therapy: Estrogen ● Surgery ● Bladder neck - This device is a flexible ring with two ridges. Once inserted into the vagina, the ridges press against the vaginal walls and support the urethra. By lifting the bladder neck, it provides better bladder control in women suffering from stress incontinence ● Penile incontinence clamps - Penile compression devices such as penis clamps have shown to cause a significant reduction in incontinence, however long-term use of these devices has the risk of complications, such as pain, urethral erosion, obstruction, and edema. ● Vaginal cone therapy - Weighted vaginal cones can be used to help women to train their pelvic floor muscles. Cones are inserted into the vagina and the pelvic floor is contracted to prevent them from slipping out. (2) Urge Incontinence Urge incontinence occurs when you have a sudden urge to urinate. In urge incontinence, the urinary bladder contracts when it shouldn't, causing some urine to leak through the sphincter muscles holding the bladder closed. Other names for this condition are: overactive bladder (OAB) bladder spasms. ● Detrusor (muscle) instability, internal sphincter weakness - important if you work in rehab and trying to develop a bladder continence program ● Overactive bladder and losses of large amounts of urine - not just leaking ● Older adults most affected, with older men more affected o urinary urgency → involuntary urination - pt get the feeling and just urinate right away o leakage is periodic, frequent, and large amounts o uncontrolled contraction or overactive detrusor ● Interventions o Drugs: Anticholinergics, antihistamines, Ca-channel brokers o Diet therapy: Avoid caffeine and alcohol o Behavioral interventions: Exercises - kegel, bladder training, habit training, electrical stimulation, botox Overflow Incontinence ● Bladder muscles overextended and have poor tone, overflow of retained urine ● “Dribbling” or constant losses of small amounts of urine - pt can wear a diaper it UI pad because the dribbling is all day long ● Occurs in people with diabetes mellitus, men with enlarged prostates, and those taking calcium channel blockers/(anticholinergics - do not dry you out, they cause dry mouth, eye, urinary retention bc the bladder can no longer contract = overflow) ● Can be due to bladder obstruction, anesthesia, surgery, ● Interventions o Surgery to relieve obstruction o Intermittent catheterization - self catheterization o Bladder compression, intermittent self-catheterization o Drug therapy o Behavioral interventions Functional Incontinence ● Physical or psychological factors impair ability to get to the toilet ● loss of urine relate to cognitive, functional, or environmental factors ● Older adults unable to transfer from wheelchair to toilet, those with walking aids that take too long to get to the bathroom (voiding large amounts of urine on floor while heading to the bathroom) o in this case the nurse should put a commode toilet next to the pts bed; bc they are not able to get to the BR fast enough o pt with dementia - forget they have to use the bathroom o pt with stroke - pt will go on a bladder training program; toilet them every 2-3 hours and increase it to every 4 so that are able to urinate o many of the pt have balance/ mobility issues ● Common in frail elderly, nursing home residents, those with dementia ● Interventions o Treatment of reversible causes - commode closed to pt, bladder training program, urinate on a schedule o Urinary habit training (if incontinence not reversible) o Final strategy: Containment of urine, protection of patient’s skin o Applied devices - PureWick - is a urine collection system that works outside the body Designed to help keep skin dry, the PureWick™ Urine Collection System gently pulls the urine from the PureWick™ Female External Catheter into the sealed collection canister. o Urinary catheterization - try to avoid due to UTI → sepsis - text book → look at table 45.16 - UI issues Incontinence: Assessment and Diagnosis • History o Do you ever leak urine: when you don’t want to; when you cough, laugh, or exercise; on the way to the bathroom? o Do you use pads or cloth in your underwear to catch urine? o Incontinence assessment tools Incontinence: Assessment and Diagnosis Incontinence: Assessment and Diagnosis • Physical Assessment o Bladder distention o Bladder scans - look at post void residual - how much is