In conjunction with the second World Continence Week 2010, nurses from various hospitals, institutions as well as private nurses were invited to submit an essay on their best case studies on how to manage incontinent patients. Entitled “Real Life Experiences”, 10 winning entries were selected and given a prize of S$300 each. This was made possible by the Society for Continence (Singapore) [SFCS] and in partnership with SCA Hygiene Singapore Pte. Ltd. In addition to the prize money, these aforementioned case studies were given generous publicity as they were displayed during the kick-off to the second World Continence Week 2010 at the Public Forum in Toa Payoh HDB Hub Auditorium on 12 June 2010.

These experiences shared by the nurses via their case studies can help contribute more awareness to the condition and also help identify solutions to guide incontinent patients. The 10 winning case studies are featured.

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.

Caring for An Incontinent Patient

Ms Siti Aisyah Bte Salleh
(Raffles Hospital)

While incontinence is not a life-threatening problem, it may have adverse effects on the patient’s quality of life due to the associated physical and emotional distress. Fortunately, urinary incontinence can be managed and treated, and nurses play a part in helping patients manage this problem by giving motivation, assurance and education.

Urinary incontinence affects more women than men, and it may be a symptom of other underlying health conditions. While many women consider that it is a norm and an expected effect of aging, it should not be accepted as normal. Nurses need to empower these women to treat the underlying cause of incontinence besides managing the problem itself.

Different types of urinary incontinence call for different kinds of treatment approach. Therefore, it is essential for nurses to be able to assess the severity and identify the type of incontinence so that the appropriate care and advice can be given to the patient.

Nurses monitor the dietary and fluid intake of the patient, and ensure that he or she receives sufficient fluid that can help reduce urinary urgency, the risk of urinary tract infection, and maintain bowel functioning. Inadequate fluid intake may result in constipation, which in turn may increase urinary urgency or urine retention. Nurses encourage patients to take water, instead of beverages containing caffeine, carbonation, alcohol or artificial sweetener as they irritate the bladder wall and can cause urinary urgency.

Nurses encourage patients to void according to timely schedule, so that the bladder is emptied before it reaches the critical volume that would cause an incontinent incident. Patients are encouraged to void at given intervals rather than wait until the urge occurs. Sometimes, nurses encourage patients to void at intervals that are more frequent than what the individual is used to, and to practice urinary urge inhibition exercises to inhibit or delay voiding, as these help to restore the voiding sensation for those who experience reduced sensation of the bladder.

Pelvic floor muscle exercise, also known as Kegel exercise, is found to be efficient in the treatment of stress urinary incontinence. This exercise strengthens the muscles that assist in bladder and bowel continence by gently tightening the muscles to stop the stream of urine. While this exercise may be learned by written instruction, when the nurses’ personally teach and train patients, it greatly increases the effectiveness of this exercise.

Being overweight is thought to damage the blood flow and nerve innervation to the bladder. The constant pressure on the bladder also gives rise to the possibility of urinary incontinence. Therefore, it is essential for nurses to educate and encourage overweight patients to lose weight as part of the treatment for incontinence. Choosing the right food in the right amount and regular exercise are part of the weight management regimen. Nurses also advise patients to cease smoking habits as part of their incontinence treatment as smoking usually causes smokers to cough often and forcefully, which can strain the pelvic floor muscle and cause incontinence. Lifestyle modifications are important for patients to gain the most out of their treatment, thus, nurses will need to encourage and motivate patients to make these changes.

Mdm Tan’s Story

Ms Lin Xindi
(Private Nursing)

Mdm Tan, Chinese, 63-years old, was admitted into hospital for high fever lasting three days and complained of frequent lower abdominal discomfort with cramp-like, shooting pain on her right side. She also described having a burning sensation while urinating. A urine analysis showed an increase in the number of WBC and traces of blood. It was suspected that she had a urinary tract infection (UTI). The infection had spread upwards into her pelvic region around the kidneys. The patient had displayed systemic symptoms such as her high fever due to her infection. Her abdominal pain was also attributed to the inflammatory response of the pyelum. The patient was diagnosed with an acute pyelonephritis.

Treatment of Mdm Tan’s condition was made according to the principles of chronic pyelonephritis management. The doctor prescribed a short course of antibiotics to help with her infection. Careful measures were taken to maintain proper sanitation for Mdm Tan so as to not worsen her condition. These included proper change of clothes and linen for having frequent changes of her incontinence pads which she uses to help facilitate with her toileting. Proper hygiene in her situation would help reduce the reoccurrence of UTI. The use of her disposable incontinence pads would also improve her hygiene as she would not unknowingly wear soiled underpants.

