Functional Urinary Incontinence

Inability of usually continent person to reach toilet in time to avoid unintentional loss of urine

Defining Characteristics: The relationship between functional limitations and urinary incontinence remains controversial (Hunskaar et al, 1999). While functional impairment clearly exacerbates the severity of urinary incontinence, the underlying factors that contribute to these functional limitations themselves contribute to abnormal lower urinary tract function and impaired continence.

Related Factors:

• Cognitive disorders (delirium, dementias, severe or profound retardation); 
• neuromuscular limitations impairing mobility or dexterity; 
• impaired vision; 
• psychological factors; 
• weakened supporting pelvic structures; 
• environmental barriers to toileting.

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

• Urinary Continence
• Urinary Elimination

Client Outcomes

• Eliminates or reduces incontinent episodes
• Eliminates or overcomes environmental barriers to toileting
• Uses adaptive equipment to reduce or eliminate incontinence related to impaired mobility or dexterity
• Uses portable urinary collection devices or urine containment devices when access to the toilet is not feasible

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

• Urinary Incontinence Care

Nursing Interventions and Rationales

1. Perform a focused history of the incontinence including duration, frequency and severity of leakage episodes, and alleviating and aggravating factors.
The history provides clues to the causes, the severity of the condition, and its management.

2. Complete a bladder log of diurnal and nocturnal urine elimination patterns and patterns of urinary leakage.
The bladder log provides a more objective verification of urine elimination patterns as compared with the history (Resnick et al, 1994) and a baseline against which the results of management can be evaluated.

3. Assess client for potentially reversible causes of acute/transient urinary incontinence (e.g., urinary tract infection [UTI], atrophic urethritis, constipation or impaction, sedatives or narcotics interfering with the ability to reach the toilet in a timely fashion, antidepressants or psychotropic medications interfering with efficient detrusor contractions, parasympatholytics, alpha adrenergic antagonists, polyuria caused by uncontrolled diabetes mellitus, or insipidus).
Transient or acute incontinence can be eliminated by reversing the underlying cause (Urinary Incontinence Guideline Panel, 1996).

4. Assess client for established/chronic incontinence: stress urinary incontinence, urge urinary incontinence, reflex, or extraurethral ("total") urinary incontinence. If present, begin treatment for these forms of urine loss.
Functional incontinence often coexists with another form of urinary leakage, particularly among the elderly (Gray, 1992).

5. Assess the home, acute care, or long-term care environment for accessibility to toileting facilities, paying particular attention to the following:

• Distance of toilet from bed, chair, living quarters
• Characteristics of the bed, including presence of side rails and distance of bed from the floor
• Characteristics of the pathway to the toilet, including barriers such as stairs, loose rugs on the floor, and inadequate lighting
• Characteristics of the bathroom, including patterns of use; lighting; height of toilet from floor; presence of hand rails to assist transfers to toilet; and breadth of door and its accessibility for wheelchair, walker, or other assistive device

Functional continence requires access to the toilet; environmental barriers blocking this access can produce functional incontinence (Wells, 1992).

6. Assess client for mobility, including ability to rise from chair and bed; ability to transfer to toilet and ambulate; and need for physical assistive devices such as a cane, walker, or wheel chair.
Functional continence requires the ability to gain access to a toilet facility, either independently or with the assistance of devices to increase mobility (Jirovec, Wells, 1990; Wells, 1992).

7. Assess client for dexterity, including the ability to manipulate buttons, hooks, snaps, Velcro, and zippers needed to remove clothing. Consult physical or occupational therapist to promote optimal toilet access as indicated.
Functional continence requires the ability to remove clothing to urinate (Maloney, Cafiero, 1999; Wells, 1992).

8. Evaluate cognitive status with a NEECHAM confusion scale (Neelan et al, 1992) for acute cognitive changes, a Folstein Mini-Mental Status Examination (Folstein, Folstein, McHugh, 1975), or other tool as indicated.
Functional continence requires sufficient mental acuity to respond to sensory input from a filling urinary bladder by locating the toilet, moving to it, and emptying the bladder (Maloney, Cafiero, 1999; Colling et al, 1992).

9. Remove environmental barriers to toileting in the acute care, long-term care or home setting. Help the client remove loose rugs from the floor and improve lighting in hallways and bathrooms.

10. Provide an appropriate, safe urinary receptacle such as a 3-in-1 commode, female or male hand-held urinal, no-spill urinal, or containment device when toileting access is limited by immobility or environmental barriers.
These receptacles provide access to a substitute toilet and enhance the potential for functional continence (Rabin, 1998; Wells, 1992).

