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Incontinence and Constipation

Incontinence and Constipation

LEARNING OBJECTIVES
A participant in this lesson will be able to:
• Know the causes of common urinary and bowel elimination problems
• Be able to state the best ways to help patients with these problems
• Understand various behavioral, nutritional, and care interventions for urinary and bowel incontinence and
constipation

What Causes Urinary Incontinence?

People who cannot control when or where they urinate suffer from urinary incontinence (UI). There are things that can be done to improve this condition, but it is important to know what the cause is so the right care and treatment can be given. This condition is not the person’s fault, and it is not necessary or normal part of growing older. It is not caused by laziness or meanness. UI is a health problem with a number of possible causes. Some of the most common causes include:
• Urinary tract infections (UTI)
• Confusion and forgetfulness
• Muscle weakness
• Vaginal problems (in women)
• Prostate problems (in men)
• Medication reactions
• Problems with clothing
• Trouble getting to the bathroom
• Constipation

What Are the Symptoms of Urinary Incontinence?

Any patient who ever wets the bed leaks urine on the way to the bathroom, or has to use protective pads or padded briefs is suffering from UI. If you notice a patient, a bed, or a room that has urine stains or a urine odor, then you know the patient needs help with this condition. However, you probably don’t know what kind of UI the patient has. You can often determine this by watching the patient closely and keeping track of his or her urinating habits on a bladder record. There is an example included with this learning guide. It shows regular daily habits as well as accidents. Keeping a bladder record is an excellent way to get information about a patient’s UI so ways can be found to treat it.

There are three different types of UI:
1. Urge incontinence. With this type, people may leak urine on their way to the bathroom, after they drink just a little bit of liquid, or as soon as they feel the urge to go.
2. Stress incontinence may cause urine to leak when people sneeze, cough, or laugh or when they exercise or move a certain way (getting out of bed, up from a chair, walking, lifting). This is common in women.
3. Overflow incontinence causes people to feel they need to urinate again right after going, to feel as though they never totally empty the bladder, or to pass small amounts of urine without feeling any need to go. It may be a sign of prostate problems in men.

What Can You Do to Help a Patient With Urinary Incontinence?

Your first responsibility is to report UI to your supervisor, the agency nurse, or the patient’s doctor. A doctor or nurse should check a patient with UI, and your observations about the patient, such as a bladder record, will help them determine the cause and type of UI.

The three treatments for UI are:
1. Medicine.
2. Surgery.
3. Behavioral treatments. These help people control their urine and use the toilet at the right time. They work well for patients who have problems getting to the bathroom or are not able to tell you when they need to urinate. We will discuss three behavioral treatments for UI that you can assist with:
• Scheduled toileting
• Prompted voiding
• Habit training

Scheduled toileting
Use scheduled toileting for patients who can’t get out of bed or can’t get to the bathroom alone. To do this treatment, assist the patient to the bathroom every two to four hours on a regular schedule.

Prompted voiding
Use prompted voiding for patients who know when they have a full bladder but do not ask to go to the bathroom. To do this treatment:
1. Check the patient often for wetness.
2. Ask, “Do you want to use the toilet?”
3. Help the patient to the toilet.
4. Praise the patient for being dry.
5. Tell the patient when you will come back to take him or her to the bathroom again.

Habit training
Use habit training for patients that tend to urinate at about the same time every day. To do this:
• Watch the patient find what times he or she urinates. A bladder record can help you do this.
• Take the patient to the bathroom at those times every day.
• Praise the patient for being dry and using the toilet.

For all behavioral treatments, remember the following things
• Be patient. These treatments take time.
• Treat the patient as an adult.
• Do not rush the patient.
• Give the patient plenty of time to completely empty his or her bladder.
• Give privacy by closing the door, even if you must stay in the bathroom.
• Never yell or be angry with the patient if he or she is wet. Say, “You can try again next time.”
• Respect dignity and confidentiality.

Other ways to help patients with urinary incontinence
• Pelvic exercises can make muscles around the bladder stronger and help with UI. These are called Kegel exercises, and to do them the person tightens the pelvic muscles that stop and start the flow of urine.
The muscles should be squeezed tightly for a few seconds and then released, up to 10 times at one sitting, four times every day. Then, whenever the person feels that urine might leak, he or she tightens those same muscles and prevents urine from leaking.
• People that can’t get out of bed or can’t get to the bathroom for some reason may need to use a bedpan, urinal, or bedside commode. These articles, if needed, should be kept by the bed.
• If a patient uses a wheelchair, walker, or cane to get to the bathroom, you can help by keeping the item near the bed, keeping the path to the bathroom clear and well lit, and answering calls for assistance as soon as possible.
• Encourage the patient to wear clothes that are easy to remove and have simple fasteners.
• If a patient needs to wear special pads or clothing to help keep the skin dry, they should be changed often. Use soft pads and clothing, keep them wrinkle-free, keep the skin clean and dry, and use protective skin creams if allowed. Remember that wet skin can develop sores and rashes.
• If the patient wets the bed at night, it might be helpful to restrict evening liquids, but you should only do this if a doctor or nurse orders it. This is usually done three hours before bedtime. The patient should use the bathroom just before going to bed.
• Some patients need to use a urinary catheter, which is a tube inserted into the bladder by a doctor or nurse. It drains urine into a bag. Sometimes men use a condom catheter that fits over the penis. Catheters can cause infections, and condom catheters that are too tight can be harmful. Catheters should be checked often. They are not recommended for most incontinence problems.

