16 Chapter 23 Incontinence __________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 23.1
Slide 49
Social Isolation
• The person with urinary incontinence may curtail social activities out of fear of having
embarrassing accidents
• Access to public toilets often limited, so patients who cannot delay voiding may be afraid
to venture far from home
• Incontinence products may permit patient to venture out without fear of wetness or odor
TALKING POINTS:
• Specially designed pads and undergarments as well as some external urine collection
devices may be used.
• What should you do if the patient has an incontinent episode?
Situational Low Self-Esteem
• Incontinent adults: too embarrassed to tell anyone about it
TALKING POINTS:
• The ability to control elimination is an important childhood accomplishment.
• Why do some older people fail to seek medical treatment for incontinence?
• You can help patients learn to manage incontinence and see that it is not a barrier to
achieving a full life.
• Your attitudes toward the patient and incontinence influence how the patient deals with
the change in body function.
Slide 51
Impaired Skin Integrity
• Skin breakdown: major problem for incontinent patient
• Urine and feces, if left in contact with the skin, cause a rash
• Continuous moisture causes the skin to lose its oily protective barrier
Slide 52
Risk for Infection
• Patient incontinent of urine is at risk for urinary tract infection and urinary calculi
• Retained urine medium for bacterial growth, and the overstretched bladder wall is
susceptible to infection
• Patients may restrict fluid intake to reduce incontinence
__________________________________________________________________ Chapter 23 Incontinence 17
LESSON 23.1
Slide 53
Question 1
• What percentage of men over age 60 experience urinary incontinence?
A. 13%
B. 17%
C. 21%
D. 25%
TALKING POINTS:
Slide 54
Question 2
• When ______ mL of urine collect in the bladder, stretch and tension receptors are
stimulated, causing the bladder to contract, and the internal sphincter to relax, sending a
message to the brain of the need to void.
A. 100-150
B. 200-250
C. 300-350
D. 400-450
TALKING POINTS:
Activities
Classroom Choose from below to make 30 minutes
Online
ASSESS BASELINE
• Have the class complete the Pretest. Collect
their work and use the results to guide how
you teach the class.
DISCUSS
• Discuss the role of family members in an
incontinent patient’s treatment.
• Ask the class to identify specific noninvasive
measures such as increased fluid intake,
ASSESS BASELINE
• Post the Pretest and the Background
Assessment online and have your class
complete them. Use the results to guide how
you teach the class.
18 Chapter 23 Incontinence __________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 23.1
DISCUSS
• Discuss the differences between transient
incontinence and persistent incontinence.
• Have students write down a specific type of
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Create a list of
the types of urinary incontinence.
DISCUSS
• Discuss why age is not necessarily a factor
in whether a patient has urinary
incontinence. Identify examples of patients
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Describe
functional incontinence and how it differs
DISCUSS
• Divide the class into small groups. Have the
groups refer to Box 23-1. For each item
listed under the Health History and Physical
Examination headings, have students
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Describe data
that should be included in the nursing
assessment of the patient with urinary
DISCUSS
• Discuss how a patient’s drug profile may
assist in the assessment and treatment of
incontinence.
• Divide the class into small groups. Assign
each group one or two nursing diagnoses
from Nursing Diagnoses, Goals, and
Outcome Criteria: Urinary Incontinence (p.
POST AND COMMENT
• Post the following discussion topic online
and have students comment. List two
nursing diagnoses for the patient with
urinary incontinence and provide three
interventions the nurse can implement for
each.
__________________________________________________________________ Chapter 23 Incontinence 19
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 23.1
Critical Thinking Question
An 81-year-old woman with Alzheimer’s disease who requires minimal assistance is
admitted to the hospital. While collecting data during admission, the nurse notes that the
patient is wearing incontinence briefs, and upon further examination, notices two decubitus
ulcers on her coccyx. The patient’s husband states that he puts briefs on his wife all the
time because she won’t go to the bathroom. He says that he tried to teach her, but just gave
up. What is the nurse’s appropriate response?
Instructor Notes/Student Feedback
20 Chapter 23 Incontinence __________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 23.2
Instructor Preparation
Textbook Objectives Covered
2. Identify the types of urinary and fecal incontinence.
4. List nursing assessment data needed to assist in the evaluation and treatment 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: geriatric nurse
• 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
Materials and Supplies
• computer and PowerPoint
projector
• drug references
• overhead projector
• Figure 23-5: The anal
sphincters and musculature
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)
• micturition (p. 347)
• neurogenic bladder (p. 355)
• neurogenic incontinence
(p. 363)
• stress incontinence (p. 355)
• symptomatic incontinence
(p. 364)
• transient incontinence (p.
