Care stud y
Promoting continence following head injury Rachel Williams, Ysbyty Gwynedd, Bangor
Care study Jim, a 61-year-old sea captain, was knocked down by a car while away from home. He sustained a severe head injury and a skull fracture, extending from the temporal region down to the base. He also suffered multiple injuries: a fractured jaw bone, fractured ribs, bilateral fractures of tibia and fibula and collapsed lungs. He was critically ill for a few months, after which he made a satisfactory recovery and was transferred to a hospital nearer his home under the care of the orthopaedic team. Jim has a supportive partner who was at his bedside the whole time. She is extremely dedicated to him. This care study will cover the 3-week period during which Jim was on my ward following the hospital transfer.
H
ead injuries are a growing problem due to the increasing number of road traffic accidents. In severe cases, rehabilita tion is a slow process and many problems may arise. One such problem is inconti nence. Continence is controlled by the long nerve pathways which become vulnerable when disease or trauma affects the nervous system. Damage to these nerve pathways at any point between the cortical bladder centre and the bladder impairs continence. In Jim ’s case, the cortical bladder centre which controls micturition may have been damaged following his head injury. The damage impairs the ability to inhibit the sa cral reflex arc efficiently. When the individ ual is conscious, bladder sensation is retain ed so that urgency is felt, but when the allimportant inhibiting signal is weak or ab sent, urgency and urge incontinence may result.
Nursing management
Ms Williams is Staff Nurse on the Trauma/Orthopaedic Unit, Ysbyty Gwynedd, Penrhoseamedd, Bangor, Gwynedd
236
Following the accident Jim was incontinent and an indwelling catheter had been in serted to enable the medical team to moni tor his urinary output. Initially, faecal in continence was a problem but once Jim re gained consciousness this situation im proved. The catheter had been a short-term answer, the intention being to remove it as his rehabilitation programme progressed so
that Jim could regain bladder control, in crease independence and eliminate the risk of urinary tract infections. The urinary catheter was removed at 06.00 hours on the morning after admission to my ward. This was common practice at the time; however, Noble et al (1990) have since shown that a policy of catheter re moval at midnight is more advantageous to both urological and nursing management. Following catheter removal, Jim appeared to have no bladder control at all and was incontinent of large volumes of urine. He also had an excessive thirst. Head-injured patients can suffer from diabetes insipidus because of lack of antidiuretic hormone; fluid restriction was therefore commenced. Jim ’s incontinence was the biggest prob lem arising from his injuries. He would pass urine in inappropriate places, e.g. on the floor and into his slippers. He felt no blad der sensation and the communication prob lems following the head injury exacerbated the situation. Depending on the area of the brain involved, communication problems can ensue as a result of the trauma (Table
!)■ I commenced a programme of care that would help promote continence. Norton (1986) states that nurses must view inconti nence as a nursing challenge rather than a problem to be tolerated. I might also add that the solution is not simply a case of pro viding pads. The causes of incontinence and the factors that influence bladder function and the ability to cope with bladder de mands are shown in Table 2.
Assessment Initial assessment of the patient is essential. It is important to take a history of present ing incontinence problems and consider the following: past medical history, mobility, psychological state, social network, envi ronment and the physical examination. In addition, the symptoms must be assessed as these may suggest the likely cause and type of incontinence. A score card, similar in design to the Norton Score, can be used. It helps nurses
British Journal of Nursing, 1992,Voi l,N o 5 Downloaded from magonlinelibrary.com by 130.237.122.245 on January 14, 2019.
Promoting continence following head injury
‘The rectum was empty and there were no signs o f an enlarged prostate gland. This confirmed that Jim did not have overflow incontinence. }
Table I. Communication problems
Table 2. Causes and influences of incontinence
Verbal:
Main causes of incontinence
Auditory:
Memory:
Difficulty in forming and organizing intelligible words, although the musculature to do so remains intact, due to damage to frontal lobe of left hemisphere.
Physiological bladder dysfunction Detrusor instability Stress incontinence Outflow obstruction Atonic bladder
Inability to recognize differences between words and between sounds due to damage to temporal lobe. Post-traumatic amnesia: memory loss for a period of time; unable to recall events prior to injury.
