Mr Brian’s case study

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Abstract

The aim of this paper is to present evidence of the effectiveness of the use of behavioural approaches as a successful way of managing urinary incontinence and promoting continence in older people.

Introduction

1.3 million and 4.2 Million people in Australia suffer from faecal and urinary incontinence. This group of people is aged 15 years and above. Even if incontinence is not mainly caused by age, the condition is largely present in people above 65 years old (Delloitte Access Economics, 2011). Nursing care in curbing or preventing incontinence plays a critical role ( Fitzsimons, Bartley & Cornwell, 2011, 18). The nurse’s role is to provide evidence based options for people who are already suffering and to advise people who are at risk of incontinence.

Many people with incontinence are shy to ask for help because the condition has been stigmatised. In most cases, the old people associate the condition to age and accept it as a normal condition. Unfortunately, this should not be the case as incontinence can affect anyone and there are options of overcoming it( Flanagan et al. 2012, 604). As a fact, nurses have a role to play in making it clear to patients that incontinence is not an old age condition and that there are treatments options available.

Nurses cannot ignore the condition due to its high prevalence rate. In every 10 men aged above 70 years, 3 of them have experienced urinary incontinence while 1 has experienced faecal incontinence. For women of the same age, 4 have experience in incontinence and 2 will have experience on faecal incontinence. This is why nurses should assess old people of the condition and advise those who have the condition already. Some of the types of incontinence include urgency, total, functional, and faecal incontinence. There are many ways of treating incontinence including supportive interventions, behavioural managements and continence aids and appliances (Abrams et al. 2009). Of all the treatment methods, behavioural training is one of the most successful methods according to previous research.

Brian’s Condition: Discus the contributing factors to brains continence problems and discus Brian’s main continence issues

Brian is an 82 year old man who is experiencing faecal and urinary incontinences. He lives with his wife who is 80 years old. He started experiencing the condition after undergoing heart surgery five years ago. Around the same time, he experienced a heart failure. In addition, Brian has gone through two knee replacements, coronary artery bypass grafts, ischaemic heart disease, aortic valve replacement, spondylitis, cervical spine fusion, and osteoarthritis. At the moment, he walks on 4 wheel frame and suffers from impaired mobility (Elizabeth & Collins, 2017). Brian suffers from urgency incontinence, functional incontinences and total incontinences.

Urgency incontinence

Brian says that he feels urgency to pass urine and some urine leaks before and after passing urine. Urge incontinence results from a problem with the detrusor muscle. For urine to enter the bladder the muscles relaxes and when one goes to the toilet, it contracts. Unfortunately, some factors cause the muscle to contract too often and the person feels an urgent need to relieve themselves. One of the causes of the sudden contraction is drinking too much caffeine or alcohol (Wyman, Burgio & Newman, 2009, 1180). As for Brian, he takes wine after or before meals in the evenings and 8 cups of coffee every day. He also suffers constipation which is another cause for urge continence. He opens his bowel after 2 or three days and each time he strains and feels some urgency to pass the bowel.

Total incontinence

This happen where the person passes large amounts of urine constantly and it is accompanied by frequent leaking. One of the causes of this incontinence is an injury on the spinal cord. Unfortunately for Brian, he has gone through a cervical spine fusion. As a fact, any injury or interference with the spine can disrupt any nerve signal communication between the bladder and the brain leading to frequent leakages (Burgio et al. 2008, 161-169).

Functional incontinence

This is common in people who have health problems that prevent them from reaching the toilet in good time or to feel the sensation to void. Some of the victims have numerous chronic medical conditions and impaired mobility, cognition, motor processing, physical activity, balance, endurance and nutrition (Bartley, 2012). As for Brian, he has impaired mobility and he uses a 4 heel frame to walk. After experiencing a number of medical interventions in his heart, he can be said to have a chronic heart condition.

Brian needs a quick alternative treatment for incontinence. Since he lives with the wife, she is the only one who helps him. For the time that he has been with the condition, he has relied on disposable pads. However, Brian complains about the cost of the pads. Since Brian is a man, he faces a higher chance of having total and urgency incontinence. Since he has advanced in age his urethra and bladder muscles have weakened and he faces higher chances of involuntary release of urine (Stephens, 2008, 139-141).

Compare through critical analysis, 2 research articles or innovation or initiative that may promote continence in older people

Urinary urgency is having a strong and urgent need to pass urine in which case, you cannot deter passing the urine. As a result, people end up in involuntary loss of urine. There are many strategies employed to deal with incontinence but behavioural methods have been identified as the most effective. The aim of behavioural strategies is to teach patients how to interrupt or inhibit detrusor contraction. Some of the interventions used for behavioural methods include changing how the patient responds to urgency, introducing scheduled voiding, teaching the patient strategies of supressing urges, encouraging patient to delay voiding, and introducing lifestyle changes like advice on fluid management(Burgio & Goode, 2008, 129).

Two research papers; one on “Systematic review of systematic reviews for the management of Urinary incontinence and promotion of continence using conservative behavioural approaches in older people in care homes” and another one on “Efficacy of behavioral training in treating symptoms of urinary urgency and urge urinary incontinence” reveal the importance and effectiveness of using behavioral strategies to promote consistencies. The first paper is by (JACPWH), Journal of the Association of Chartered Physiotherapists in Women’s Health and the second one is by JAN.