11. Assist the client with limited mobility to obtain evaluation for a physical therapist and to obtain assistive devices as indicated (Maloney, Cafiero, 1999); assist the client to select shoes with a nonskid sole to maximize traction when arising from a chair and transferring to the toilet.

12. Assist the person to alter their wardrobe to maximize toileting access. Select loose-fitting clothing with stretch waist bands rather than buttoned or zippered waist; minimize buttons, snaps, and multilayered clothing; and substitute Velcro or other easily loosened systems for buttons, hooks, and zippers in existing clothing.

13. Begin a prompted voiding program or patterned urge response toileting program for the elderly client with functional incontinence and dementia in the home or long-term care facility:

• Determine the frequency of current urination using an alarm system or check and change device
• Record urinary elimination and incontinent patterns on a bladder log to use as a baseline for assessment and evaluation of treatment efficacy
• Begin a prompted toileting program based on the results of this program; toileting frequency may vary from every 1.5 to 2 hours, to every 4 hours
• Praise the client when toileting occurs with prompting
• Refrain from any socialization when incontinent episodes occur; change the client and make her or him comfortable 

Prompted voiding or patterned urge response toileting have been shown to markedly reduce or eliminate functional incontinence in selected clients in the long-term care facility and in the community setting (Colling et al, 1992; Eustice, Roe, Patterson, 2000).
Geriatric

1. Institute aggressive continence management programs for the community-dwelling client in consultation with the patient and family.
Uncontrolled incontinence can lead to institutionalization in an elderly person who prefers to remain in a home care setting (O'Donnell et al, 1992).

2. Monitor elderly clients for dehydration in the long-term care facility, acute care facility, or home. Dehydration can exacerbate urine loss, produce acute confusion, and increase the risk of morbidity and morality, particularly in the frail elderly client (Colling, Owen, McCreedy, 1994).

Home Care Interventions

1. Assess current strategies used to reduce urinary incontinence, including fluid intake, restriction of bladder irritants, prompted or scheduled toileting, and use of containment devices.
Many elders and care providers use a variety of self-management techniques to manage urinary incontinence such as fluid limitation, avoidance of social contacts, and absorptive materials that may or may not be effective for reducing urinary leakage or beneficial to general health (Johnson et al, 2000).

2. Teach the family general principles of bladder health, including avoidance of bladder irritants, adequate fluid intake, and a routine schedule of toileting (refer to care plan for Impaired Urinary elimination).

3. Teach prompted voiding to the family and patient with mild to moderate dementia (refer to previous description) (Colling, 1996; McDowell et al, 1994).

4. Advise the patient about the advantages of using disposable or reusable insert pads, pad-pant systems, or replacement briefs specifically designed for urinary incontinence (or double urinary and fecal incontinence) as indicated. Many absorptive products used by community-dwelling elders are not designed to absorb urine, prevent odor, and protect the perineal skin. Substitution of disposable or reusable absorptive devices specifically designed to contain urine or double incontinence are more effective than household products, particularly in moderate to severe cases (Shirran, Brazelli, 2000; Gallo, Staskin, 1997).

5. Assist the family with arranging care in a way that allows the patient to participate in family or favorite activities without embarrassment. Careful planning can retain the dignity and integrity of family patterns.

6. Teach principles of perineal skin care, including routine cleansing following incontinent episodes, daily cleaning and drying of perineal skin, and use of moisture barriers as indicated. Routine cleansing and daily cleaning with appropriate products help maintain integrity of perineal skin and prevent secondary cutaneous infections (Fiers, Thayer, 2000).

7. Refer to occupational therapy for help in obtaining assistive devices and adapting the home for optimal toilet accessibility.

8. Consider use of an indwelling catheter for continuous drainage in the patient who is both homebound and bed-bound and receiving palliative or end of life care (requires physician order). An indwelling catheter may increase patient comfort, ease care provider burden, and prevent urinary incontinence in bed-bound patients receiving end of life care.

9. When an indwelling catheter is in place, follow prescribed maintenance protocols for managing the catheter, drainage bag, perineal skin, and urethral meatus. Teach infection control measures adapted to the home care setting. Proper care reduces the risk of catheter-associated UTI.

Client/Family Teaching

1. Work with the client, family, and their extended support systems to assist with needed changes in the environment and wardrobe and other alterations needed to maximize toileting access.

2. Work with the client and family to establish a reasonable, manageable prompted voiding program using environmental and verbal cues, such as television programs, meals, and bedtime, to remind caregivers of voiding intervals.

3. Teach the family to use an alarm system for toileting or to perform a check and change program and to maintain an accurate log of voiding and incontinent episodes.