Real Life Experiences - Winning Case Studies
Managing An Incontinent Patient
Ms Chow Ru Yi, Ruth
(National University of Singapore - School of Nursing)
A slightly overweight woman 64-years of age who had a past history of hypertension and diabetes of 8 years, was readmitted into the hospital due to a fall at home. An assessment of the patient revealed that she had been frequently dripping urine before going to the toilet. She fell as she was rushing to the toilet to prevent any spillage on the floor. The doctor diagnosed the patient as having mixed (stress and urge) incontinence.
While nursing her sprained wrists, I realised that she did not really understand what urinary incontinence was about. She was very worried that this may affect her independence and that her children may send her to an old folks home because of her condition. She clearly did not understand the term “urge” and “stress” incontinence and I was given the chance to explain the condition and how to manage it so that she can continue living her life as independently as possible. I fi rst told her that the two groups of people that run a higher risk of urinary incontinence were the elderly and women. Factors such as childbirth, diabetes, obesity, constipation and damage to the bladder can be the cause of it.
Therefore, in order to manage her condition, we had to identify ways to prevent the causes of her incontinence. 1) Obesity and diabetes have been linked to incontinence. Hence, a healthy diet and exercise regimen can be put in place to aid her in reducing weight and maintaining good blood glucose levels. 2) Avoiding the intake of fluids may result in the irritation of the bladder lining which will further aggravate her condition. 3) Schedule toileting every two to three hours will help her fix a frequent time so that she will not wait till her bladder is full before emptying it. 4) Kegel exercises should be taught to support her bladder and sphincter function. 5) Absorbent pads and products which are readily available off the shelves at pharmacies can be  an option so that going out need not be embarrassing if leakage occurs. 6) Surgical procedures are available to treat incontinence such as the artificial urinary sphincter, injection therapy, sling procedures, neuromodulation and bladder augmentation.
I was given the opportunity to speak to her daughter who was living with her. I informed her that supporting her mother overcome obstacles would help maintain her psychological health. Moreover, being an agile elderly, introducing her to a support group such as the Society for Continence (Singapore) could help her come to terms with her condition better as she can attend talks and interact with other people who might have similar experiences. Therefore, I feel that the holistic care of a patient with urinary incontinence is important, as many factors can contribute to a better quality of life for the patient with this
condition.
Unintentional Unnoticed Urgency
Ms Shannah Mae C Caceres
Bright Vision Hospital
One of the universal and distressing problems which may have a fanatical impact on the quality of life amongst the elderly is urinary or bladder incontinence (UI). This is the involuntary leakage of urine and losing the ability to maintain urine from the urethra, the tube that carries urine out of the body from the bladder. It can range from an irregular escape of urine, to a complete inability to hold any urine. Women are more prone to having UI than men due to the urinary tract structure. On the other hand, infants and children are not considered as sufferers of incontinence, but are merely untrained, up to the time of toilet training.
The bladder starts to load with urine from the kidneys, stretching to allow for more urine. The first urge to urinate occurs when around one cup of urine has been stored in the bladder. A healthy nervous system will react to this stretching sensation by prompting you to urinate, while also allowing the bladder to continue to fill. The average person can hold around two cups of urine. The ability to urinate depends mainly on having a normal anatomy, a normally functioning nervous system, and the capacity to distinguish and react to the urge to urinate.
Taking the case of Mr LYY, an 84-year old Chinese man living with his wife and younger son and family with past medical history of hypertension 20 years ago, gout, Alzheimer’s Disease for two years, left RCC (diagnosed December 2007 during workup for CRF, however patient declined surgery). An abdominal MRI done on 14 June 2008 have shown results of a heterogeneous mass and sever cortical thinning of the left kidney suggesting chronic obstructive uropathy, leading to chronic renal failure.
He arrived in BVH on 15 April 2010 and is still with us to date. He has an abbreviated mental test score of 5/10. He is full weight-bearing and has a nasogastic tube, used for dietary and fluid management. Upon skin inspection, we noticed that his perineum was excoriated. We managed to initially place him on our current “Tena Diaper”. After each soiling, we would clean his skin using the “Tena Wash”. No powder was used as it will inhibit skin healing. Subsequently, by bladder training or toileting schedule, a period linking urination which is progressively increased until a satisfactory time interval is consistently achieved and bladder chart (intake and output volume that shows its progress and improvements). Lastly, we did some reinforcement until he was able to feel and develop the ability to recognise and respond to the urge to urinate. At the moment, he is able to call for urge to urinate with about two to four hours of interval.
Without a doubt, what matters most is how we treat our patients. It is indeed through understanding and respect, and above all, through tender loving care. After all, it is rewarding to know that at the end of the day, we have been part of our patient’s care and recovery.