The two researches agree that incontinence is common in older people and that it causes a lot of negative effects on the patient. According to the JACPWH research, one lady in the study admitted that they felt embarrassed due to the condition ( Bromley & Cool, 2011, 14-19). The JAN research conducted a study where it found out that there are between 31% -70% prevalence of the condition in care homes for the old(Flanagan et al. 2014, 478). Even with such evidence, the issue that largely trouble many researchers is how to help patient to overcome incontinences.

There are many behavioural interventions including habit retaining, prompted voiding, timed voiding, and bladder training. The JAN report does not seem to identify the need for incontinence pads while the JACPWH research identifies it as an important intervention. Although patients feel shy to wear the pads, they have a positive influence on them as they help them to relate socially with other people. The patients in the study highlighted that incontinences denied them the opportunity to meet with friends, travel and it actually affected the quality of their life. JACPWH however highlights that patients who use incontinence pads are able to live a normal life because they can travel, visit other people without the fear of leaking ( Bromley & Cool, 2011, 14-19).

The pads are a good strategy to employ while patient is in the learning stage of behavioral methods. The quality of life is not affected and they can continue living a normal life. The only negative thing about the pads is the high cost of buying the pads. Some patients find it such a burden and it motivates them to embrace the behavioral training more quickly.

The JACPWH research provides a successful strategy of embracing the behavioral strategy; training the patient on normal and abnormal functions of the bladder. The information helps them to establish healthy bladder habits ( Bromley & Cool, 2011, 14-19). The training is best carried out in care homes or where the patient has someone to help them in terms of moving around or scheduling voiding if they have mobility or memory issues.

The two reports agree that rushing to the toilet worsens incontinences. This is because as the patient rushes, their detrusor contracts and some urine is released involuntarily. Being near the toilet is a visual trigger which increases incontinence. The only way to deal with rushing to the toilet is to teach the patient to practice being calm when they feel an urge to relieve themselves before rushing to the toilet. After they calm down, that is when they should relieve themselves.

The two researches agree that urinary incontinence can lead to stress, depression and morbidity to the caregiver. This is in the cases where the caregiver is not a trained nurse or medical provider (Srikrishna, 2007, 481-486). The inability of the caregiver to provide the needed care leads to ineffectiveness of the intervention and the patient ends up in care homes.

The researches differ on their emphasis on the success of behavior methods as a way of promoting constituencies. The JAN report emphasizes on the success of using prompted voiding together with incontinence pads (Flanagan et al. 2014, 478). On the other hand, JACPWH is keen on the importance of early assessment as an assurance of success in behavioral methods. According to its finding, early assessment combined with behavioral methods and training on how the bladder works motivates the patient to embrace the treatment better.

Synthesis this learning into recommendations for how RNs might improve personal practice and influence the practice of others

The two researches provide very effective ways of dealing with faecal and urinary incontinence. Behavioural training is challenging considering the age groups that suffer from incontinences. People between 15 years and above already have a lifestyle and behaviour training requires altering the lifestyle in major and minor ways to overcome incontinences (Cooper & Koenka, 2012, 450). Registered nurses should look for ways to overcome the challenges facing behavioural training and incontinences to be able to successfully promote consistencies.

The first challenge is the attitude of some patients and RNs towards incontinences. Some patients above 65 years old believe incontinence is a condition for the old. It is unfortunate to notice that some nurses hold the same mind-sets too. Registered nurses who treat incontinences as an old person condition should change their attitude since it is not true. There are some risk factors that place old people at a higher risk of getting incontinences but it is not an old man condition. After they change their attitude, they will be able to convince patients that incontinence is not a permanent condition (Draper, 2014, 2240). As long as nurses and patients agree that incontinence is not a permanent condition, they will work together to finding a solution.

Behavioural training involves changes in lifestyle. As a starting point, the nurses should explain to the patients how the bladder works and the cause of incontinence (Aslan et al. 2008, 225). As long as there is a clear understanding of the condition and how the patients can work together with the nurses to overcome it, the training will be successful.

The RNs should assess people with risk factors for incontinences for the condition so as to start treatment early. As a fact, early detection guarantees successful healing a long as proper support is available. So, early detection combined with proper education on the condition and a change of attitude towards incontinence is an assurance of successful treatment (Fink et al. 2008, 1340). Registered nurses who abide by the three conditions find their practice in promoting constituencies very successful and their colleagues emulate them.

Conclusion

Incontinence is a normal condition so no one should stigmatise it. Nurses have a role in eradicating stigmatization of the condition. They are charged with educating people on the condition and informing them of the available treatments. Behavioural training is one of the most successful treatments. The success of the treatment depends on finding the right behaviour training strategy that suits the patient and working with them until they overcome incontinences.

Reference

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Aslan E., Komurcu N., Beji N.K. & Yalcin O. 2008, Bladder training and Kegel exercises for women with urinary complaints living in a rest home. Gerontology 54, 224–231.

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