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Is your facility continence-friendly?

Mrs. B. bad always been continent. But one morning, her bed sheets were found soaked with urine. She had wanted to use the bed-pan, she explained, "but it was too hard, cold, arid uncomfortable, "especially with her injured hip.

Because Mr. J. had always been independently ambulatory and continent, the nursing staff was surprised when he needed help changing into dry clothing. On the day his room was changed from the first to the second floor, no one had thought to tell him where the new restroom was.

Mrs. M. knew where the restroom was. But the siderails were up on her bed and it was 15 minutes before her call light was answered.

Numerous environmental factors can literally render a continent person incontinent, because some sort of obstacle -- physical, even emotional -- acts as a barrier between the individual and the toilet.

Unfortunately, research devoted to the subject of environmental incontinence is virtually nonexistent, with the exception of a handful of indirect references. This glaring gap in our understanding of the issue leaves extended, acute, and home health care providers with a number of unanswered questions: What is environmental incontinence? Which of our residents fall into this category? Do our physical surroundings and practices contribute to the incontinence problem? If so, how can they best be manipulated to reduce or even eliminate the problem?

The definition of environmental incontinence has been somewhat muddled by a tendency to lump two distinctive impairments -- cognitive and environmental -- under the general heading of "functional incontinence." The so-called cognitively incontinent individual no longer feels or recognizes the urge to urinate, a situation that requires behavioral or medical interventions directed at the resident himself. The environmentally incontinent individual recognizes that urge and knows what to do about it, but is essentially prevented from doing so by something in his or her surroundings.

Fortunately, environmental incontinence is 100% reversible. But before effective interventions can be matched with the appropriate candidates, the distinctions between these two very different subsets of incontinent elderly residents must be made using a thorough history and evaluation. Once residents are assessed and environmentally incontinent residents identified, attention should then turn to an assessment of the facility and its care practices. In essentially determining whether or not your facility is continence-friendly, the goal is to identify and change factors that may be contributing to incontinence.

There are four broad issues to consider: accessibility, safety, comfort, and privacy. As questions are asked from the following checklists, many considerations will overlap from one category to another, and some will require more investigation than others, but all are important:


* Is there sufficient staff to transport or assist residents to the toilet on all shifts? Do they make themselves available when needed?

* Is the call light answered in a timely fashion? What is considered "timely" by both residents and staff?

* How far is the restroom from the residents' rooms, dining area, activities room, lobby, etc? What is considered an optimal distance for ambulatory and for wheelchair-bound residents? Are residents with private in-room bathrooms less likely to be incontinent than those who must share a community restroom? Are restrooms clearly marked? What is the most recognizable and visible way to do so? Are doors that are marked at eye level for ambulatory residents also visible to those in wheelchairs?

* Are residents shown where the nearest bathrooms are located when in different surroundings (eg, during room changes, daily activities, visits to the dining room, etc.)?

* Are all bathroom facilities barrier-free and easily entered and exited, whether walking or in a wheelchair?

* Do bedrails or restraints prevent residents from toileting independently? If so, are less restrictive safety precautions an option?


* Do ambulatory residents feel secure and sufficiently strong to walk to and from the bathroom?

* Are wheelchairs designed for easy transfer on and off the toilet?

* Are handrails available?

* Is there a call button within easy reach and sight of residents who need assistance. Is that call light answered promptly?

* Are the floors clean and dry?

* Is lighting in residents' rooms, hallways, and restrooms sufficient for both day and nighttime use? What type of lighting source is most effective?


Are the toilet seats themselves comfortable with respect to height, size, temperature and cleanliness?

* Are the seats in good condition: any chips or scratches that might irritate the skin?

* Are toilets or commodes equally comfortable for residents with hip injuries, skin breakdown, arthritis?

* How long are residents left sitting on the toilet? Does the staff member wait outside the door or continue with duties and return according to a predetermined schedule? (This question also relates significantly to the residents' perception of safety.)


* (First described as an accessibility issue.) Is the resident with a private bathroom more likely to be continent than those who share a community restroom? Are residents embarrassed by the need to use the bathroom separated from another resident by only a partition? If so, are they less likely to use the bathroom or more likely to wait until it is empty?

* Is the curtain drawn and the door closed when residents use a bedside commode or bedpan?

* Is the bathroom door easily opened and closed by the resident?

* Do staff members conspicuously wait outside the room when the bathroom is in use?

* Are staff, visitors, and other residents instructed to knock before entering residents' rooms or community restrooms?


The best source of information about existing difficulties and potential solutions to environmental incontinence is the residents themselves. Importantly, the information yielded from this type of assessment may be transferable to acute care settings and to the home for use as an integral part of discharge planning guidelines.