After a week, Mdm Tan’s condition improved. Her fever broke, and her cramp-like pain disappeared. She commented that with the more frequent changes in her incontinence pad, it made her feel more comfortable and clean.

Mdm Tan was discharged from the hospital after a week of stay.

She was advised to:

  1. Follow up with her medical checkup regularly to monitor her kidneys to prevent the risk of uremia
  2. Keep good toileting habit for both urine and bowels
  3. Maintain her daily water intake
  4. Regular exercise
  5. Empty her bladder properly as it is important not to keep residual urine after going to the toilet. NOTE: It was important for Mdm Tan to know that the bladder could only be emptied completely when she is sitting or standing. Patient education is important with management of her condition.
  6. Supplement her dietary intake with nutritional approaches which help prevent recurrence of UTIs. (e.g. consuming cranberry juice, blueberry juice, fermented milk products containing probiotic bacteria which helps inhibit adherence of bacterial to epithelial cells of the urinary tract).

My Beloved Mother

Ms Lim Lee Yah
(Parkway Group Hospital)

My beloved mother is a very beautiful and graceful lady who is 65-years old now. She has always been very independent and puts on a lovely smile when talking to everyone. Being a homemaker all her life, she stays at home most of the time to look after the family. She does the household chores by herself, including the laundry among others. Even at her age, she would often handwash her laundry by herself early in the morning. I would often offer to do the laundry for her, not wanting my mother to exhaust herself, but she always declines politely saying that she could handle it by herself.

Lately, my mother complained that she has not been feeling very well. She cannot walk fast due to a severe pain in her right leg joint. As a result of that, she has gradually reduced the workload from the household chores. She had always been a neat and tidy woman preferring to wipe things clean on her own; but with the difficulty in moving, my mother is forced to rest more often. But despite it all, it was noted that every morning without fail she would still be handwashing her laundry in the morning.

One morning, I awoke to find my mother seated by her bedside looking upset and disappointed. She was staring upon her bed holding onto her nightclothes which she had worn the night before. To my surprise, I realised that she had wetted her bed and she was holding onto her wet underpants and pajamas. I never knew my mother had a urinary incontinence problem, and she never mentioned it before. Upon seeing me she broke down and cried saying that she was very sad being unable to get out of bed in time to get to the toilet. She went on telling me that this problem has been occurring for quite some time. Being unable to walk fast enough to the toilet, there had been a few incidents whereby she stained her underpants on her way to the toilet; and that was why she has been washing her underpants in the morning.

She kept on blaming herself for wetting her bedclothes. Not wanting to see my mother worry so much, and I told her that it is quite normal for elderly people to experience such symptoms of urinary incontinence. With my experience working as a nurse my whole life, I have handled many similar cases like her. I tried explaining to my mother how urinary incontinence was common amongst the elderly so that she does not have to feel ashamed about it. I brought my mom to a GP to confirm her problem, and the doctor agreed that using adult diapers help manage her problem. I have asked around family and friends, and they advised me to get TENA as a solution. These days, I wake up to a smiling face on my mother at the coffee table when I see her in the morning. She no longer feels ashamed about her urinary incontinence problem, and she claims to feel dry and functional with the aid of the adult diapers.

Incontinence is Nothing to Sneeze At Caring Experiences on Managing the Elderly with Incontinence

Mr Ricarte B Acena
(The Salvation Army Peacehaven Nursing Home)

Incontinence can be embarrassing and a life-altering problem, it can be slightly bothersome or totally debilitating as well, which may have a profound impact on the quality of life. However, incontinence is not something our residents necessarily have to live with.

In the nursing home, our primary goal is to effectively manage or even reverse incontinence. Another one of our goals is to return individuals to their daily routine without any inconvenience related to incontinence. Based from our experience, our most challenging obstacle in managing incontinent residents is under-staffing. Another common problem is the communication barrier between old generation residents and the foreign workers. In addition, we also experience having residents who already prefer using a diaper instead of going to the toilet. On the contrary, and with higher prevalence, we learned that incontinence can have severe emotional effect to the patients. Residents, especially those who are new to incontinence, feel humiliated, so they isolate themselves until depression sets in. We also observed, that psychologically, some of them started to cut back on drinking liquids and therefore risk dehydration, just to avoid wetting. So, we thought, how do we manage them successfully?

I recall real-life strategies in managing our incontinent residents. First, we should educate our nurses. By understanding more about the causes and treatments of the different kinds of incontinence, nurses can open the opportunity for a more comfortable dialogue with residents over the sensitive issues surrounding elimination problems. Therefore, currently, we are strongly advocating that incontinence should not be accepted as a normal occurrence in the elderly, and that relying on diapers to manage incontinence is an unfortunate practice. Next, we need to reassure our residents that they are not alone and need not suffer the indignities of incontinence. That way, we are already establishing rapport with them as well as gaining their cooperation. Our continence society initiates the whole process, up to the identification of potential residents for rehabilitation. Next, we will then make a focused incontinent care plan, implement and evaluate it to find out if it is effective or not.