left after urination • The post void residual, normal 50-75; 100 will be repeated. depending on HCP order, pt may be catheterized. We try not to leave the foley in, but it depends on how distended the bladder is (the more distended → more likely to have a urinary catheter to allow the bladder to shrink). o Bowel sounds o Pelvic and rectal (DRE) exams by provider - done by physician • These exam are done to determine the weakness or the tension of pelvic floor muscles Incontinence: Assessment and Diagnosis Laboratory Assessment ◦ Urinalysis ◦ Prostate-specific antigen ◦ taking the Hx and physical to determine general health: do pt have HTN, DM, voiding log (how often are they voiding), what are the factors that contribute to UI (mobility. dexterity, cognitive function) Imaging (rare) ◦ There arent alot of imagining ◦ Voiding cystourethrogram → detects stress incontinence ◦ Other urodynamic studies ● -oscopy, bladder pressure, flowmetry Incontinence: Collaborative Management ● Lifestyle modifications ◦ Smoking cessation; weight reduction; bowel management; caffeine reduction; alcohol reduction; avoiding other “bladder irritants”; appropriate fluid intake ● Scheduled Voiding Regimens ◦ Timed voiding; prompted voiding; bladder training ● Pelvic floor muscle strengthening o Kegel exercises; biofeedback; electrical stimulation - inhibits bladder activity and improves awareness, contractility, and the efficiency of the pelvic muscle contractions . ● Anti-incontinence devices o Pessaries, condom catheters, external clamps or urethral plugs ▪ A pessary is a prosthetic device that can be inserted into the vagina to support its internal structure. It's often used in the case of urinary incontinence and a vaginal or pelvic organ prolapse. A prolapse occurs when the vagina or another organ in the pelvis slips out of its usual place. ● Supportive devices ◦ Elevated toilet seats for functional UI; gait training for functional UI; modified clothing; absorbent pads or undergarments ● Medications ◦ Anticholinergics (for urge incontinence – overactive bladder) such as oxybutynin (Ditropan) - reduce bladder contractions ◦ Topical estrogen (women with stress incontinence) - reduces urethral irritation and increases responses to UTI ● Surgery ◦ Elevate urethral position and/or bladder neck ◦ Artificially open and close urethra ● An anticholinergic agent is a substance that blocks the neurotransmitter acetylcholine in the central and the peripheral nervous system. These agents inhibit parasympathetic nerve impulses by selectively blocking the binding of the neurotransmitter acetylcholine to its receptor in nerve cells. The nerve fibers of the parasympathetic system are responsible for the involuntary movement of smooth muscles present in the gastrointestinal tract, urinary tract, lungs, and many other parts of the body. ● Oxybutynin chloride exerts a direct antispasmodic effect on smooth muscle and inhibits the muscarinic action of acetylcholine on smooth muscle. Incontinence: Community-Based Care • Home environment assessment • Self-management education o Lifestyle modifications, drug therapy, exercises, devices • Prevention of Complications **** o Skin breakdown; UTIs • Psychosocial support • Continence clinics o urology and urogynecology Sexual Health & The Older Adult Why is sexual health important? ● Is important to an individual’s self-identity and general well-being. ● Contributes to the satisfaction of physical needs. ● Fulfills social, emotional, and psychological components of life. ● Evokes sentiments of joy, romance, affection, passion, and intimacy. Sexuality … o provides for expressions of affection and passion. o Enhances avowal of life. o Enriches communication. Sexuality is alive and well among older adults: o Research conducted by Lindau et al (2007) revealed that in a study of 3005 U.S. older adults current sexual activity was reported in 73% of adults aged 57 to 64, 53% of adults aged 65 to 74 and 26% of adults aged 75 to 84. o In 2018, the University of Michigan National Poll on Healthy Aging asked a national sample of adults age 65–80 about sex and their experiences related to sexual health. 