Immobility Environment Mental function Emotions Carers
frustrated and sudden mood changes. Can be meaningless. Dysphasia.
Other:
May have writing difficulties. Understanding impaired.
a hospital inpatient as he was normally fit. Fluid intake and diet Jim enjoyed most drinks. He drank jugs of water daily and enjoyed a healthy diet.
to assess and identify their patients’ prob lems. The score obtained determines whether or not continence is possible. The important goal of planned care should be the promotion of continence rather than the management of incontinence. Jim ’s assess ment score showed that he had a good chance of becoming continent. Jim suffered from urgency of micturition, the warning time between the first sensa tion of bladder filling and the need to empty having been curtailed. Urge inconti nence occurred because Jim was unable to get to the toilet/urinal in time; passive in continence was also prevalent. Jim also had nocturnal enuresis and occasionally nocturia (Table 3). At this stage it was impossible to make a reliable diagnosis based on the history of the symptoms alone. However, symptoms provide clues and Jim ’s problem had not altered: he was being incontinent up to 10 times in 24 hours. An ‘all-in-one’ garment was used at night, i.e. an adult-sized napkin able to absorb 1700 ml of urine without harming the skin, the aim being to contain the amount of urine passed at night. Past medical history Before this admission Jim had never been British Journal of Nursing, 1992, Vol l,N o5
Urinary tract infection Faecal impaction Drug therapy Endocrine disorder Bladder pathology
Factors affecting ability to cope with bladder demands
Behavioural Aggression, impatience, problems: short temper, quickly
Speech:
Factors influencing bladder function
Mobility Jim had external fixations to both lower legs. He was lifted out into the chair using the Australian technique. He needed help to use the commode but was able to use the urinal. Physical examination Jim ’s bladder was not palpable. A mid stream specimen of urine was sent to the laboratory for culture and sensitivity. A normal result was returned. A rectal examination was performed by the doctor. The rectum was empty and there were no signs of an enlarged prostate gland. This confirmed that Jim did not have overflow incontinence. A simple in-out catheter was passed by the doctor to observe for post-micturition residual volume. This test was negative, which showed that Jim emptied his bladder completely — a volume of about 100 ml is normally significant.
Charting Norton (1986) states: ‘The chart is prob ably the single most useful nursing tool in assessing continence. At the same time it is often also the most misused.’ The chart acts as a record and, in conjunction with
237
Downloaded from magonlinelibrary.com by 130.237.122.245 on January 14, 2019.
Promoting continence following head injury cFor urge incontinence, goals are set in an attempt to retrain the unstable bladder. It is termed unstable as there are involuntary bladder contractions during filling. 5
Table 3. Problems relating to
necessary expertise, but medical support and interest ensure that a more accurate di agnosis is made.
micturition Urinary incontinence following removal of catheter
Results of charting When the assessment was complete, the chart was studied. Jim appeared to be drinking 5 litres of fluid per 24 hours which had caused his urinary output to increase. He was not interested in using a urinal. He was ‘dry’ for periods that varied between 2 and 9 hours per day. It was rather ‘hit and miss’ but a pattern was emerging. The most likely bladder dysfunction was urge incontinence and there was also thought to be trauma to the micturition centre.
