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Incontinence management: help for the hands-on staff.

Good incontinence management often founders on nursing assistants' simple reluctance to get involved. Here's how to get past that

The job is stressful, the turn over rate is tremendous, and the staff is frequently undervalued. So how do you convince the nursing assistant to manage incontinence, rather than simply apply a diaper and hope for the best?

As a basic rule, a program supported by management will work wonderfully; a program without that support doesn't stand a chance. The person put in charge of that program - preferably a nurse manager at the unit level - should be knowledgeable, motivated, and highly visible and accessible to the primary care staff.

With management in place, few things are more beneficial to any program's success than staff morale, as exhibited by primary caretakers who know they are valued members of the care team. And this, first and foremost, is accomplished through education. Too often, nursing assistants are done a disservice by a lack of emphasis on educating them to do their jobs properly. Education should begin shortly after orientation with a program on incontinence, reducing pres sure sores, and related topics. While it is true that staff development personnel may provide helpful suggestions or written materials, it seems that programs run by nursing management at the unit level tend to be better received than those conducted by staff development in a distant room. These programs also help to establish the teaching role of the nurse manager.

Subsequent informal meetings at the nurses' station with the nurse manager and four or five nursing assistants should be held to review admissions and determine the resident issues requiring attention over the next few days. Involving nursing assistants in the development of programs they are expected to implement goes a long way toward motivating quality care and making staff feel valued. Having nursing assistants included in care planning meetings can enhance this sense of self-worth and provide the rest of the staff with unique insights-those of the nursing assistants-into residents' needs.

Overcoming Staffing Problems

But what about the short-staffed nursing home? It's important to understand that staffing isn't a numbers game and that the term "short-staffed" is a misnomer and is largely a matter of perception. On any given day, a visit to almost any nursing home will reveal two or more diametrically opposed views of the staffing status. One nursing assistant caring for as many as 10 residents may be providing excellent care, while another assigned to only six may complain of being short-staffed.

What makes the difference between those perceptions? The quality of management, nursing leaders and primary nursing. Management and leadership can be improved by developing a head nurse or nurse manager role at the unit level. That person should have total 24-hour responsibility for resident care, along with the authority to determine what will and will not happen on that unit.

Meanwhile, primary nursing focuses on relationships rather than tasks. The caregiver responsible for the total care of a resident for 2 weeks or 1 month understands that resident's idiosyncrasies and subtle needs, and is much more likely to be invested in his or her care than the staff member assigned to specific fragmented tasks such as making beds, toileting, or bathing.

Avoiding Assessment Pitfalls

The first mistake made by many nursing homes occurs upon admission, when a resident's incontinence is attributed to age and the need for a thorough assessment to identify etiology goes unrecognized.

It is important to teach the staff to differentiate between the normal aging process and the disease process that may cause or contribute to incontinence. Unlike the loss of muscle tone and bone mass that affect all elderly, incontinence is not a normal part of aging.

Determining the cause of incontinence requires a commitment to develop and apply a system to all residents admitted. One person - preferably a nurse manager at the unit level - should accept responsibility for monitoring the program and delegating nursing assistants to follow through.

Determining etiology begins with a thorough history that should address the following issues:

* Is the patient coming from home or the hospital? A resident admitted from home may have simply been unable to get to the bathroom because of immobility or inaccessibility. If the resident was admitted from the hospital, as many are, a foley catheter removed just prior to discharge gives the bladder no time to resume routine function. Bladder tone can often be restored by retraining or by clamping the catheter if left in place.

* What is the duration and severity of the problem? How displeasing is it to the resident and the family? Long-term and short-term problems differ, both in etiology and in potential treatment. Also, the resident's desire to reduce incontinence must always be considered.

* Describe the onset of the problem. Did the female resident have problems during pregnancy or dribbling after childbearing years?

* What are the resident's personal habits with respect to fluid intake. Are these related to a pattern of incontinence?

* Are there any conditions or medications that may be contributing to the problem?

Interviews with residents and family are best conducted separately. The interviewer can then cross-reference and use his or her professional skills to determine the accuracy of the information given. The resident may be reluctant to admit to the problem in front of family members and should never be forced to do so. And family, who are frequently dealing with feelings of guilt, may deny the existence of incontinence, even though it may actually be a major factor in the decision for placement.

Once the history is obtained, the next step is a physical examination, sometimes supplemented with simple laboratory tests. The nursing staff may meet with some resistance from physicians reluctant to order laboratory work. Thus, it's important to explain that only a few tests to rule out causes, such as infection, are needed, rather than an elaborate, costly series.

Three Approaches to Treatment

The minimum data set (MDS) provides a fairly comprehensive set of guidelines for finding the causes of incontinence in a particular resident. Using this, after the history and physical, a pattern of incontinence can be established with a 3 to 5 day assessment of intake and output initiated and monitored by the nurse manager.

Decisions must be made with respect to specimen collection, measurement, storage, and forms for documentation. The tracking will help to identify problem areas, such as times of the day and shifts when residents are prone to being wet.

Once these data are collected, the nursing process goes into effect with the skill and knowledge of the frontline staff, nursing assistants, LPNs, RNs, and nurse manager applied to formulate a plan of care involving one of three responses:

1 RETRAINING. A 14- to 30-day retraining program to increase bladder tone is appropriate for the resident with a brief history of incontinence that may be due to medication or recent catheterization.

2 MAINTENANCE. A maintenance program (checking the resident for wetness every 2 hours) is aimed at retaining dignity and keeping the skin intact. This type of program is indicated for residents with incontinence of long duration in whom the detrussor muscle is "gone." These are the people who have no sensation prior to voiding and are unable to detect a pattern.

3 KEEP DRY. The keep dry program is geared toward preventing incontinence and developing a system that matches the resident's individual voiding pattern by toileting before anticipated voiding and checking in between. The resident who is dry at 6:00 AM and voids a great deal at 7:00, for example, can be awakened and toileted at 6:30, maintaining a dry state. These residents may also respond to contraction exercises to stimulate the detrussor muscle.

No matter which program is implemented, constant monitoring and evaluation of the program's ongoing efficacy is essential. If the program is intact and wetness persists, the program should be reevaluated.

Teaching the Art of Maintaining Dignity

Maintaining the residents' dignity is an integral part of any system used to reduce incontinence. The process involves educating the "hands-on" staff not only about skin breakdown, but also about the feelings, both physical and emotional, associated with being wet.

First and foremost, primary caretakers should be taught to respect and maintain residents' privacy. It is never appropriate to walk into the day room and place a hand down the back of the pants to check for wetness. A staff member who responds along the lines of "he doesn't even know his own name" should be told to assume that such checking maneuvers are a violation of any resident's dignity, regardless of mental status.

Recognition of this is the necessary foundation for any successful program of incontinence management.

Julie Ditzler, RN, BSN, is a Long-Term Care Consultant with Creative Nursing Management of Minneapolis, MN, and was a nursing facility administrator and director of nursing for 15 years.
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Title Annotation:nursing homes
Author:Ditzler, Julie
Publication:Nursing Homes
Date:Mar 1, 1993
Previous Article:Basic guidelines for the nursing home staff.
Next Article:Prompted voiding enters the computer age: report on a work in progress.

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