40% of adults aged 65 to 80 were sexually active, and more than half, 54 %, said sex was important to their quality of life. (Malani & Solway, 2018) Pathological Changes Medical conditions that may cause sexual dysfunction among older people: o Heart Disease o Diabetes o Depression o Breast and prostate cancers o HIV/AIDS o Dementia o erectile dysfunction and changes in testosterone lvl o concern about STDs in the elderly population ● Arthritis Sexual Behaviors Common to Cognitively Impaired Older Adults Dementia and Inappropriate Sexual Behavior By Jasmine Amena Brathwaite, MD, and Priya Mendiratta, MD, MPH, AGSF Today's Geriatric Medicine Vol. 8 No. 3 P. 26 make a suggestion of sexual intercourse to (someone with whom one is not sexually involved), especially in an unsubtle or offensive way. Sexual Health & Sexuality Among Minority Groups How is it different? • LGBT - less likely to wear protection because they can't get pregnant; resulting in more STD transmission. • Prisoners • Ethnic minorities - Cultural factors impacting sex • Disabled persons • “May-December” Affair - When one partner is substanualty older than other • Institutionalized persons ● In long term care it is common to see spikes of syphilis/ HIV bc pt do not use protection due to lack of the education What are the barriers and facilitators or sexual health among older adults? Barriers ● physical ● lack of education Facilitators ● providers should educate pts about these issues so that the pt can be aware of what can be done to avoid/ prevent them from occurring ● normalize that pts sexual health is important and is prioritized Fast Facts: STI 2018 Data from CDC - due to lack of education (not using condoms/protection) • Chlamydia│1.8 million cases;19% increase since 2014 • Gonorrhea│ 583,405 cases; 63% increase since 2014 • Primary and Secondary Syphilis│35,063 cases; 71% increase since 2014 • Congenital Syphilis│1,306 cases; 185% increase since 2014 • STD Surveillance: Sexual Health & Older Adults ● Older adults remain sexually active and may engage in risky behaviors. ● CDC 2016 report: ○ 43,409 cases of chlamydia among people 45 and older in 2016, up from 38,185 in 2015 and 26,405 in 2012. ○ Gonorrhea had 33,879 cases in the same age group, up from 26,005 in 2015 and 16,257 in 2012. ○ Primary and secondary syphilis, 5,650 cases in same age group. Up from 4,848 in 2015 and 3,176 in 2012. Sexual Health & Older Adults • AARP Survey of Sex, Romance, and Relationships 2010 (Survey of 1,670 Americans ages 45 and older) o During the past 6 months: ▪ 58% - Kissing and hugging - once a week of more ▪ 44% - Sexual touching or caressing ▪ 28% - Sexual intercourse ▪ 16% - Oral sex ▪ 3% - Anal sex ▪ this slide is saying that these things still occur is this population HIV Among People Aged 50 and Older • Older Americans are more likely to receive a diagnosis of HIV infection later in the course of their disease. • According to 2018 HIV Surveillance Report, new HIV diagnoses are declining among people aged 50 and older, around 1 in 6 HIV diagnoses in 2017 were in this group. • There were 38,739 new HIV diagnoses in the US and dependent areas in 2017, 6,640 WERE AMONG PEOPLE AGED 50 AND OLDER. • Among people aged 50 and over, blacks/African Americans accounted for 39.2% of all new HIV diagnoses in 2017. • At this age pts already have other possible comorbidities and now they are introducing HIV. What are the implications? What are the implications? Older Adults & STI Risk • Many of the same risks as younger adults: o Lack of knowledge about STIs and how to prevent transmission o Inconsistent condom use o Multiple partners ● Widowed/divorced individuals begin dating again and are especially lacking in knowledge about STIs and prevention Older Adults & STI Risk • Women who no longer worry about pregnancy may not insist on condom use by their partner • Use of condom also requires a fully erect penis • Availability of erectile dysfunction medications may facilitate sex in older men who otherwise would not have been capable Common STIs ● Syphilis ○ primary ■ single or multiple chancres (painless indurated lesions) ■ regional lymphadenopathy ■ exudate and blood from chancres are highly infectious ○ secondary ■ flu like symptoms: malaise, fever, sore throat, headaches, fatigue, arthralgia, generalized adenopathy ■ mucus patches in the mouth ■ symmetric nonpruritic rash bilaterally on the trunk, palms or soles ■ weight loss, alopecia ■ condylomata lata (moist, weeping papules) in the anogenital area ● Chlamydia ○ often have no symptoms ○ pain with urination, urethral discharge ○ pain and swelling of the testicles (RARE) ○ rectal