Urgency (having to hurry to pass urine) Urge incontinence (unable to get to the toilet in time) Passive incontinence (being unaware of it happening) Nocturnal enuresis (bedwetting while asleep) Nocturia (waking at night to pass urine) Polyuria (excessive increase in urine output)
Care plan and goals other findings, aids diagnosis and care plan ning. Chart one The chart used on my ward is designed by Coloplast Ltd. Initially a baseline chart was kept for a week. Its format is kept simple so that less information needs to be record ed, thus increasing the chance of accuracy. Although it is preferable for the patient to complete his/her own chart, in Jim ’s case this was not possible. All urine needs to be measured. Jim was checked hourly and if he was wet it was recorded that he was ‘damp’ or ‘soaking’. This gives a rough estimate of the volume of urine passed. A fluid balance chart, monitoring and recording fluid intake and urinary output, was also maintained. Continence assessment checklist There are various assessment checklists but the one chosen was that of Norton (1986). The check was carried out at the end of the first week of charting. Jim was assessed using the activities of daily living, giving most attention to his incontinence problem. The checklists were completed in two sessions so that Jim would not lose interest and concentration. The questions were simple and confusing terminology was avoided. Jim was involved as much as poss ible but because of his communication diffi culties, most of the information was obtain ed from medical and nursing records and general observation. Ideally, joint nursing and medical assessments should be made. However, as Norton (1986) states: ‘We do not live in an ideal world and often nursing and medical assessments are made indepen dently with little liaison.’ Nurses have the British Journal ol Nursing, 1992, Vol I, No 5
For urge incontinence, goals are set in an attempt to retrain the unstable bladder. It is termed unstable as there are involuntary bladder contractions during filling (Ferrie et al, 1984). The usual care is to set goals for the patient to ‘hang-on’ for 5 minutes before passing urine. The time is then in creased over a number of weeks until the patient is able to hang-on for 3 hours. This goal was totally unrealistic in Jim ’s case. Chart two A second chart was then commenced, the special instructions being that a urinal was to be offered at set times taking into ac count the amount Jim had been incontinent in the first week. It was a case of catch and contain. Fluid intake was restricted to 2 litres in 24 hours as his previous high in take may well have contributed to the prob lem. Fluid restriction is not usually the answer as it can aggravate the problem. However, this amount of fluid is a satisfac tory intake. Medical intervention The medical team was involved and Micturin (terodiline) 125 mg twice daily was prescribed. This is an anticholinergic calcium antagonist which relaxes the detrusor muscle of the bladder and is used in patients with urge incontinence and detrusor instability. Jim was observed for the side effects of a dry mouth and blurred vision. Micturin has recently been with drawn from use as it causes cardiac prob lems in the elderly. Fluid restriction posed a problem. I men tioned to the medical team that Jim could be suffering from diabetes insipidus, a defi ciency of antidiuretic hormone most com monly due to hypoactivity or destruction
239
Downloaded from magonlinelibrary.com by 130.237.122.245 on January 14, 2019.
Promoting continence following head injury
of part of the hypothalamic-neuro hypophyseal system resulting from primary or metastatic neoplasms or infection. In some instances no apparent cause can be identified (Watson, 1979). The doctors were not convinced as the urinary output was not excessive. Nursing intervention The care for Jim’s nocturnal enuresis re mained the same. Regular skin care was performed to prevent soreness. Jim had an excessive thirst and the jug was kept out of his reach. He was given a drink at set times but, on a few occasions, was found drinking the flower water out of the vase and also trying to drink out of the tap at the washbasin. By the end of the second week there was some improvement. He passed urine be tween the set times but sometimes used the urinal. Nocturnal enuresis became less of a problem and so did the urine output in general. 1 wondered whether the improve ment was due to the medication although it usually takes about 2 weeks to take effect. Chart 3 A third chart was commenced and the set toiletting times were slightly altered. Blad der retraining is most successful for patients who are motivated. Unfortunately, Jim was not and the establishment of ‘ideal’ individ ualized toiletting times was probably going to take several weeks.
KEY POINTS • Assessment and identification of related problems are crucial In the management of incontinence and the promotion of continence. • Assessment checklists and regular recording of incontinence using appropriate charts (toilet charting) help the nurse to diagnose the problems. • It is not sufficient just to identify incontinence as the problem; assessment should be much more specific, e.g. identifying problems such as nocturia, nocturnal enuresis, urgency, urge incontinence and polyuria. • Planning and implementing care should always promote the optimum level of continence as its final ideal goal. Appropriate and adequate management of any specific aspect/type of incontinence should be considered only if the ideal goal is unachievable. • The tools and charts used for assessment are also useful in evaluating the effectiveness of care. • Incontinence aids should be chosen only after careful assessment and should be used to lessen the specific problem and help promote continence. They should not be used to encourage continuing incontinence.