353)
• urge incontinence (p. 353)
• urinary incontinence (p. 347)
• urinary overflow incontinence
(p. 354)
• void (p. 347)
__________________________________________________________________ Chapter 23 Incontinence 21
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 23.2
Student Preparation
Assignments 2 hours
1
READ – Textbook (pp. 363-365)
2
READ – Textbook (pp. 363-365)
ANSWER – Study Guide
• Part IIF: 9, 10 (p. 133)
3
READ – Textbook (pp. 361-363)
REVIEW
• Table 23-4: Types of Fecal Incontinence (p. 363)
ANSWER – Text
ANSWER – Study Guide
• Part IIF: 8, 11 (p. 133)
• Part IIIG: 1, 2, 5, 6, 7 (pp. 134-135)
4
READ – Textbook (pp. 363-365)
REVIEW
• Box 23-2: Assessment of Patients with Fecal Incontinence (p. 364)
ANSWER – Text
• Review Questions for the NCLEX Examination: 10 (p. 367)
ANSWER – Study Guide
• Part IIIG: 3 (p. 135)
5
READ – Textbook (pp. 363-365)
22 Chapter 23 Incontinence __________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 23.2
Lecture Outline 20 minutes
1
Slide 55
Fecal Incontinence
• Fecal incontinence is less common than urinary incontinence, but it can be very
distressing for patients
• Usually related to anal sphincter dysfunction caused by anal surgery, trauma during
Slide 56
Physiology of Defecation
• The muscles of the pelvic floor and the external sphincter are under voluntary control
• The bowel has its own nerve network that stimulates peristalsis when it is distended
TALKING POINTS:
• If defecation does not occur soon after this pressure is felt, the sensation of needing to
defecate soon fades.
• What are the results of ignoring the sensation to defecate?
Diagnostic Tests and Procedures
• Evaluation of fecal incontinence may include
• Assessment of rectal sphincter tone
Slide 58
Common Therapeutic Measures
• Enemas
• Stimulate emptying of the bowel in patient prone to impaction
• Pouches
• May be applied to the perianal area and held in place with adhesive
TALKING POINTS:
• Why is frequent use of large-volume enemas not advised?
• An alternative to the pouch is an adult incontinent brief or (for bed patients) linen
protectors.
__________________________________________________________________ Chapter 23 Incontinence 23
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 23.2
Slide 59
Common Therapeutic Measures (cont.)
• Biofeedback
• Motivated patients able to follow directions and whose external anal sphincter is
capable of responding to rectal distention may achieve bowel control
• Dietary changes
TALKING POINTS:
• How is biofeedback performed?
• Biofeedback has been effective for many patients but has not proved useful for patients
with fecal incontinence associated with diabetes, spinal cord injury, rectal trauma, or
radiation injury.
2
Slide 60
• What may fecal incontinence be caused by?
Types of Fecal Incontinence
• Fecal overflow incontinence
• Caused by constipation in which the rectum is constantly distended
• Medical treatment
• Immediate relief of the constipation and long-term control of the problem
• Cleanse the colon
• Regular evacuation
TALKING POINTS:
• The fecal mass backs up until the entire colon is full.
• The patient passes semisolid stools frequently.
Slide 61
Types of Fecal Incontinence (cont.)
• Neurogenic incontinence
• Defecation is not voluntarily delayed
• One or two formed stools occur after meals
• Medical treatment
• Scheduled toileting based on usual time of defecation
TALKING POINTS:
• When food enters the stomach, it stimulates activity throughout the digestive tract and
causes movement of the fecal mass into the rectum.
• Neurogenic incontinence occurs most often in patients with what diagnosis?
24 Chapter 23 Incontinence __________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 23.2
Slide 62
Types of Fecal Incontinence (cont.)
• Symptomatic incontinence
• Result of colorectal disease
• Medical treatment
• Identify and treat the cause
• Anorectal incontinence
• Nerve damage that causes the muscles of the pelvic floor to be weak
• Medical treatment
• Pelvic muscle exercises; sometimes biofeedback
4
&
5
Slide 63
Health History
• Chief complaint
• Determine usual bowel pattern, changes, stool characteristics, and related symptoms,
such as pain or cramping
• Bowel pattern
TALKING POINTS:
• Bowel patterns are usually well-established in the adult.
• What is the normal frequency of bowel movements in the adult?
• Terms used to describe consistency include liquid, watery, pasty, tarry, semiformed,
formed, and hard.
Slide 64
Health History (cont.)
• Medical history
• Document chronic illnesses, past acute illnesses, and surgeries or trauma to the
abdomen or rectum
• Neurologic conditions, including stroke, spinal cord injury, and dementia, are
significant
Slide 65
Health History (cont.)