Among others, measures that we observed and have proven to be effective in managing incontinence is to first establish good rapport and get the residents’ cooperation so we can literally wean them off their diapers. One concrete example is we actively assist them in timed urination using the urinal. Incontinence management needs the virtue of patience and a passion to go the extra mile. At this point in time, actively reassuring and encouraging the residents are the nurses’ primary focus. Then, once bladder retraining is successful, and the residents get their confidence back, we then train them to be independent in using their urinals until they are fully independent of going to the toilet. We assist them by titrating and monitoring their fluid intake. We also actively promote their physical exercise, we control their diet and we keep and monitor their blood sugar under control if they are diabetic.

Finally, with equal importance, is for a nurse (or caregiver) to give his or her full support to the resident to develop a good attitude or routine and urge his residents to urinate regularly with a strong sense to educate them not to ignore their restroom urges. Rehabilitative training for incontinence residents with dementia is a great challenge. Once both parties have achieved and realised that they have touched each other’s lives, they will both feel happiness and fulfillment, and that is just one of the greatest experiences that I can only describe.

How Madam Ho’s Incontinence was Managed

Ms Ang Man Yun
(Alexandra Hospital)

When I was student working at a community hospital, I was exposed to clients who are undergoing rehabilitation so as to regain their maximum capabilities when they return to the community.

Madam Ho, 79-years old, Cantonese speaking lady (not her real name) was admitted to an acute hospital because she was found on the floor face down motionless by her son. She was then diagnosed with delirium secondary to urinary tract infection. Other causes for her delirium investigated were Iron and B12 deficiency anemia.

After resolving the problems of UTI and anemia, she was then transferred to a community hospital for rehabilitation because of her previous independent premobid status. Madam Ho was placed on diapers and she had a sloughy wound (3x3cm) over her left hip due to poor pressure ulcer management in the acute hospital. When I interviewed Madam Ho’s son about her behavior when she was hospitalised, he verbalised that she was constantly placed on restraint due to her restlessness, which may have led to another fall. She was also placed on diapers during her stay in the hospital. I was determined that Madam Ho will be able to be weaned off from diapers because she was independent before hospitalisation and that delirium is just one of the transient causes of incontinence. Moreover, dependence on the use of diapers in the long run reduces Madam Ho’s urethra’s external sphincter muscle tone and causes the breakdown of skin integrity when in-contact with urine or feces for long periods of time.

When she was under my care, I wanted to find out which type of incontinence she was having, so I asked the staff what her urinary patterns were. It seems that she was able to call for toileting needs but she was unable to control it until she reaches the toilet and there are times she has already slightly wet her diaper. Therefore, I suggested to the staff to place a bedside commode near her so that she will not feel pressured to reach the toilet in time. Secondly, Madam Ho was given a three hourly timed voiding schedule to be carried out during her stay. Although Madam Ho was forgetful at times, the timed schedule voiding act as a reminder to pass urine regularly.

While she was in bed, an absorbent incontinence sheet was placed under her bottom so as to accommodate accidental leakage. Madam Ho would not feel embarrassed when she was found to wet the entire bed.

Before discharge from the hospital, I advised Madam Ho’s son to purchase a bedside commode for her at home and if he had any problems at home to voice it out to Madam Ho’s doctor during the next appointment. After one month of her stay in the community hospital, I was glad that Madam Ho was able to wean off her diapers after discharge from the hospital.

Tender Loving Continence Care

Ms Gladys A Songayab
(Kwong Wai Shiu Hospital)

91%…That’s the figure of Kwong Wai Shui Nursing Home residents who are on diapers. I could just imagine the number of diapers being used everyday. Urinary incontinence goes to show that it is common and prevalent among the elderly but I believe there are some residents included in that figure that have the potential to be off the diapers. This is where our program comes in – to identify, assess and if the residents or their loved ones agree, implement our weaning methods by adding a cheerful, caring and driven attitude from the staff, we believe that these chosen few residents can be weaned off from diapers, it may not be nighttime yet, but daytime wetting at the very least.