240
The sheath system The sheath system was implemented so that the urine passed at night could be contain ed. Sheaths are designed to collect urine that is voided from the penis and store it in a collection bag until it can be conveni ently emptied. The correct sizing of the pa tient is essential as complications can other wise occur (Playford, 1987). The ward stock was limited and so I contacted the health authority’s continence adviser who provided me with a measuring guide and a variety of different sized sheaths. Seth (1987) mentions that penile manage ment has advanced dramatically in recent years, the most up-to-date design being the one-piece sheath. Jim soon became accus tomed to the sheath; there were few prob lems initially, but these were soon solved.
Evaluation At the end of the third week, Jim was pass ing urine at the set times. His fluid intake and output were satisfactory and his excess ive thirst had subsided. I shall never know whether he had suffered from diabetes insipidus. He no longer wet the floorbut still pass ed urine in inappropriate places. Jim ’s medication was continued without any evi dence of side effects. His mobility was improving rapidly. There were slight problems at night as he would wake up wanting to pass urine, re move the sheath and be incontinent while trying to find the urinal in the dark. He was tried for a period without the sheath and this appeared to improve matters. Three weeks was insufficient time to solve the problem completely. While I feel that I helped him a great deal, there was room for improvement. However, the care needs to be ongoing, so plans were made for Jim to be transferred to a cottage hospi tal nearer his home and partner. The author would like to thank E Hugheston-Roberts, Lecturer in Nursing, and Ruhi Behi, Director, Post Registration Studies, School of Nursing and Midwifery Studies, UCNW, Bangor, for their help in writing this article. Ferrie BG et al (1984) Experience with bladder training with sixty-five patients. Br ] Urol 56: 482-4 Noble JG et al (1990) Midnight removal: an improved approach to removal of catheters. Br J Urol 65: 615-7 Norton C (1986) Nursing for Continence. Beaconsfield Publishers, England Playford V (1987) Management of male incontinence using a sheath. Prof Nurs 2: 227-8 Seth C (¡987) Male incontinence. Community Outlook (Suppl) Nurs Times 83(5): 20-21 Watson JF (1979) Medical-Surgical Nursing and Relat ed Physiology, 2nd edn. WB Saunders, London: 756
British Journal of Nursing. 1992. Voi l.N o5 Downloaded from magonlinelibrary.com by 130.237.122.245 on January 14, 2019.
Promoting continence following head injury Rachel Williams, Ysbyty Gwynedd, Bangor
Care study Jim, a 61-year-old sea captain, was knocked down by a car while away from home. He sustained a severe head injury and a skull fracture, extending from the temporal region down to the base. He also suffered multiple injuries: a fractured jaw bone, fractured ribs, bilateral fractures of tibia and fibula and collapsed lungs. He was critically ill for a few months, after which he made a satisfactory recovery and was transferred to a hospital nearer his home under the care of the orthopaedic team. Jim has a supportive partner who was at his bedside the whole time. She is extremely dedicated to him. This care study will cover the 3-week period during which Jim was on my ward following the hospital transfer.
H
ead injuries are a growing problem due to the increasing number of road traffic accidents. In severe cases, rehabilita tion is a slow process and many problems may arise. One such problem is inconti nence. Continence is controlled by the long nerve pathways which become vulnerable when disease or trauma affects the nervous system. Damage to these nerve pathways at any point between the cortical bladder centre and the bladder impairs continence. In Jim ’s case, the cortical bladder centre which controls micturition may have been damaged following his head injury. The damage impairs the ability to inhibit the sa cral reflex arc efficiently. When the individ ual is conscious, bladder sensation is retain ed so that urgency is felt, but when the allimportant inhibiting signal is weak or ab sent, urgency and urge incontinence may result.
