This assignment will explore a case study and identifying a specific aspect of care which will be discussed in details. An appropriate assessment tool will be used to help plan care and to examine continence. Mental state,emotional well being, mobility, history of falls and nutritional fluid intake will also be looked into and linked with continence. In addition a description of care give with government and professional guidelines and critical analysis of the care will be included. Initially
This assignment will use a case study of a fictitious patient to examine continence. Its management will be discussed within the context of current guidelines. The Bladder and Bowel Assessment Tool (Toronto, 2006) will be introduced to help plan care. Mental health, mobility, history of falls, nutrition and fluid intake will also be explored and linked with continence. Any issues relating to safeguarding adults will also be addressed.
Lucille McKenzie, a 72-year-old retired teacher of Jamaican descent who lives alone has been admitted via Accident and Emergency after a fall at home. She presented with fever, dyspnoea, indigestion, low haemoglobin, urinary tract infection, delirium, a painful right hip, dehydration, chest infection and a sore sacrum. Lucille has had these unexplained falls in the past nine months and has become dependent upon her step-daughter Marjorie Wilson (a pseudonym) for her needs. She takes aspirin once daily, ibuprofen and gaviscon when required but has not visited her General Practitioner for several years. She also smokes 10-15 cigarettes daily, has lost weight due to her decreased appetite, is sleep-deprived, unkempt and has been urinary incontinent for over three days. So continence was chosen because it is a fundamental aspect of everyday life (Department of Health, 2001a).
Urinary incontinence is the complaint of any involuntary loss of urine (Abrams et al, 2009). It presents itself in different forms including stress, urge, mixed and overflow incontinence (NHS Information Centre) and is associated with increased risk of falls, embarrassment, denial, sexual avoidance, prolonged hospitalisation, caregivers burden and many others (Rhodes, 1995).
However, to deliver high quality care, a comprehensive assessment should be conducted to establish possible transient causes. Transient causes of urinary incontinence can be due to delirium resulting from infection or sleep deprivation, dehydration, stool impaction, depression, medication or restricted mobility (Gray, 2000a).
Prior to this, nurses should explain the process of assessment to Lucille, gain consent (NMC, 2008), allocate sufficient time and establish a nurse-patient relationship that is based on trust, respect and empathy. This will encourage the disclosure of worries and concerns (Letvak, 1995). Also good communication skills are extremely important, as any relationship comes about through communication (Nolan et al, 2003).
It is advisable that nurses use an assessment tool to guide them with their process (NICE, 2006). In this case, the Bladder and Bowel Assessment Tool (Toronto, 2006) can be used to collect information about Lucille’s past medical history, medication, fluid and dietary intake, bowel movement, urinalysis, environmental barriers, dexterity, vision, cognitive, mobility and patterns of voiding which can be ascertained by completing a bladder diary. The bladder diary has been cited as the single most valuable tool in assessing urinary incontinence (Norton, 2001). There are varying opinions in literature as to how many days of recording are useful. Although the seven-day bladder diary is the most studied and reliable tool (Jeyaseelan et al, 2000), a three-day bladder has been found to have a good reliability (Yap and Cromwell, 2006) and is recommended by NICE (2006).
Asking Lucille whether incontinence happens on exertion, coughing, sneezing or when there is a strong urge to the toilet will also help to define the type of incontinence.
Once this has been done, a plan of care that is specific, based upon the goals, needs and strengths must be developed in conjunction with Lucille and her carer (SIGN, 2004). This ensures patient-centred care. Management strategies should include treating urinary tract infection with antibiotics. The aim of antibiotics is to relieve symptoms (SIGN, 2006). Still on this, a midstream specimen should be sent for culture and sensitivity. Although urinalysis is an effective screening tool, it should not be used in isolation to guide treatment because false results can occur if the sample is contaminated or left to stand for too long (Simerville et al, 2005).
