Introduction to Medical-Surgical Nursing, 6th ed.
23
Lesson Plans for
Incontinence
CHAPTER LESSON PLANS & OBJECTIVES
Lesson 23.1: (Urinary Incontinence)
2. Identify the types of urinary and fecal incontinence.
4. List nursing assessment data needed to assist in the evaluation and treatment of incontinence.
1. Identify common therapeutic measures used for the incontinent patient.
3. Explain the pathophysiology and treatment of specific types of incontinence.
5. Assist in developing a nursing care plan for the patient with incontinence.
CHAPTER TEACHING FOCUS
• In this chapter, students will be introduced to the types of urinary and fecal incontinence, the
pathophysiology and treatment for specific types, and common therapeutic measures used for the
patient.
• In addition, students will have the opportunity to review the data needed to assist in the evaluation and
treatment of incontinence and assist in the development of a care plan for a patient with incontinence.
CONCEPTS
The following conceptual themes and specific concepts match those presented in Giddens, J. R. (2013).
THEME: Homeostasis and Regulation
• Concept: Elimination
• Exemplar: Stress Incontinence, p. 355
• Nursing Care Plan: Patient with Stress Incontinence, p. 356
• Exemplar: Bowel (Fecal) Incontinence, p. 361
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Introduction to Medical-Surgical Nursing, 6th ed.
CHAPTER PRETEST
Have the students answer these questions prior to covering this chapter to understand where they stand
in relation to the content.
1) Mr. Brown is catheterized for residual urine after voiding. The bladder is inadequately emptied if the
residual urine is greater than __________.
a) 50 mL
b) 100 mL
c) 150 mL
d) 200 mL
2) A blood test commonly reviewed to determine adequate urinary function is __________.
a) sodium
b) creatinine
c) amylase
d) phosphorus
3) The nurse teaching a patient with urinary incontinence about pelvic muscle exercises should explain
that __________.
a) improvement in urinary control may take 6 to 8 weeks
b) the exercises should only be performed for 1 month
c) these exercises should be performed only at night in privacy
d) these exercises require the patient take a deep breath, hold it, and then bear down
4) A common type of urinary incontinence attributed to aging is __________.
a) urge
b) reflex
c) overflow
d) stress
5) Mrs. Carter has been doing a self-catheterization for residual urine every 4 hours. The physician has
instructed that Mrs. Carter may lengthen the self-catheterization intervals to every 6 hours when the
residual is less than __________.
a) 200 mL
b) 300 mL
c) 400 mL
d) 500 mL
6) A common antispasmodic medication that acts directly on the detrusor muscle is __________.
a) milk of magnesia
b) glutaraldehyde cross-linked collagen
c) docusate sodium
d) tolterodine
7) Consistent failure to recognize the urge to defecate will place the patient at risk for __________.
a) diarrhea
b) constipation
c) colon cancer
d) flatus
8) A chronic dependence on laxatives or enemas increases the risk for __________.
a) Hyponatremic reflux
b) somatic diarrhea
c) overflow incontinence
d) acute constipation
9) The best time to take patients to the toilet for purposes of bowel training would be __________.
a) 1 hour after their shower
b) 2 hours before bedtime
c) between 2 PM and 4 PM
d) 30 minutes after eating
10) Which of the following is the most appropriate nursing assessment for bowel functioning?
a) Palpating the bladder
b) Testing stool for blood
c) Auscultating for bowel sounds
d) Determining adequate fiber intake
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Introduction to Medical-Surgical Nursing, 6th ed.
Chapter Pretest Answers
CHAPTER BACKGROUND ASSESSMENT
Discuss these questions with your students prior to covering this chapter to understand where they stand
in relation to the content.
Question: A 68-year-old male stroke patient is completing his first week on the rehabilitation unit. He is
catheterized to check for postvoid residual. As the nurse palpates his bladder, she finds that his
underwear is slightly damp and smells of urine. His residual urine measures 325 mL. What is the nurse’s
best response?
Answer: Because he has had a stroke, the patient may not be able to sense a full bladder. He needs to
Question: A 28-year-old female patient delivered her first baby 6 days ago. She experienced a turbulent
vaginal delivery and required extensive repair of her perineum. She has not yet had a bowel movement
because she is too afraid she will “rip apart again.” How should the home care nurse respond to this
patient’s concerns?