Nursing management
Ms Williams is Staff Nurse on the Trauma/Orthopaedic Unit, Ysbyty Gwynedd, Penrhoseamedd, Bangor, Gwynedd
236
Following the accident Jim was incontinent and an indwelling catheter had been in serted to enable the medical team to moni tor his urinary output. Initially, faecal in continence was a problem but once Jim re gained consciousness this situation im proved. The catheter had been a short-term answer, the intention being to remove it as his rehabilitation programme progressed so
that Jim could regain bladder control, in crease independence and eliminate the risk of urinary tract infections. The urinary catheter was removed at 06.00 hours on the morning after admission to my ward. This was common practice at the time; however, Noble et al (1990) have since shown that a policy of catheter re moval at midnight is more advantageous to both urological and nursing management. Following catheter removal, Jim appeared to have no bladder control at all and was incontinent of large volumes of urine. He also had an excessive thirst. Head-injured patients can suffer from diabetes insipidus because of lack of antidiuretic hormone; fluid restriction was therefore commenced. Jim ’s incontinence was the biggest prob lem arising from his injuries. He would pass urine in inappropriate places, e.g. on the floor and into his slippers. He felt no blad der sensation and the communication prob lems following the head injury exacerbated the situation. Depending on the area of the brain involved, communication problems can ensue as a result of the trauma (Table
!)■ I commenced a programme of care that would help promote continence. Norton (1986) states that nurses must view inconti nence as a nursing challenge rather than a problem to be tolerated. I might also add that the solution is not simply a case of pro viding pads. The causes of incontinence and the factors that influence bladder function and the ability to cope with bladder de mands are shown in Table 2.
Assessment Initial assessment of the patient is essential. It is important to take a history of present ing incontinence problems and consider the following: past medical history, mobility, psychological state, social network, envi ronment and the physical examination. In addition, the symptoms must be assessed as these may suggest the likely cause and type of incontinence. A score card, similar in design to the Norton Score, can be used. It helps nurses
British Journal of Nursing, 1992,Voi l,N o 5 Downloaded from magonlinelibrary.com by 130.237.122.245 on January 14, 2019.
Promoting continence following head injury
‘The rectum was empty and there were no signs o f an enlarged prostate gland. This confirmed that Jim did not have overflow incontinence. }
Table I. Communication problems
Table 2. Causes and influences of incontinence
Verbal:
Main causes of incontinence
Auditory:
Memory:
Difficulty in forming and organizing intelligible words, although the musculature to do so remains intact, due to damage to frontal lobe of left hemisphere.
Physiological bladder dysfunction Detrusor instability Stress incontinence Outflow obstruction Atonic bladder
Inability to recognize differences between words and between sounds due to damage to temporal lobe. Post-traumatic amnesia: memory loss for a period of time; unable to recall events prior to injury.
Immobility Environment Mental function Emotions Carers
frustrated and sudden mood changes. Can be meaningless. Dysphasia.
Other:
May have writing difficulties. Understanding impaired.
a hospital inpatient as he was normally fit. Fluid intake and diet Jim enjoyed most drinks. He drank jugs of water daily and enjoyed a healthy diet.
to assess and identify their patients’ prob lems. The score obtained determines whether or not continence is possible. The important goal of planned care should be the promotion of continence rather than the management of incontinence. Jim ’s assess ment score showed that he had a good chance of becoming continent. Jim suffered from urgency of micturition, the warning time between the first sensa tion of bladder filling and the need to empty having been curtailed. Urge inconti nence occurred because Jim was unable to get to the toilet/urinal in time; passive in continence was also prevalent. Jim also had nocturnal enuresis and occasionally nocturia (Table 3). At this stage it was impossible to make a reliable diagnosis based on the history of the symptoms alone. However, symptoms provide clues and Jim ’s problem had not altered: he was being incontinent up to 10 times in 24 hours. An ‘all-in-one’ garment was used at night, i.e. an adult-sized napkin able to absorb 1700 ml of urine without harming the skin, the aim being to contain the amount of urine passed at night. Past medical history Before this admission Jim had never been British Journal of Nursing, 1992, Vol l,N o5
Urinary tract infection Faecal impaction Drug therapy Endocrine disorder Bladder pathology
Factors affecting ability to cope with bladder demands
Behavioural Aggression, impatience, problems: short temper, quickly
Speech:
Factors influencing bladder function
Mobility Jim had external fixations to both lower legs. He was lifted out into the chair using the Australian technique. He needed help to use the commode but was able to use the urinal. Physical examination Jim ’s bladder was not palpable. A mid stream specimen of urine was sent to the laboratory for culture and sensitivity. A normal result was returned. A rectal examination was performed by the doctor. The rectum was empty and there were no signs of an enlarged prostate gland. This confirmed that Jim did not have overflow incontinence. A simple in-out catheter was passed by the doctor to observe for post-micturition residual volume. This test was negative, which showed that Jim emptied his bladder completely — a volume of about 100 ml is normally significant.