As for her fever (a raised temperature of 37.8C), Lucille should be given anti-pyretics to avoid complications (Kozier et al, 2008) and she should be monitored for signs of deterioration using the Early Warning Scale. This is effective in reducing mortality and morbidity of deteriorating patients (Hourihan et al, 1995). Since Lucille is producing thick yellow sputum, a sample for culture and sensitivity must be obtained and treatment must be commenced immediately. Yellow phlegm is a sure sign of a viral infection.
Other nursing interventions should include referring Lucille to physiotherapists for pelvic floor exercises, referral to Continence Specialist Nurses, bladder retraining, modifying the environment and addressing constipation. Though Lucille is not constipated, she must be encouraged to drink more fluids and a Bristol Stool Chart should be completed. Laxatives to help with bowels can be prescribed as constipation can detrusor contractility (Gray, 2000a). Her medication should also be reviewed. Aspirin and ibuprofen are NSAIDS which can irritate the bladder (BNF, 2012). Also simplifying her clothing by using Velcro straps and elastics to help with dexterity can promote continence.
Furthermore, the use of absorbent pads can be a highly effective solution. They shield embarrassment but offering them can lead to psychological dependence on them and reluctance to accept treatment (SIGN, 2004). Therefore they should be used as a last resort or where urgency, cognitive or mobility impairment are involved (NICE, 2006).
Additionally, prompted voiding has been shown to reduce incontinence in cognitively impaired patients (National Collaboration Centre for Women and Children Health, 2006). This requires caregivers to prompt patients to urinate. Therefore nurses should initiate an individualized prompted voiding schedule for Lucille.
Since health promotion is at the forefront of nursing, advice on losing weight should
be given as increased weight exerts extra pressure on the bladder (Abrams and Artibani, 2004). Lucille should also be encouraged to quit smoking and to eliminate bladder irritants as these can induce urinary incontinence (Bump and McClish, 1994). However, it is possible that through following the above principles, Lucille’s incontinence may be resolved.
Moreover, everyday nursing care should include helping Lucille with self-care needs like personal hygiene, remembering to involve her to optimise independence. This time also affords nurses to inspect her skin integrity. Since Lucille has a red and painful sacrum, nurses should immediately clean her after every episode and utilise barrier creams to prevent exacerbation (Errsser et al, 2005). Nurses should also encourage her to re-position herself to redistribute weight (NICE, 2001). Alternatively, pressure relieving aids like mattresses can be used and a wound care plan must be initiated.
In terms of reducing Lucille’s pain, comfortable positions and analgesics should be provided. Scoring scales should be used and a personalised pain plan should be implemented.
Rather than focusing on incontinence in isolation, nurses should ensure that Lucille’s fundamental needs such as nutrition and hydration, mental state and emotional well-being, mobility and history of falls are met.
Good nutrition and hydration are vital for health and its deficit can lead to a number of serious health problems. Therefore a nutritional assessment should be conducted on Lucille (NICE, 2006) to identify malnutrition. This can be undertaken using a Malnutrition Universal Screening Tool (Bapen, 2007). Since Lucille is at high risk, nurses should refer her to a dietician, determine her food preferences to meet her cultural needs and arrange to have these provided as appropriate, weigh her regularly, adhere to protected mealtimes and implement a red tray system for her (Hungry to be heard, 2006). Nurses should also explain to her the need for increasing fibre to facilitate bowel movement, thus preventing constipation which also precipitates urinary incontinence (Sarkar and Ritch, 2000). The assessment should also enquire about her dentures and oral health, and referral to the dentist should be made if there are any concerns.
Also encouraging Lucille to drink at least 1.5-2 litres of fluids daily (NICE, 2006) is vital because dehydration makes urine to become concentrated, which in turn can irritate the bladder thereby causing urgency and frequency (RCN and NSPA, 2007). This must be monitored by completing fluid balance charts. It should be noted that fruits, yoghurt and soup contribute to fluid intake (ESFA, 2010).