• Review of systems
• Problems that may be related to fecal incontinence, such as motor, sensory, or
cognitive impairments
• Functional assessment
• Habits that may be related to bowel function, including diet, fluid intake, exercise or
activity pattern
• Physical examination
TALKING POINTS:
• Determine whether the patient has the mobility and dexterity to manage toileting
independently.
• Why would recent travel to other countries be significant?
__________________________________________________________________ Chapter 23 Incontinence 25
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 23.2
5
Slide 66
Bowel Incontinence
• Continued monitoring
• Documentation of usual bowel pattern
• Explain normal bowel physiology and interventions for incontinence to the patient
TALKING POINTS:
• How is a bowel program established?
• Work with the dietitian to teach the patient that fresh fruits and vegetables provide bulk
and fiber that keep the stool moist and soft.
Impaired Skin Integrity
• After each incontinent stool, cleanse the patient’s perianal area thoroughly
• Apply creams or ointments per agency policy
Slide 68
Situational Low Self-Esteem
• Loss of bowel control can be devastating
• Express understanding of the patient’s distress and encourage to strive for as much
improvement as possible
Activities
Classroom Choose from below to make 30 minutes
Online
DISCUSS
• Discuss why disorders of the central nervous
system and spinal cord do not usually lead
to fecal incontinence as much as they do to
loss of bladder control.
• Ask students to describe the process of
defecation and refer to the anatomic
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Discuss what
types of foods a patient with fecal
incontinence should avoid.
26 Chapter 23 Incontinence __________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 23.2
DISCUSS
• Discuss why using senna or lactulose
instead of enemas, suppositories, or
laxatives may be a more beneficial treatment
for older patients.
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Describe the
process of the gastrocolic reflex.
DISCUSS
• Discuss the unique issues that arise when
treating a patient who has incontinence and
dementia.
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Describe
pelvic muscle exercises such as Kegel
DISCUSS
• Discuss appropriate questions to ask a
patient or family member to explore the
patient’s fecal incontinence history.
• A patient has just been prescribed
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Create a table
of data to be included in the assessment of
the patient with fecal incontinence.
DISCUSS
• Discuss why relieving constipation caused
by fecal overflow incontinence is not a long–
term solution.
• Divide the class into small groups. Have
POST AND COMMENT
• Post the following discussion topic online
and have students comment. List the two top
nursing diagnoses for the patient with fecal
incontinence and include two interventions
__________________________________________________________________ Chapter 23 Incontinence 27
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 23.2
Critical Thinking Question
A 72-year-old man is admitted for a hypertensive crisis. During the nursing assessment, the
patient indicates that he uses over-the-counter enemas about twice a week so that he can
have a “complete” bowel movement. He tells the nurse that he uses enemas more frequently
when he feels constipated. The patient also indicates that he sometimes leaks fecal matter
into his underwear. What kind of nursing interventions can be implemented to assist this
patient with an appropriate bowel evacuation program?
Discussion Guidelines: This patient may be experiencing fecal overflow incontinence. The
Instructor Notes/Student Feedback
28 Chapter 23 Incontinence __________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
23
Assessments for
Incontinence
CHAPTER 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.
5. Assist in developing a nursing care plan for the patient with incontinence.
Lesson 23.2: (Fecal 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.
Assessments by Lesson & Objective
Lessons 23.1 and 23.2
1
Study Guide
• Part IC: 1-8 (p. 132)
Evolve Instructor Resources
• Test Bank: 1-4, 7, 12-14, 18, 20, 22, 26-29, 31, 34
2
Study Guide
• Part IA: 1-6 (p. 131)
Evolve Student Resources
• NCLEX Review: 4
3
Study Guide
• Part IIF: 1, 3, 7, 8, 11, 19-23 (pp. 132-134)
• Part IIIG: 1, 2, 5, 6, 7 (pp. 134-135)
Evolve Instructor Resources
• Test Bank: 5, 6, 25, 33
Evolve Student Resources
• NCLEX Review: 6, 7, 9, 10
Study Guide
Evolve Instructor Resources
• Test Bank: 8-11, 15, 19, 21, 30, 32
Evolve Student Resources
• NCLEX Review: 1, 5
__________________________________________________________________ Chapter 23 Incontinence 29
Introduction to Medical-Surgical Nursing, 6th ed.
Assessments by Lesson & Objective
5
Study Guide
• Part ID: 1-3, 6 (pp. 132-133)
• Part IIIH: 1-4 (pp. 135-136)
Evolve Instructor Resources
• Prioritization: 1-5
Instructor’s Notes/Student Feedback