Many of these questions can be addressed with common sense and answered with the help of simple observation. Still others may require formal research. But numerous beneficial changes can be made while we await research-supported conclusions.

Some accessibility problems are more easily solved than others. Staffing shortages and distance between residents' rooms and restrooms may be impossible to improve or, at best, will be addressed as part of a long-range plan for change. There are, however, some simple steps that can be taken with little effort and expense:

* Large block lettering on bathroom doors visible to both ambulatory and wheelchair-bound residents can be easily applied. Residents might be surveyed about the wording and type of signs that are most recognizable.

* Call lights should, of course, be answered as promptly as possible. Use of an intercom system (with residents able to hear and respond) will help to prioritize their need for assistance.

* Residents should be routinely oriented to restroom facilities whenever a room change is made, whether to a different floor or simply down the hall. The same should be done when residents attend activities or meals. Some will need to be reminded on a daily basis.

* In one of the few studies relating to continence and the environment, a daily exercise program consisting of simple assisted ambulation had an impact on mobility, balance and urine control. As a result of assisted ambulation, subjects were able to walk significantly greater distances without tiring. The incidence of daytime incontinence decreased.(1)

Such a program is easily run with the assistance of either nursing or physical therapy assistants. Rather than sitting all day and becoming increasingly frail and fearful of falling, residents who become accustomed to ambulating each day not only become stronger and more adept at walking but also feel safer and more confident in their ability to walk to and from the bathroom. And residents who feel safe traveling to and from the bathroom are much more likely to maintain their toileting independence.

* Accessibility and safety issues may also be addressed with a careful examination of policy with respect to the use of soft restraints. In Vermont, an early state to promote barrier-free extended care, one of the first to achieve this goal was Pleasant Manor Nursing Home. Under the direction of Maggie Saco, DON, this 60-bed level I and II nursing facility installed a six-month barrier-free program in 1990. A decrease in incontinence was noted. Prior to the change, soft restraints were used to prevent falls in residents who were unsteady on their feet and to prevent wandering. The first of these problems was solved with a daily ambulation program (as described above) and the second with wander alarms. Dignity enhancement is, of course, an additional benefit from such a policy.

* The wheelchair issue is a critical one in terms of safety, comfort, and accessibility. Wheelchairs are not one-size-fits-all items. Both stationary chairs and wheelchairs should be individualized for each resident to best facilitate getting in and out of the chair with the least amount of energy. Both the chairs and the residents who use them should be evaluated by the physical or occupational therapist. That therapist should also be responsible for ordering the chair according to the resident's individual needs. Standards exist for heights of wheelchair seats and armrests, but even the standards must be adjusted to accommodate individual body differences.

* Research is required with respect to optimal toilet height and design. Raising the toilet to recommended levels leaves many residents sitting with their feet off the ground, which may decrease their ability to relax for voiding and to use their abdominal muscles for sitting.

* Other safety measures can be taken fairly easily: checking frequently for wet bathroom floors; leaving bathroom and hallway lights on during the night; increasing wattage in dimly-lit areas: installing call lights and handrails and instructing staff to wait within earshot of residents who need assistance getting off the toilet.

* Perhaps the simplest comfort issue to address is that of the cold, hard toilet seat. Padded seats are relatively inexpensive and easy to install. In all cases, however, residents should never be left sitting on the toilet. Staff should be close by to assist them when they are ready to leave the restroom (but, again, should try to avoid being conspicuous about it).

* Privacy issues probably have a critical effect on continence and are frequently overlooked or simply dismissed. A comparative study of incontinence among residents with private bathrooms and those who use community restrooms may shed some light on this issue. But until such a study is conducted, the basic principles of dignity that should be central to the policy and practices of all extended care facilities should provide the guidelines for the care of all residents, continent and incontinent.


1. Jirovec MM, The impact of daily exercise on the mobility, balance and urine control of cognitively impaired nursing home residents. Int J Nursing Studies 1991: 28(2):145-151.

Nancy Faller, RN, BSN, CETN, is employed by Rutland Regional Medical Center, Rutland, VT, where she has served as an ET nurse consultant for extended, acute and home care settings for 20 years. Her direct care experience also includes positions as staff nurse, head nurse, assistant director of nursing, and acting director of nursing at a Vermont pediatric rehabilitation facility. Ms. Faller is co-editor (with Dr. Katherine F. Jeter) of the textbook, Nursing for Continence, and her articles have appeared in numerous publications, including the American Journal of Nursing, Ostomy Wound Management Nursing, Journal of ET Nursing, and World ET Nursing Journal.
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Title Annotation:Special Advertising Section; nursing homes
Author:Faller, Nancy
Publication:Nursing Homes
Date:Mar 1, 1994
Previous Article:What the quality monitors expect of nursing homes.
Next Article:Nighttime incontinence care and sleep: compatible goals.

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