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老人尿失禁的照護技巧 The Techniques of Caring the Aging with Urinary Incontinence PowerPoint PPT Presentation


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老人尿失禁的照護技巧 The Techniques of Caring the Aging with Urinary Incontinence. 王炯珵 恩主公醫院泌尿科 Chung Cheng Wang Department of Urology En Chu Kong Hospital. State of the Science on Urinary Incontinence.

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老人尿失禁的照護技巧 The Techniques of Caring the Aging with Urinary Incontinence

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老人尿失禁的照護技巧The Techniques of Caring the Aging with Urinary Incontinence

王炯珵

恩主公醫院泌尿科

Chung Cheng Wang

Department of Urology

En Chu Kong Hospital


State of the Science on Urinary Incontinence

  • Nurses have in their toolboxes some help for first-line UI intervention and screening [Diane Newman, 2002 July]

  • The first priority is to increase awareness among nurses. [Mary Palmer, 2003AJN]

  • Noninvasive behavioral interventions can be effective in long-term care setting

  • But staff compliance was problematic [Palmer MH 1997]


Epidemiology

  • 20 million American have UI [Abram P 2002]

  • 22% of women aged 65 and older had UI in daily life [Tseng 2000]

  • More than 50% of nursing home residents [Fantl J,1996]


Differences in Gender

  • Female: male = 2:1[Hunskaar S 2001]

  • stress or mixed UI: female

  • Pure urge UI: equal

  • Postvoid dribbling, nocturnal enuresis: male [Temml C 2000]

  • Women were more likely to regularly use strategies for UI management [Johnson TM 2000]


Risk Factors in Women

  • Gravidity and parity

  • One vaginal birth: 2.5 times for UI [Nygaard IE 1994]

  • Breech presentation, use of forceps, tearing, central episiotomy, oxytocin

  • Pelvic organ prolapse

  • Gynecologic surgery

  • Menopause

  • Obesity [Roe B 1999]


Risk Factors in Men

  • A history of radical or transurethral prostatectomy[Umlauf 1996]

  • The first year of admission to a long-term care facility [Palmer MH 1991]

  • Causes of urge UI in elderly men: UTI, prostate inflammation, bowel dysfunction [Herzog AR 1990]


UI in the Frail Elderly

  • Frail: decline in physical activity [Bortx WM 2002]

  • Frail elderly: >65, UI, can not go out without assistance, dementia, admitted to a long-term care facility [Fonda D 1998]


Risk Factors in Frail Elderly

  • Multiple medical morbidities

  • Immobility

  • Cognitive impairment (dementia)


Screening

  • Routine assessment for UI can be easily incorporated into the general history questions [Feneley RC BJU 1997]

  • Screening by risk factors

  • Urge UI + Nocturia >2 + daytime voiding frequency of < 2hr = 90% detrusor overactivity on UDS [Gray M, 2001]


Assessment of UI in the Frail Older Adult

  • History and symptom assessment

  • Clinical and physical assessment

  • Environmental assessment

  • Identify possible diagnosis or clinical impression


Potential Reverse Causes

  • Delirium, dementia, depression

  • Infection (UTI)

  • Atrophic vaginitis

  • Pharmaceuticals

  • Psychological, Pain

  • Excess fluid (polyuria, edema)

  • Restricted mobility

  • Stool (constipation)


Behavioral Therapy

  • AHCPR guideline

  • Bladder training: strongly recommended for urge and mixed incontinence and also recommended for stress UI

  • Pelvic floor rehabilitation: strongly recommended for stress UI

  • The first line of treatment[Fantl J 1996]


Nonpharmacologic Management of UI in Adults

  • Lifestyle or risk factors modification

  • Scheduled voiding regimens

  • Pelvic floor muscle rehabilitation

  • Anti-incontinence devices

  • Supportive interventions


Lifestyle Modification

  • Reduce risk factors

  • Stress UI: smoking cessation,change body position [Norton PA 1994], weight reduction [Deitel M 1988]

  • Constipation: good bowel hygiene

  • Urge UI: caffeine reduction, selected dietary and fluid modification

  • No study support: bladder irritants, alcohol [Wyman JF 2000]