Another essential aspect to overall health is mental health and emotional well-being (DH, 2011). Common prevalent mental health disorders in older people include depression, anxiety, delirium and dementia. The NSF (Standard 2 and 3) stipulates that all who present with mental health illness should be assessed and treated. In respect of Lucille who has delirium, she must be screened using the Confusion Assessment Method (Inouye et al, 1990). Nursing interventions to reduce Lucille’s delirium should include nursing her near the nurses’ station, calling her with her preferred name, relieving her pain symptoms, encouraging sleep, reorientation, correcting sensory deficits, encouraging frequent visits from Marjorie and the Pastor, reassuring her, ensuring adequate nutrition, oxygenation and hydration. Dehydration can affect cognition which in turn can cause a person to lack the incentive to go to the toilet (Sansevero 1997) . Thus combining words with pictures to promote continence (Grealy et al, 2005) is ideal.
Again falls are a major concern in the older people. They can lead to disability and psychological trauma. Given this, Lucille should undergo a thorough assessment using a Falls Risk Assessment Tool (Nandy et al, 2004) to enable strategies to be implemented. The assessment must identify history of falls, environmental hazards, medication, balance, osteoporosis, visual, postural hypotension and mobility. Standard 6 in the NSF for older people (DH, 2001a) outlines strategies to reduce the number of falls that result in serious injuries.
They include keeping beds low, applying brakes on beds, lockers and wheelchairs, strength training with the physiotherapist, use of assistive devices like Zimmer Frames, avoiding dehydration, use of non-slip mats and proper footwear to reduce slipping in urine, adjusting heights of toilets, use of grab rails, modifying the environment and ensuring that call bells are within easy reach and these strategies should also be applied to Lucille. Nurses should also consider placing Lucille near toilet facilities or wheel her to the toilet on the commode. A vision referral should also be made so that Lucille can have her glasses replaced. Her athritis and low haemoglobin should be treated. Low haemoglobin results in decreased strength, thereby affecting the ability to get to the toilet (Ouslander and Schnelle, 1995).
Moreover, bed rails can be safely used to reduce the risk of patients falling, sliding or rolling from beds (NICE, 2006) but they are not suitable for every patient. Confused patients exhibit unsafe behaviour such as climbing out of bed without assistance and knowing that Lucille is delirious, nurses should consider this to reduce the risk of such untoward incidents.
Also protecting vulnerable adults from abuse is an integral part of nursing practice (NMC, 2011a). By definition, vulnerable adults are people over the age of 18, who are in need of community care services, who finds it difficult to protect themselves from harm (DH, 2000). Abuse can be physical, psychological, financial, sexual or any act of neglect. Effects include bruises, burns, bites, fractures, pressure sores, malnutrition, unkempt appearance, confusion, withdrawal, inappropriate use of medication and many others and in respect of Lucille who has had several unexplained falls, nurses should respond appropriately. The DH clinical governance and adult safeguarding flow chart (DH, 2010) comprises of a series of steps to be taken and nurses need to adhere to this pathway. By all means, facts should be recorded objectively, signed and dated. The matter should be referred to Social Services within 12 hours (Birmingham Safeguarding Adults Board).
Finally, older people even those with disability wish to return home (Martin et al, 1994). So discharge planning should commence on admission. Also involving Lucille and Marjorie in decision-making is crucial for timely and appropriate discharge (Health and Social Care Act, 2001). Decision to discharge Lucille should come from multiple sources and nurses should ensure that any services needed by Lucille upon discharge have been put in place. Thus an occupational therapy should be carried out at Lucille’s home and equipment like walking frames and commodes should be provided. Nurses should also inform Lucille’s GP about her discharge and a referral to district nurses for her sacral wound assessment and care should be made.
Section 2 must also be issued (NHS Community Care, 2003). This is a notification to Social Services that requires a Social Worker assessment. Also home help or respite care to give Marjorie some down time should be considered since Marjorie is finding it difficult to cope whilst working full-time. Teaching regarding medication should be given and this can be reinforced by the provision of leaflets. Information about local support groups and benefits should be provided to Lucille and Marjorie as they are not getting anything from health and social agencies. Also transport should be arranged and follow-up appointments should be scheduled.
In summary, urinary incontinence impacts so much on the quality of life and those who present with it should undergo a holistic assessment so that management strategies can be implemented. Also nurses should be aware of abuse that can befall the elderly. Above all effective discharge should begin at admission.