Charting Norton (1986) states: ‘The chart is prob ably the single most useful nursing tool in assessing continence. At the same time it is often also the most misused.’ The chart acts as a record and, in conjunction with
237
Downloaded from magonlinelibrary.com by 130.237.122.245 on January 14, 2019.
Promoting continence following head injury cFor urge incontinence, goals are set in an attempt to retrain the unstable bladder. It is termed unstable as there are involuntary bladder contractions during filling. 5
Table 3. Problems relating to
necessary expertise, but medical support and interest ensure that a more accurate di agnosis is made.
micturition Urinary incontinence following removal of catheter
Results of charting When the assessment was complete, the chart was studied. Jim appeared to be drinking 5 litres of fluid per 24 hours which had caused his urinary output to increase. He was not interested in using a urinal. He was ‘dry’ for periods that varied between 2 and 9 hours per day. It was rather ‘hit and miss’ but a pattern was emerging. The most likely bladder dysfunction was urge incontinence and there was also thought to be trauma to the micturition centre.
Urgency (having to hurry to pass urine) Urge incontinence (unable to get to the toilet in time) Passive incontinence (being unaware of it happening) Nocturnal enuresis (bedwetting while asleep) Nocturia (waking at night to pass urine) Polyuria (excessive increase in urine output)
Care plan and goals other findings, aids diagnosis and care plan ning. Chart one The chart used on my ward is designed by Coloplast Ltd. Initially a baseline chart was kept for a week. Its format is kept simple so that less information needs to be record ed, thus increasing the chance of accuracy. Although it is preferable for the patient to complete his/her own chart, in Jim ’s case this was not possible. All urine needs to be measured. Jim was checked hourly and if he was wet it was recorded that he was ‘damp’ or ‘soaking’. This gives a rough estimate of the volume of urine passed. A fluid balance chart, monitoring and recording fluid intake and urinary output, was also maintained. Continence assessment checklist There are various assessment checklists but the one chosen was that of Norton (1986). The check was carried out at the end of the first week of charting. Jim was assessed using the activities of daily living, giving most attention to his incontinence problem. The checklists were completed in two sessions so that Jim would not lose interest and concentration. The questions were simple and confusing terminology was avoided. Jim was involved as much as poss ible but because of his communication diffi culties, most of the information was obtain ed from medical and nursing records and general observation. Ideally, joint nursing and medical assessments should be made. However, as Norton (1986) states: ‘We do not live in an ideal world and often nursing and medical assessments are made indepen dently with little liaison.’ Nurses have the British Journal ol Nursing, 1992, Vol I, No 5
For urge incontinence, goals are set in an attempt to retrain the unstable bladder. It is termed unstable as there are involuntary bladder contractions during filling (Ferrie et al, 1984). The usual care is to set goals for the patient to ‘hang-on’ for 5 minutes before passing urine. The time is then in creased over a number of weeks until the patient is able to hang-on for 3 hours. This goal was totally unrealistic in Jim ’s case. Chart two A second chart was then commenced, the special instructions being that a urinal was to be offered at set times taking into ac count the amount Jim had been incontinent in the first week. It was a case of catch and contain. Fluid intake was restricted to 2 litres in 24 hours as his previous high in take may well have contributed to the prob lem. Fluid restriction is not usually the answer as it can aggravate the problem. However, this amount of fluid is a satisfac tory intake. Medical intervention The medical team was involved and Micturin (terodiline) 125 mg twice daily was prescribed. This is an anticholinergic calcium antagonist which relaxes the detrusor muscle of the bladder and is used in patients with urge incontinence and detrusor instability. Jim was observed for the side effects of a dry mouth and blurred vision. Micturin has recently been with drawn from use as it causes cardiac prob lems in the elderly. Fluid restriction posed a problem. I men tioned to the medical team that Jim could be suffering from diabetes insipidus, a defi ciency of antidiuretic hormone most com monly due to hypoactivity or destruction
239
Downloaded from magonlinelibrary.com by 130.237.122.245 on January 14, 2019.