Kwong Wai Shui Hospital and Nursing home started the “Promotion of Continence in the Nursing Home” last year with the aim of improving the continence of the residents, enhance their self esteem and dignity, reduce the risk of urinary tract infections and skin problems and to equip nurses with the knowledge and skills to better manage the incontinence and promote continence through the weaning of diapers. For the staff to understand urinary incontinence, training was given on the skills to assess the types and causes of incontinence, how to use the bladder and continence chart to understand the micturition pattern. The staff was taught to use the bladder scanner to evaluate the post void residual urine and weaning process with toileting regimes. In this program, the continence assessment form was given emphasis. To successfully wean off a resident from diapers, one must start from history taking which is the most important step followed by a systematic physical examination. Past medical history is vital to determine whether the incontinence is related to an underlying cause. Understanding this step is basic in planning the management strategy.

After one year of implementing the Continence Program, we attempted to wean off 36 residents out of diapers, it’s not a lot but at least we have started to do so. Four residents were off diapers completely, 21 required the assistance of the staff to help them stay dry with toileting regime in the daytime, while two residents managed to maintain social continence with the use of diapers but will pass urine in the toilet or commode at the bedside.

To spread this good news of promoting continence, KWSH had attended bi-monthly meetings with other nursing homes to share the news about successful residents who were weaned off and learned the minor setbacks encountered in the process. These projects benefitted our residents tremendously as many had expressed their satisfaction and were very happy to be taken off the diaper. The project helped us to be more cost effective, environmental friendly as we have less diapers to dispose, and has also enabled us to promote better quality care for our residents.

The staff and the nurses really played a vital role in the project. Their patience, loving attitude and understanding have contributed profoundly to the success of this project and for that, I extend my deepest appreciation and many thanks.

Mdm Mary Koh’s Sharing

Ms Baty Ng
(Home Nursing Foundation)

Mdm Mary Koh is 83-years old. She was referred to HNF by Yishun Polyclinic for two weekly change of catheter. Patient has chronic retention of urine. Currently patient is staying with one unmarried son who is a taxi driver and one daughter. Her daughter suffers from depression and still on follow-up in IMH. Home visit made two weekly for change of catheter as ordered by Polyclinic.

She is currently on silicone elastoma catheter ch 14. Patient ambulates with walking frame at home. She will usually coil up the catheter and hide under her clothing. Patient has no social interactions as she refuses to go out of her house due to her indwelling catheter. Besides that, she is living on the 7th fl oor. Hence, there is a need to improve her social interaction and to get her out of her house to mix with other elderly in her block.

Options available are:
1) Patient to do intermittent catherisation
2) To use leg-bag
3) To use flip-flo

Option 1: Tried out and taught to patient, unsuccessful after several attempts as she has difficulties to localise her urethra.

Option 2: Patient refused as it is too costly and she needs to go to the toilet to empty the bag frequently.

Option 3: Use of flip-flo, attached to urine catheter and link to night bag when she goes to bed. Patient taught the proper way of releasing the urine every two to three hourly following the time as shown on the clock.

Now patient is very happy and looks forward to the nurse’s visit. She also goes down to the void deck and socialise with other elderly surrounding her block.

Dealing with Incontinent Patients

Ms Quek Yanting
(Singapore General Hospital)

Dealing with incontinent patients is part of a nurse’s daily work. It may seem like an easy job, however, it will only be effective if the proper method is being used. One of the main issues that we should look into before performing any intervention will be the types of incontinence. Different incontinence problems should be dealt with differently, such as stress incontinence for example, which is caused by a sudden pressure on the lower abdomen muscles due to cough, laugh, sneeze or even exercise. As for such cases, we will suggest the patient to put on an incontinence pad or diaper to maintain dryness and comfort. However, due to his or her disease, the patient may be bed bound and so the perinea area will constantly be in contact with the acidity of the urine or sometimes stool. With that, rash or broken skin will develop causing more problems to the patient. As a nurse, our role is to change and maintain hygiene to prevent such potential problems. However, the role of the nurse is not enough, the type of product is important as well. Having a product that can enhance dryness and promote comfort will be optimal.

I had a female patient who is 89-years old. She was admitted to the hospital due to uncontrolled diabetes and a toe wound that was not properly nursed, resulting a below knee amputation. She was having stress incontinence due to the weakened pelvic muscle during childbirth; therefore, she was nursed on diapers and resting in bed most of the time. Due to the poor quality of the diaper she brought from home and the poor hygiene practice at home, she came to the hospital with a sacral sore and excoriation around the groins. To prevent the worsening of the condition, we nurses changed the diapers to one that will be able promote dryness and provide frequent diaper care, while at the same time, nursing the sacral sore. A week later, the excoriation was healed completely, the sore was healing well and the wound bed was getting smaller also. The patient also mentioned that she could sleep and rest better without having the discomfort of the wetness of the diaper or pain caused by the excoriation and sore. Another week passed, the sacral wound was healed completely and the patient was discharged from the hospital. The caregiver was taught on the proper techniques of using the diaper as well as about perinea care.