What Causes Bowel Incontinence?

People who cannot control when or where they pass gas or stool suffer from bowel incontinence. There are things that can be done to improve this condition, but it is important to know what the cause is so the right care and treatment can be given. This condition is not the person’s fault, and it is not a necessary part of growing older. It is a health problem that is not caused by laziness or bad behavior.
Some of the most common causes include:
• Incorrect diet or fluid intake
• Confusion and forgetfulness
• Muscle injury or weakness (the anal muscles)
• Nerve injury
• Medication reactions or laxative abuse
• Trouble getting to the bathroom
• Constipation or impaction
• Diarrhea

What can you do to help a patient with bowel incontinence?
Your first responsibility is to report episodes of bowel incontinence to your supervisor, the nurse, or the patient’s doctor. A doctor or nurse should check the patient, and your observations may help them determine the cause of the problem. Treatments for bowel incontinence include:
• Medicine
• Surgery
• Dietary management
• Bowel management and retraining, with the establishment of a habit regimen
• Biofeedback

Two of these treatments involve the care you provide: diet management and bowel retraining. These treatments are the same as those used to help people with constipation, so we will discuss the treatments together after examining the issue of constipation.

What causes constipation?
People usually say they are constipated when they are having infrequent bowel movements, but constipation is also used to refer to a sense of bloating or intestinal fullness, a decrease in the amount of stool, the need to strain to have a bowel movement, or the need to use laxatives, suppositories, or enemas to maintain regular bowel movements. It is normal for most people to have bowel movements anywhere from three times per day to three times per week, but some people may go a week or longer without discomfort or harmful
effects. Many things can cause constipation, but the most common causes include:
• Inadequate fiber and fluid intake
• Inactivity or a sedentary lifestyle
• Change in routine
• Abnormal growths or diseases
• Damaged or injured muscles (sometimes from repeatedly ignoring the urge to go)
• Medication side effects and laxative abuse (it is not necessary to have a bowel movement every day)

Constipation may be diagnosed if movements occur fewer than three times weekly on an ongoing basis.

What can you do to help a patient with constipation?

Your first responsibility is to report a patient’s constipation problems to your supervisor, the nurse, or the patient’s doctor. A doctor or nurse should check the patient, and your observations may help them determine the cause of the problem. Treatments for constipation include:
1. Medicine
2. Surgery
3. Dietary management
4. Bowel management and retraining, with the establishment of a habit regimen

Two of these treatments involve the care you provide: diet management and bowel retraining. These treatments are the same as those used to help people with bowel incontinence. We will discuss them now.

Dietary management for urinary incontinence
While there is no dietary treatment for urinary incontinence, some foods and drinks can irritate the bladder, such as sugar, chocolate, citrus fruits (oranges, grapefruits, lemons, limes), alcohol, grape juice, and caffeinated drinks like coffee, tea, and cola. Patients with UI could try eliminating these foods and beverages from their diet and determine whether the condition improves.

Dietary management for bowel incontinence and constipation
The average American diet contains 10 to 15 grams of fiber per day. The amount of fiber recommended for good bowel function is 25 to 30 grams of fiber per day, plus 60 to 80 ounces of fluid. Look at the table below to get an idea of the fiber we get in different foods. Most people can successfully treat their bowel irregularities, both incontinence, and constipation, by adding high-fiber foods to their diets, along with increased fluid intake to desired levels. Increase dietary fiber slowly to give the bowel time to adjust.

Bowel Retraining for Bowel Incontinence and Constipation

Food sensitivities
Some people are sensitive to, or even allergic to, certain foods that cause them constipation or diarrhea. Dairy products such as milk and cheese, wheat products such as bread, and foods containing chocolate are some of the more common problem foods. A physician should evaluate a patient who seems to have particular food sensitivities.

Habit training
Habit training means designating a specific time each day to have a bowel movement. Keep a record of the patient’s bowel habits, just as you do with a bladder record. If a pattern develops, that pattern can be used to set up a habit regimen that will reinforce a scheduled time each day to have a bowel movement. If no pattern can be seen in the patient’s bowel activities, then a regimen can be established by selecting a convenient time each day, or even three times per day in the case of someone with bowel incontinence, for the patient to try to have a bowel movement. Be sure to help the patient stick with this schedule, even when he or she does not feel the need to go. Over time, the body will develop a habit that conforms to the scheduled routine.

Exercises
The Kegel exercises that are used to prevent urinary incontinence can be slightly modified to strengthen the anal muscles that control the outflow of stool. To do them, the person tightens the muscles around the rectum. The muscles should be squeezed tightly for a few seconds and then released, up to 10 times at one sitting, four times every day.