chlamydia= anorectal pain, discharge, bleeding, pruritus, mucus coated stools, painful bowel movements, tenesmus ● Gonorrhea ○ dysuria, purulent urethral discharge, epididymitis ○ women: increased vaginal discharge, dysuria, frequency of urination or bleeding after sex ○ rectal infection: mucopurulent rectal discharge or bleeding, anorectal pain, pruritis, tenesmus, mucus coated stools, painful bowel movements ● Genital herpes ○ primary episode: ■ burning, tingling, itching at the site of inoculation (prodromal stage) ■ small painful blisters (vesicular stage) ■ lesions rupture and form shallow ulcerations (ulcerative stage) ■ crusting and epithelialization of the erosions (final stage) ● HPV and genital warts ○ single or multiple papillary growths that are white to gray ○ itching may occur with anogenital warts ● Candida infections ○ Need to know the manifestations of these STIs PLISSIT MODELis a modeling system used in the field of sexology to determine the different levels of intervention for individual clients. PLISSIT Model Sexual Health: Assessment and Diagnosis ● Sexual health screening performed at every encounter o Many healthcare providers do not ask older patients about sexual activity ▪ 38% of older men and 22% of older women reported discussing sex life with their providers - this % is way to low, and this area needs to be addressed like any other and same for STDs. ● They also do not test them for HIV o Older adults over age 50 at risk for HIV were 80% less likely to be tested for HIV as at-risk adults 20 to 30 years of age Sexual Health: Assessment and Diagnosis • Past history of STIs • Past OB/GYN surgeries; circumcision • Menstrual history • Sexual history - never assume, just ask o Sexual orientation o Type and frequency of sexual activity o Number and sex of sexual contacts/partners • Contraceptive history • Preventive healthcare practices o Pap tests, regular STD/HIV screenings Sexual Health: Assessment and Diagnosis • Assessment o Oropharyngeal, abdominal, genital/pelvic, anorectal • Laboratory assessments o Urinalysis, hematology o Cervical, urethral, oral, and/or rectal specimens o Lesion samples for microbiology and virology o HPV screening and rectal swabs is very important Sexual Health Assessment • Little information related to HIV screening in long term care settings • However, as per the CDC, ALL patients should be educated, screened, and tested if at risk o Routine testing up to the age of 64 - test pt at any age if they are sexually active o Testing over the age of 64 if risk factors present ● Syphilis & Chlamydia/gonorrhea are asymptomatic so make sure you also screen pt ○ with Chlamydia males might have burning with urination Case Study A 69-year-old male is admitted to your facility. He is a veteran who has previously lived alone, but has a partner who visits often. His medications include: HCTZ 25 mg QD and Lisinopril 20 mg QD. He denies health problems. He is very quiet and you have concerns about his sexual health and safety. ● What is the nurses first action here? ● How would the nurse proceed with an assessment and management of this resident? ● What other members of the interdisciplinary team should be involved in the care of the sexuality issues with this residents? ● Discuss how the nurse would help to meet the needs of the resident and his partner in this case? Case Study Mrs. N is a highly functioning 79-year-old widow who was recently admitted to a nursing home with mild cognitive impairment. Mrs. N began a friendship with Mr. O who is wheelchair bound. Mr. O is married to a woman who resides outside the facility. The nursing staff has noticed more and more intimate touches between Mrs. N and Mr. O and is concerned about whether Mrs. N is competent to make the decision to participate in this increasingly intimate relationship. The staff is also concerned about the moral and ethical issues surrounding Mr. O relationship with a woman other than his wife. ● What is the nurses first action here? ● How would the nurse proceed with an assessment and management of these patients? ● What other members of the interdisciplinary team should be involved in the care of the sexuality issues with these residents? ● Discuss how the nurse would help to meet the needs of patients and families in this case? Sexual Activity and the Older Adult: Johns Hopkins Sex, Love and Intimacy in Later Life: Manchester