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 23.1
Instructor Preparation
Textbook Objectives Covered
1. Identify common therapeutic measures used for the incontinent patient.
3. Explain the pathophysiology and treatment of specific types of incontinence.
5. Assist in developing a nursing care plan for the patient with incontinence.
Lesson Preparation Checklist
• Prepare lecture from TEACH lecture slides available on Evolve.
• Guest speaker: nurse from a rehabilitation facility
• Student performance evaluation of all entry-level skills required for student comprehension of
principles underlying incontinence, including:
• Types of incontinence
• Pathophysiology and treatment
• Common therapeutic measures
• Assessment data for evaluation and treatment
• Developing a nursing care plan
• Assemble materials and supplies needed for each lesson as indicated below.
Materials and Supplies
• computer and PowerPoint
projector
Key Terms
• anorectal incontinence
(p. 364)
• Credé technique (p. 355)
• detrusor overactivity (p. 353)
• fecal incontinence (p. 347)
• fecal overflow incontinence
(p. 363)
• functional incontinence
(p. 357)
• transient incontinence (p.
353)
• urge incontinence (p. 353)
• urinary incontinence (p. 347)
• urinary overflow incontinence
(p. 354)
• void (p. 347)
Student Preparation
Assignments 2 hours
1
READ – Textbook (pp. 349-353)
REVIEW
• Figure 23-2: An artificial urinary sphincter (p. 353)
ANSWER – Text
• Review Questions for the NCLEX Examination: 1, 3, 4, 5 (pp. 366–367)
ANSWER – Study Guide
• Part IC: 1-8 (p. 132)
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LESSON 23.1
2
READ – Textbook (pp. 353-357)
ANSWER – Study Guide
• Part IA: 1-6 (p. 131)
3
READ – Textbook (pp. 347-353)
REVIEW
• Table 23-2: Types of urinary incontinence (p. 354)
• Table 23-3: Medications that cause urinary retention or incontinence (p. 355)
ANSWER – Text
• Review Questions for the NCLEX Examination: 6, 7, 8 (p. 367)
ANSWER – Study Guide
• Part IIF: 1, 3, 7, 19-23 (pp. 132-134)
4
READ – Textbook (pp. 349-353)
REVIEW
ANSWER – Study Guide
• Part IIF: 2-4, 13-18 (pp. 132-134)
5
READ – Textbook (pp. 353-361)
REVIEW
• Nursing Care Plan 23-1: Patient with Stress Incontinence (p. 356)
ANSWER – Study Guide
• Part ID: 1-3, 6 (pp. 132-133)
• Part IIIH: 1-4 (pp. 135-136)
6 Chapter 23 Incontinence __________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 23.1
Lecture Outline 20 minutes
Slide 1
Chapter 23
Incontinence
1
Slide 2
Incontinence
• Definition
• Involuntary passage of urine (urinary incontinence) or feces (fecal incontinence)
• Many conditions and situations can cause either temporary or permanent
incontinence
• Person with incontinence: physical, psychosocial, financial burdens
TALKING POINTS:
• What conditions may cause incontinence?
Slide 3
Urinary Incontinence: Prevalence and Costs
• Surveys found that 5% to 25% note leakage at least once a week and 5% to 15%
experience it daily or most of the time
• Among U.S. women who live in the community, 15%-50% have urinary incontinence; 7%
to 10% have severe leakage
TALKING POINTS:
• What may cause statistics on urinary incontinence to vary?
• Exact figures are difficult to obtain because people often do not report the problem to
health care providers.
Slide 4
Urinary Incontinence: Prevalence and Costs (cont.)
• The cost of managing incontinence in the United States is estimated to be more than $15
billion each year
• Health care providers need to recognize the economic and personal value of treating
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 23.1
Slide 5
Physiology of Urination
• Urination or micturition
• The passage of urine
Slide 6
Physiology of Urination (cont.)
• Bladder receives urine continuously from the kidneys
• Bladder function: store urine until it can be eliminated
TALKING POINTS:
• What happens when the amount of urine the bladder can hold is exceeded?
• The bladder, urethra, and adjacent structures. A, Female. B, Male.
Slide 7
Laboratory Tests
• Clean-catch urinalysis with culture and sensitivity testing usually ordered to assess for
infection
Slide 8
Postvoid Residual
• Amount of urine remaining in the bladder after voiding
• One method: catheterize patient immediately after voiding; measure amount of urine
obtained
Slide 9
Diagnostic Tests and Procedures
• Imaging procedures
• Computed tomography
• Magnetic resonance imaging
Urodynamic Testing
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LESSON 23.1
Uroflowmetry
• Measures voiding duration and the amount and rate of urine voided
Cystometry
• Evaluates neuromuscular function of the bladder
TALKING POINTS:
• Signed consent is obtained before beginning the procedure.