Nonpharmacologic Management of UI in Adults

  • Lifestyle or risk factors modification

  • Scheduled voiding regimens

  • Pelvic floor muscle rehabilitation

  • Devices

  • Supportive intervention


Scheduled Voiding Regimens

  • Timed voiding

  • Habit retraining

  • Patterned urge response toileting

  • Prompted voiding

  • Bladder training


Nonpharmacologic Management of UI in Adults

  • Lifestyle or risk factors modification

  • Scheduled voiding regimens

  • Pelvic floor muscle rehabilitation

  • Anti-incontinence devices

  • Supportive intervention


Pelvic Floor Muscle Rehabilitation

  • Pelvic floor muscle exercise

  • Vaginal weight training

  • Biofeedback

  • Electric stimulation

  • Magnetic stimulation


Nonpharmacologic Management of UI in Adults

  • Lifestyle or risk factors modification

  • Scheduled voiding regimens

  • Pelvic floor muscle rehabilitation

  • Anti-incontinence devices

  • Supportive intervention


Anti-incontinence Device

  • Intravaginal support device

  • External occlusive device

  • Intraurethral occlusive device

  • Complex valved catheter

  • External collection device

  • Urethral catheter


Intravaginal Support Device

  • Pessary

  • Support the bladder neck, relieve minor pelvic prolapse and change pressure transmission

  • Stress UI

  • Estrogen replacement for postmenopausal women


External Occlusive Device

  • A small single-use device that covers the urethral meatus for women

  • A penile clamp for men

  • Need good manual dexterity

  • Complication: periurethral irritation or penile erosion


Intraurethral Occlusive Device

  • Urethral plug

  • A small single-use device that is worn in the urethra to provide mechanical obstruction

  • Used for stress UI in cognitively intact patient

  • Complication: urethral irritation, hematuria, UTI or migrate into bladder


Complex Valved Catheter

  • Intraurethral occlusive device with a unidirectional valve

  • Left indwelling for long period

  • Must be inserted and removed by a clinician

  • Being test for female stress UI, overflow UI

  • Complication: urethral irritation, hematuria, UTI


External Collection Device

  • Condom catheter with leg bag

  • Used in men with urge, stress and overflow UI and in those with functionally impairment

  • More comfortable, less painful and less restrictive than use of an indwelling catheter [Saint S 1999]

  • Risk for UTI, penile skin marceration


Urethral Catheters

  • Disposable, single-use catheter and indwelling catheters

  • Used for overflow UI

  • Bedbound, mobility impairment and severe UI

  • Clean intermittent catheterization is the standard care of spinal cord injury [Perrouin-Verbe B 1995]


Indications for Long-term Indwelling Catheters

  • Persistent overflow UI, symptomatic UTI or kidney disease

  • Surgical or pharmacologic intervention failed

  • Contraindication for CIC

  • Changes of bedding, clothing and absorbent products may be painful or disruptive for p’t with an irreversible medical condition

  • Not healed grade 3-4 pressure ulcers

  • Patients live alone without a caregiver


Nonpharmacologic Management of UI in Adults

  • Lifestyle or risk factors modification

  • Scheduled voiding regimens

  • Pelvic floor muscle rehabilitation

  • Anti-incontinence devices

  • Supportive intervention


Supportive Interventions

  • Toileting substitutes and other environmental modifications

  • Physical and occupational therapy

  • Absorbent products


Toileting Substitutes and Other Environmental Modifications

  • Urinals, bedside commodes, elevated toilet seats

  • Used for patients with mobility impairment that make it difficult to reach a toilet in a timely fashion


Physical and Occupational Therapy

  • Gait and strength training

  • Used for frail older patients with mobility or manual dexterity impairments that make it difficult to reach a toilet and disrobe in a timely fashion


Absorbent Products

  • Reusable and disposable pads and pants system

  • Some products contain a polymer that absorbs urine and binds with urine, changing it into gel[Newman D 2002]

  • Used for all types of incontinence

  • But never be used solely for the convenience of the caregiver


Behavioral Therapy in Frail Elders

  • Adequate fluid intake

  • Bowel regularity

  • Perineal hygiene

  • Voiding every 2 to 4 hours

  • Avoid caffeine in urge UI

  • Toileting programs


Skin Care

  • Perineal hygiene after toileting

  • Skin dryness

  • Comfortable clothes

  • Skin ulcer: isolation cream, Duoderm, Comfeel


Prevention of Excess Disability

  • The two primary risk factors for UI among the frail elderly are immobility and cognitive impairment

  • Tailored programs that enhance physical mobility and cognitive function [Schnelle J 2000]

  • Optimal management of acute and chronic illness

  • Environmental modification

  • Prosthetic support [Weindrug R 1991]


Algorithm -- I

  • Three-day bladder record, measure RU

  • Determine which type of UI

  • What trigger it

  • Individual care plans

  • Four goals: fewer incontinence episodes, daytime continence, 24-hour continence, the prevention of skin breakdown and odor


Algorithm -- II

  • Behavioral interventions

  • Ambulatory assistance

  • Cognitively intact  PFM training

  • Passive exercise

  • Goal one to goal three

  • Goal four is reserved for comatose or very debilitated patients


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