Promoting continence following head injury
of part of the hypothalamic-neuro hypophyseal system resulting from primary or metastatic neoplasms or infection. In some instances no apparent cause can be identified (Watson, 1979). The doctors were not convinced as the urinary output was not excessive. Nursing intervention The care for Jim’s nocturnal enuresis re mained the same. Regular skin care was performed to prevent soreness. Jim had an excessive thirst and the jug was kept out of his reach. He was given a drink at set times but, on a few occasions, was found drinking the flower water out of the vase and also trying to drink out of the tap at the washbasin. By the end of the second week there was some improvement. He passed urine be tween the set times but sometimes used the urinal. Nocturnal enuresis became less of a problem and so did the urine output in general. 1 wondered whether the improve ment was due to the medication although it usually takes about 2 weeks to take effect. Chart 3 A third chart was commenced and the set toiletting times were slightly altered. Blad der retraining is most successful for patients who are motivated. Unfortunately, Jim was not and the establishment of ‘ideal’ individ ualized toiletting times was probably going to take several weeks.
KEY POINTS • Assessment and identification of related problems are crucial In the management of incontinence and the promotion of continence. • Assessment checklists and regular recording of incontinence using appropriate charts (toilet charting) help the nurse to diagnose the problems. • It is not sufficient just to identify incontinence as the problem; assessment should be much more specific, e.g. identifying problems such as nocturia, nocturnal enuresis, urgency, urge incontinence and polyuria. • Planning and implementing care should always promote the optimum level of continence as its final ideal goal. Appropriate and adequate management of any specific aspect/type of incontinence should be considered only if the ideal goal is unachievable. • The tools and charts used for assessment are also useful in evaluating the effectiveness of care. • Incontinence aids should be chosen only after careful assessment and should be used to lessen the specific problem and help promote continence. They should not be used to encourage continuing incontinence.
240
The sheath system The sheath system was implemented so that the urine passed at night could be contain ed. Sheaths are designed to collect urine that is voided from the penis and store it in a collection bag until it can be conveni ently emptied. The correct sizing of the pa tient is essential as complications can other wise occur (Playford, 1987). The ward stock was limited and so I contacted the health authority’s continence adviser who provided me with a measuring guide and a variety of different sized sheaths. Seth (1987) mentions that penile manage ment has advanced dramatically in recent years, the most up-to-date design being the one-piece sheath. Jim soon became accus tomed to the sheath; there were few prob lems initially, but these were soon solved.
Evaluation At the end of the third week, Jim was pass ing urine at the set times. His fluid intake and output were satisfactory and his excess ive thirst had subsided. I shall never know whether he had suffered from diabetes insipidus. He no longer wet the floorbut still pass ed urine in inappropriate places. Jim ’s medication was continued without any evi dence of side effects. His mobility was improving rapidly. There were slight problems at night as he would wake up wanting to pass urine, re move the sheath and be incontinent while trying to find the urinal in the dark. He was tried for a period without the sheath and this appeared to improve matters. Three weeks was insufficient time to solve the problem completely. While I feel that I helped him a great deal, there was room for improvement. However, the care needs to be ongoing, so plans were made for Jim to be transferred to a cottage hospi tal nearer his home and partner. The author would like to thank E Hugheston-Roberts, Lecturer in Nursing, and Ruhi Behi, Director, Post Registration Studies, School of Nursing and Midwifery Studies, UCNW, Bangor, for their help in writing this article. Ferrie BG et al (1984) Experience with bladder training with sixty-five patients. Br ] Urol 56: 482-4 Noble JG et al (1990) Midnight removal: an improved approach to removal of catheters. Br J Urol 65: 615-7 Norton C (1986) Nursing for Continence. Beaconsfield Publishers, England Playford V (1987) Management of male incontinence using a sheath. Prof Nurs 2: 227-8 Seth C (¡987) Male incontinence. Community Outlook (Suppl) Nurs Times 83(5): 20-21 Watson JF (1979) Medical-Surgical Nursing and Relat ed Physiology, 2nd edn. WB Saunders, London: 756
British Journal of Nursing. 1992. Voi l.N o5 Downloaded from magonlinelibrary.com by 130.237.122.245 on January 14, 2019.