• The physician may administer a drug that stimulates bladder tone and repeat the test.
• After the test, the patient should force fluids if not contraindicated.
• What symptoms should the nurse advise the patient to report after a cystometry?
Provocative Stress Testing
• Detects involuntary passage of urine when abdominal pressure increases
• Patient may be in a standing or lithotomy position
Slide 14
Cystoscopy
• A scope is inserted through urethra to visualize urethra and bladder
• Procedure may be done under local or general anesthesia
• Postprocedure care includes monitoring urine output and encouraging fluid intake
Slide 15
Bladder Training
• Patient education
• Information about normal urinary anatomy and physiology and the bladder retraining
program
• Scheduled toileting
TALKING POINTS:
• Bladder retraining uses patient education, scheduled toileting, and positive reinforcement.
• How frequent is the patient scheduled to void when using scheduled toileting?
Habit Training
• Similar to bladder training in that patient is encouraged to void at scheduled intervals
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 23.1
Slide 17
Prompted Voiding
• Often used with habit training for people who are dependent or cognitively impaired
• Caregiver checks the patient for wetness at regular intervals and asks the patient to state
whether wet or dry
Slide 18
Pelvic Muscle Rehabilitation
• Aims to strengthen the pelvic floor
• Kegel exercises
• Actively exercise the pubococcygeus muscle
Slide 19
Pelvic Muscle Rehabilitation (cont.)
• Vaginal weights
• Ceramic devices of various weights are inserted into the vagina
• Begins with lightest cone, inserts it, and tries to retain it for up to 15 minutes twice
daily
• When lightest cone successfully retained, heavier cones then used in succession
Urge Suppression
• If you have the urge to void, stop what you are doing; sit down or stand quietly
Reflex Training
• Uses the Valsalva maneuver with rectal stretching to force urine from the bladder
• Valsalva maneuver performed by taking a deep breath, holding it, and bearing down
TALKING POINTS:
• Reflex training is sometimes used by people with spinal cord injury.
• How much residual volume is expected?
• Alpha-adrenergic agonists
• Estrogen
Drug Therapy
• Anticholinergics
• Smooth muscle relaxants
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LESSON 23.1
Slide 23
Drug Therapy (cont.)
• Creams and sprays are available to coat and protect the skin of the perineum and
buttocks of the incontinent patient
• A light dusting of powder can be used to absorb moisture
abrasive paste
TALKING POINTS:
• What is periurethral bulking?
Slide 24
Urine Collection Devices: External
• Useful for males
• Latex sheaths, sometimes called condom catheters or Texas catheters, drain urine into a
bag that is usually secured to the leg
• Effective in maintaining dryness, but the adhesive may cause skin irritation on the penis
Urine Collection Devices
• Indwelling catheters
• Clean technique rather than sterile is usually taught for use in the home setting
Urine Collection Devices (cont.)
• Intermittent self-catheterization
• Requires dexterity, adequate vision, and ability and motivation to learn
TALKING POINTS:
• If more than 500 mL of urine is obtained, the time interval is shortened.
• If less than 200 mL is obtained, the time is extended.
Slide 27
Urine Collection Devices (cont.)
• Garments and pads for incontinence
• Help maintain dryness
• Disposable briefs and pads
• “Geri pads”
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LESSON 23.1
Slide 28
Garments and Pads for Incontinence
• Penile clamp
• A device applied to the penis
• It compresses the urethra, preventing the passage of urine
• To prevent circulatory impairment and pressure sores, the clamp must be removed
and repositioned frequently
Slide 29
Pelvic Organ Support Devices
• Pessary
• Device inserted into the vagina to hold the pelvic organs in place
TALKING POINTS:
• When are pessaries generally recommended?
• Within 24 hours after pessary placement, the patient must be reexamined to ensure
proper placement and to rule out urinary obstruction.
Slide 30
Pelvic Organ Support Devices (cont.)
• Bladder neck support prosthesis
• For women with stress incontinence
Slide 31
Surgical Treatment
• Surgical procedures
• Remove obstructions
• Treat severe detrusor overactivity
• Implant an artificial sphincter
Surgical Treatment (cont.)
