Most clients are able to hold their urine and feces until they make it to the bathroom or until a receptacle like a bedpan or a urinal is provided. However, some clients have urinary or fecal incontinence, meaning they have involuntary loss of urine or feces. This is particularly uncomfortable for the client because their clothes and bedsheets get soiled and smell foul. It’s important that you know how to assist them.
TYPES OF URINARY INCONTINENCE
There are several types of urinary incontinence. Urge incontinence is when someone has a sudden urge to urinate followed immediately by involuntary urination. This usually results in frequent urination, especially at night. Urge incontinence can occur after a bladder infection, which can cause the muscle of the bladder to spasm, leading to unintentional urination (Fig. 1a).
Stress incontinence is when urine leaks out when pressure inside the abdomen increases. Often, the problem is a weakened sphincter muscle. When the intra-abdominal pressure increases, like when you sneeze, cough, laugh, or bear down, the pressure inside the bladder also increases, and urine leaks out through the weakened sphincter (Fig. 1b).
Overflow incontinence is when the bladder can’t empty normally, so the urine builds up until it overflows or leaks out. This can be due to a blockage of the urethra caused by a tumor or an enlarged prostate. Weakened muscles in the bladder wall can also cause this type of incontinence because they can’t push all the urine out when voiding. This type of incontinence results in a weak or intermittent urinary stream or hesitancy, where it takes awhile for the urine to begin to flow (Fig. 1c).
Reflex incontinence happens when damage to the nervous system disrupts normal bladder functions. Various conditions, like spinal cord injuries, Parkinson disease, and multiple sclerosis, as well as procedures, such as prostatectomy or hysterectomy, can damage parts of the nervous system involved with the urination reflex. As a result, the bladder can contract on its own without warning, and the urine leaks out without the client feeling the urge to urinate (Fig. 1d).
Figure 1: Four types of urinary incontinence are A. urge incontinence, B. stress incontinence, C. overflow incontinence, and D. reflex incontinence.
INCONTINENCE PADS, BRIEFS, AND BED PROTECTORS
Urinary incontinence can be either temporary or permanent. If the cause can be treated, like a bladder infection, the incontinence will resolve as you treat the cause. However, if the cause is an untreatable disorder, such as dementia, then urinary incontinence is more likely to be permanent. You’ll need to know the different products that are available when helping a client control urinary incontinence. These include incontinence pads, briefs, bed protectors, and catheters. These help keep the client dry and sanitary. At night, make sure they have a bed protector. Remember, pads, briefs and bed protectors have to be changed regularly. Provide them with a washcloth or pre-moistened wipes if they are able to clean themselves; otherwise, you might need to assist in perineal care. Either way, make sure they’re comfortable and dry in order to avoid the development of skin problems, such as rashes.
Figure 2: Products that can help a client control urinary incontinence.
To control urinary incontinence in clients who have penises, condom catheters can be used. They consist of a soft plastic sheath that’s placed over the penis like a condom. Urine flows from the urethra to a tubing and then into a collection bag that’s attached to the client’s leg. Check to see that the condom fits the penis tightly enough to prevent leaks but not so tightly that it obstructs blood circulation. The catheter might have a special material on the inside to secure it to the penis. If it doesn’t, you can use a strip of elastic tape. Make sure to apply the tape in a spiral pattern because a circular pattern is more likely to cut off circulation during an erection. Also, remember that a condom catheter requires daily change and cleaning of the penis and the perineal area.
Figure 3: Appropriate fit for a condom catheter.
Bladder training can help some clients control urinary elimination. During the training, they’ll re-learn how to hold their urine.
Bladder training has multiple components.
- Clients are encouraged to urinate at scheduled times. The training plan depends on the client’s current voiding habits. For example, if they have the urge to go every 30 minutes, the training will gradually increase the time between voiding by 5–10 minutes over a period of days (Fig. 4).
- Clients’ fluid intake should be on a schedule too, like two glasses with each meal and no fluids two hours before sleep.
- Kegel exercises are also taught to help prevent leaks. First, the client experiments to identify the muscles they use to stop the urine flow. Once they know which muscles to contract, they’ll train daily to isolate and strengthen them by repeatedly flexing these muscles in sets of 10–15 three times a day.
- Urge suppression is a technique where clients distract themselves with positive thoughts until the urge passes. Doing kegel exercises during this time can help prevent potential leaks.
- Finally, if they can’t go to the bathroom, clients may use a bedpan or a urinal. Either way, regular emptying of the bladder helps prevent involuntary urination. In addition, by keeping track of urination, they will know when urination is likely to occur and they can go to the bathroom soon enough to avoid accidents.
Figure 4: Bladder training includes encouraging the client to urinate at scheduled times.
When assisting someone with urinary incontinence, you should report the following to the healthcare provider:
- if the client has any new or worsening pain or difficulty urinating
- if the urine is discolored, cloudy, or has an abnormal odor
- if there’s a change from the client’s normal voiding habits, like a change in frequency
Make sure you document:
- the date and time
- anything atypical in the urine or voiding behavior
- the color, quantity, and quality of urine
Fecal incontinence is the involuntary loss of feces from the bowel. Similarly to urinary incontinence, fecal incontinence can be temporary or permanent. Temporary incontinence can occur when a person has severe diarrhea and cannot get to the bathroom in time or if the call light is not answered promptly. Permanent fecal incontinence develops in more chronic disorders, such as dementia.
You can help the client control their bowel movements with bowel training.
- Ask the client to keep track of their bowel movements and offer them the toilet facilities, such as a commode, which resembles a chair with a built-in toilet seat, and a collecting bin, or a bedpan, which is a pan designed to collect body waste from bedridden people (Fig. 5).
- Help the client keep to a schedule. Because eating will stimulate bowel movement, a good daily schedule is 20–40 minutes after a meal.
- Kegel exercises, similar to the ones used for bladder training, can also be helpful, but in this case, they’re focused on strengthening the anal sphincter muscles.
- Biofeedback is a technique where a probe connected to a computer screen can help the client visualize their sphincter muscle contraction.
- For people with constipation, a suppository or enema can help soften the stool.
- Using a lubricated finger to massage the anus in a circular motion can also help relax the sphincter. This can be done daily until normal bowel habits are established.
Figure 5: Bowel training includes asking the client to keep track of their bowel movements and offering them toilet facilities.
When you are assisting a client with fecal incontinence, you should report the following to the healthcare provider:
- if they have any new or worsening pain or difficulty passing feces
- if there’s bleeding from the anus during or after a bowel movement
- if the feces is discolored, has mucus or blood, or is abnormally foul-smelling
- if there’s a change in bowel habits, like diarrhea or constipation
Don’t forget to document:
- the date and time
- anything atypical in the bowel behavior
- the color, quantity, and quality of feces