VOL: 103, ISSUE: 26, PAGE NO: 50
Alison Harris, BSc, Dip DN, RN, is senior lecturer, Department of Primary, Public and Child Health, Middlesex University, London
The fundamental skill that students undertaking continence care modules within higher education are expected to ach…
The fundamental skill that students undertaking continence care modules within higher education are expected to achieve is that of accurately assessing people presenting with continence problems. Without a thorough and competent assessment a patient’s treatment and care pathway will be ineffectual.
This article will look at two documents when considering the assessment of women presenting with urinary incontinence (UI): The Standardisation of Terminology of Lower Urinary Tract Function (Abrams et al, 2003) and Urinary Incontinence: The Management of Urinary Incontinence in Women (NICE, 2006).
The NICE guidance requires practitioners to categorise the cause of the UI based on the first clinical assessment (Table 1). The onus is on all nurses working with women with bladder problems to have the level of skill and experience necessary to recognise symptoms and to be able to categorise them so that first-line management strategies can be appropriately instigated.
WHY IS ASSESSMENT NECESSARY?
The assessment of continence is often patchy and inadequate, and the responsibility to improve care lies with all health professionals. The Royal College of Physicians’ pilot audit of continence services in primary, secondary and care homes found evidence that a basic assessment, which ought to include a rectal examination and urinalysis, did not occur in 58% of the audited hospital sites and in 54% of the audited care homes. The audit also identified that 60% of the hospitals had no written protocol for providing a basic assessment for people with bladder and bowel problems (Royal College of Physicians, 2004).
UI has been shown to reduce the quality of life of people (Hagglund et al, 2003) and has also been demonstrated to be significantly linked with falls in older people (Brown et al, 2000). Many people presenting for help have delayed doing so due to embarrassment or because they believe their condition is normal (Shaw et al, 2006). The nursing management of continence problems is often aimed at containment rather than curative strategies (Dingwall and McLafferty, 2006), but UI is rarely intractable. Getting the assessment right can reduce the burden on individual patients and the cost to the health service.
It is essential that a full assessment is carried out so that the underlying causes of UI can be identified. The initial information-gathering and documentation should include the relevant past medical history, possible causative factors and lifestyle and behaviours as well as the current presenting symptoms. The initial assessment can take the clinician a considerable amount of time.
Symptoms are subjective indicators of a disease (Abrams et al, 2003) and are defined by the patient’s or carer’s perspective and experience. They help guide the clinician towards categorising the cause of the UI and NICE (2006) guidance suggests that categorisation based on symptoms and history-taking is ‘sufficiently reliable to inform initial, non-invasive treatment decisions’. Table 2 provides an outline of the assessment interview and the presenting symptoms that will contribute towards the initial nursing categorisation of the cause of the UI.
A physical assessment will also be required before categorisation can be made and the treatment and management interventions planned. Continence specialist nurses or those working at an advanced level of practice may initiate non-invasive treatments. The general nurse can use the assessment to draw up a plan of care in alliance with GPs or their specialist colleagues.
Cultural variations exist in both patients presenting for treatment (Huang et al, 2006) and in the experience of UI. The culturally competent assessment should include information on any diversity in the self-management of UI, the understanding of the cause of the problem and the expectation of care.
An assessment of bowel habits - notably constipation that can cause outflow difficulties, reduce bladder capacity and increase urinary frequency - is an essential part of the assessment. Reports of hard stool or constipation should be dealt with before the treatment plan for the UI is started. The patient should be asked specific questions about frequency of bowel actions and stool consistency. In this regard the Bristol stool chart is a valuable assessment tool.
Bladder pain and discomfort
Bladder pain or discomfort should be assessed and close questioning may reveal the nature and cause of the pain. Discomfort may be due to vaginal dryness or pelvic organ prolapse and may be associated with sexual intercourse (dyspareunia). Women presenting with post-menopausal dryness may benefit from an assessment for topical oestrogen therapy. A referral to a physician or gynaecologist should be considered.
UI can have an impact on relationships and sexual function as well as self-esteem and socialisation and the clinician’s approach to the assessment should consider the patient’s anxiety and possible embarrassment.
Pain that is associated with voiding may be indicative of a urinary tract infection (UTI) and a urinalysis must be carried out. NICE guidance differentiates between a positive urine sample (showing leucocytes and nitrites) in those who have symptoms of a UTI (such as pain, frequency, gross haematuria, pyrexia) and those who are asymptomatic. When assessment reveals a positive urinalysis associated with symptoms a urine sample should be sent for microscopy, culture and sensitivity, and antibiotics should be commenced.
The use of bladder diaries to collect objective data regarding frequency and incontinence episodes is well established in clinical practice. A minimum recording of three days of bladder activity is suggested by NICE (2006). Fluids consumed, including the amount of caffeine, are an essential part of the assessment and a fluid matrix can be used as a guide (Abrams and Klevmark, 1996).
Residual urine volumes
Women presenting with complex symptoms of a voiding dysfunction, including frequency, hesitancy, straining and a sensation of incomplete bladder emptying, may require a measurement of a post-void residual urine. This can be safely performed with a portable bladder-scanning machine. In the absence of this, and with an agreed plan of care between patient and physician, a residual catheterisation can be performed by competent nurses. Generally, a significant post-void residual urine, in otherwise fit and healthy women, is classified as that which exceeds 10% of the bladder capacity (Thuroff et al, 2006).
In people over 85 years or those with physical disability a plan of care that takes into account the bothersome nature of UI and the person’s ability to consent to and cope with any treatment for the urinary retention is needed.
Large residual volumes of urines are associated with neurological disorders such as multiple sclerosis and require an agreed plan of management with the patient, the physician and the wider multiprofessional team.
Examinations of the abdomen, perineum and pelvic floor are essential components of the assessment and must be carried out by competent specialist practitioners. Observation of the perineum may reveal vaginal atrophy (dark red or purplish colouring, loss of hair and shrunken labia). Asking the patient to cough while they are in the supine position may reveal a pelvic organ prolapse. Pelvic floor tone, strength and endurance can be assessed by palpation of the vagina.
Patients whose UI could possibly have a neurogenic cause will require an extensive neurological assessment.
A person’s functional ability may lead to UI, for example if a toilet cannot be easily accessed because it is upstairs or the indiviual is unable to undo fastenings on clothes. A woman presenting with difficulties in performing any activity of daily living will require an assessment of her mobility, dexterity and cognition. In addition information regarding the home environment, support networks and any equipment used at home will be beneficial in identifying those treatment and management interventions that are most likely to succeed.
Medication such as diuretics used to treat congestive cardiac failure may heighten the already overactive and overburdened bladder of an older woman and certain antidepressants, with antimuscarinic properties, may cause retention of urine. During assessment it is important to find out whether any such medications are being taken by the patient.
The use of urodynamics in the diagnosis of all women with UI is no longer considered valid or reliable. NICE identified that the procedure may be required for certain groups of women who are considering surgical approaches to treatment (NICE, 2006).
The new NICE guidance on the management of UI in women can support nurses. Continence assessments can be time consuming and nurses need to have certain competencies before they can carry out these assessments in full.
UI can lead to feelings of low self-esteem and social isolation. Holistic assessment is essential in order to provide timely and effective management and treatment. Nurses needing to develop competencies in this area can find support from CPD programmes and continence specialist practitioners.