• Implantation of electrodes
• Electrostimulation: electrodes that stimulate the pelvic floor muscles
Slide 33
Surgical Treatment (cont.)
• Artificial sphincter
• Inflatable cuff, a reservoir of fluid that fills the cuff, and a pump
• Cuff is positioned around the urethra or bladder neck
TALKING POINTS:
• View picture in text: An artificial urinary sphincter in place.
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LESSON 23.1
2
&
3
Slide 34
Urge Incontinence
• The involuntary loss of urine shortly after a strong, abrupt urge to urinate
• Idiopathic urge incontinence
• A specific cause cannot be identified
TALKING POINTS:
• What is the most common cause of incontinence in older adults?
• Urinary tract infection and fecal impaction sometimes cause temporary urge incontinence.
Slide 35
Urge Incontinence (cont.)
• Management
• Aimed at correcting the cause, if possible
TALKING POINTS:
• When the problem is not related to reversible conditions, behavioral techniques, drug
therapy, or surgical intervention may be used.
• What drugs are most commonly used for urge incontinence?
Slide 36
Overflow Incontinence
• Involuntary urine loss from overdistended bladder
• Small amounts of urine are lost continuously or at frequent intervals
• Contributing factors
TALKING POINTS:
• In addition to passing through the urethra, urine may flow out of the bladder and back into
the ureters and kidneys, causing hydronephrosis—a condition that can damage the
kidneys.
• What drugs may cause urinary retention?
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 23.1
Slide 37
Overflow Incontinence (cont.)
• Management
• Depends on the cause
• The physician may prescribe drugs to stimulate the bladder and relax the internal
sphincter
TALKING POINTS:
• What is the Credé method?
• Credé method is not used for patients with reflex incontinence.
• Overdistention of the bladder may trigger a very serious reaction called autonomic
dysreflexia, in which the blood pressure rises to life-threatening levels.
Slide 38
Stress Incontinence
• The involuntary loss of small amounts of urine during physical activity that increases
abdominal pressure
• Coughing, laughing, sneezing, and lifting
Slide 39
Stress Incontinence (cont.)
• Management
• Behavioral methods
• Maintain a fluid intake of at least 2000 mL/day
Functional Incontinence
• Description
• Voiding inappropriately because unable to get to the toilet or to manage the mechanics of
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LESSON 23.1
Slide 41
Functional Incontinence (cont.)
• Management
• Depends on the cause
• Environment should be arranged to permit independent toileting
TALKING POINTS:
• In long-term care facilities, it is important to promote the attitude that incontinence can
usually be improved even in physically and cognitively impaired patients.
4
&
Health History
• Chief complaint
• Thorough description of chief complaint is essential
TALKING POINTS:
• Ask the patient how often incontinent episodes occur and whether they are associated
with any particular activities, such as sneezing or laughing.
• If a patient is incontinent, measurements of urine can only be estimated; however, the
Slide 43
Health History (cont.)
• Medical history
• Urologic, gynecologic, neurologic, and endocrine conditions
• Specifically ask if patient has diabetes mellitus
TALKING POINTS:
• What drugs might contribute to urinary incontinence?
Slide 44
Health History (cont.)
• Review of systems
• The review of systems may detect clues to conditions that contribute to incontinence
• Constipation can contribute to incontinence
• Functional assessment
__________________________________________________________________ Chapter 23 Incontinence 15
LESSON 23.1
Slide 45
Physical Examination
• Measurement of vital signs and height and weight
• Be alert for fever, tachycardia, and weight gain
• Level of awareness and appropriateness of responses
• Inspect the skin for edema
TALKING POINTS:
• Sometimes incontinence is first recognized when you detect an odor of urine during the
examination or when providing care.
assess for prolapse of abdominal organs and to evaluate perineal muscle tone.
5
Deficient Knowledge
• Patient and caregiver education key to managing urinary incontinence
• Emphasize that improvement or correction is possible for most people
Slide 47
Bladder Training or Retraining
• Recommended for stress and urge incontinence
• Establish schedule for voiding every 2 to 3 hours
• Patient is not usually asked to get up during the night, so pads or an external collection
Slide 48
Habit Training
• Incontinence record: establish timed voiding
• You or other caregivers must then remind the patient to try to void at the scheduled
times
TALKING POINTS:
• What stimuli may encourage voiding?