Incontinence Case Study

Urinary Incontinence Case Study
Author: Annemarie Dowling-Castronovo, RN, MA-GNP
Copyright 2006-2007, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved
Learner Outcomes
At the completion of this case study, the student should be able to:
1.
Discuss the differences between transient and established

persistent urinary incontinence (UI).
2.
List essential elements of a focused history and physical

pertaining to UI.
3.
Develop an evidenced-based plan of care based on

assessment findings for an older adult with UI.
4.
List the appropriate indications for indwelling urinary catheter

usage.
Required Reading
Module 3: Atypical Presentation: Urinary Incontinence (UI)

ConsultGeriRN Topics on UI. Available at:
www.ConsultGeriRN.org
National Guideline Clearing House: Evaluation of Urinary
Incontinence available
Opening Statement
Mrs. P. is a 69 year-old white widow who is status post an ORIF

of her L hip subsequent to a fall down the stairs. She is admitted
to sub- acute rehabilitation on post-op day two.
Mrs. P has a history of Alzheimers type dementia,
hypertension, osteoporosis and psoriasis.
Mrs. Ps social history is questionable for alcohol abuse.
Tobacco use includes one pack per day. She is widowed for a
year and lives in two family home with her daughters family.
Mrs. Ps daughter has hired a certified nursing assistant (CNA)
to stay with her 24-hours per day.
Subjective Data
On the initial encounter with Mrs. P on the sub-acute unit, she

offers no complaints and states: Im fine.
Her daughter is present and appears very anxious,

expressing the following:
1.
When will my mothers urine tube come out? Dont those

tubes cause infections?
2.
You cannot use that number pain scale, and she will
never say that she has pain. In the hospital I told them to
make sure she got pain relievers, otherwise she will not
move.
3.
My mom has not moved her bowels in three days, and

she usually goes every morning.
Subjective Data: Problem List
Review of Mrs. Ps medical records, discussion with the

daughter and your initial impression resulted in the development
of this problem list:
1) Recent fall with left hip fracture - s/p ORIF
2) Recent urinary catheterization
3) Pain
4) Recent obstipation/ constipation
5) Caregiver anxiety/?stress
6) PMH of Alzheimers dementia, hypertension, psoriasis
Question # 1
What other subjective information specific to problem #2

(indwelling catheter) do you need to know?
Answers:
1. Is there an appropriate indication for the indwelling urinary
catheter?
Appropriate indication for a urinary catheter include:
a) acute management of a medical condition requiring
strict intake and output measurements;
b) stage III-IV pressure ulcer on the trunk, or
c) urinary retention unmanaged by other means.
Question # 1 continued

Answers:
2. What was Mrs. Ps continence status prior to her hip fracture?
It is essential for nurses to assess ALL patients continence

status and determine if the incontinence is
transient
(acute) or established (chronic). A careful history
is the
cornerstone to the appropriate diagnosis of UI type.
Without
an accurate assessment it is difficult to develop a
successful plan of care.
Question # 1 continued
Answers:
3. What objective data from the nursing assessment is
needed?
It is vital to perform direct visual assessment of the skin to note
any pressure ulcer formation. The nurse should not rely on
transfer documentation or verbal reports, but rather, direct
observation. Other objective data include review of the
medical record to determine if a physician order is present for
strict intake and output and to determine if urinary retention
was present prior to the insertion of the catheter.
Another vital aspect is Mrs. Ps cognitive status, functional
status and motivation. Input from this assessment will help to
determine the plan of care.
Additional Subjective &

Objective Data
Mrs. Ps daughter informs you that prior to the fall her mom was
independent with activities of daily living (ADL), but required
assistance with instrumental activities of daily living (IADLs).
You completed a Mini-Mental State Examination on Mrs. P and
her score was 13/30. Errors were in recent memory, calculation
and visual spatial [drawing a pentagon].
Assessment of the integument reveals silvery scaly plaques
consistent with psoriasis, otherwise the skin is intact.
Based on these data, you conclude that there is no appropriate
indication for the urine catheter.
Plan of Care
Because there is no appropriate indication for the indwelling

catheter, you plan to pursue having it discontinued by:
Consulting with the primary care provider and obtaining an
order.
Following discontinuation, you follow the nurse-led protocol
which is institution specific, and continue to monitor Mrs. P.
Question # 2
(pain) do you need to know?
Answers:
1.
Has a pain scale for the cognitively impaired been utilized

by the nursing staff? Pain assessment is very important,
but presents challenges when an older adult has impaired
cognition and/or communication. Using a Checklist for
Non-Verbal pain indicators (visit ConsultGeriRN.org and
select: Try This Series: Assessing pain in persons with
dementia) helped the nursing staff to observe and collect
data consistent with pain. This data about Mrs. P. included
moaning, grimacing and clutching the bed lines with
movements, replying ouch frequently and withdrawing
from activity.
Question # 2
Answers:
2.
What were the components of pain management in the

hospital? Mrs. P was medicated with Percocet 1-2 tablets
by mouth every 6 hours. It appeared to control her pain,
but periodically non-verbal behaviors were observed. This
observation of continued pain, prompted further nursing
assessment and revealed that Mrs. P was also
experiencing abdominal pain. This is imperative to identify
as narcotic analgesia lead to constipation, particularly in
an older adult who is less active. The daughter's report of
no BM for 3 days is very relevant, thus prompting a
complete abdominal as well as rectal assessment.
Question # 2
Answers:
3.
What is Mrs. Ps response to activity? Given the current

problem list, it is vital to increase Mrs. P mobility and level
of activity when she is pain-free. This requires attention to
the timing of medication so that increased activity can
take place. As activity improves, so too can a return to
normal bowel habits. If lack of bowel movements persist,
additional nursing intervention to prevent fecal impaction
is warranted.
Post-Op Day 4
Mrs. P daughter comes to you demanding to know why her

mother is in a diaper.
Question #3
How do you respond to Mrs. P and what is your rationale?

Answer:
You need to respond to Mrs. Ps daughter and the situation
in a calm and respectful manner. Stating that you will look
into it right away. This provides the daughter with immediate
reassurance as well as it confirms that you dont know, but
will check into it.
Question #3
How do you respond to the fact that Mrs. P. is wearing a diaper
and what is your rationale?
Rationale:
Often care is focused on containment and not management.
Traditionally, nurses assistance and nurses are taught about
incontinence care-frequent toileting and/or skin care with diaper
changes and barrier creams. While studies do reveal poor
staffing is a perceived barrier to maintaining toileting
schedules- this cannot be applied in this case, because there is
a private CNA. Therefore, it should be questioned what
attitudes and beliefs the private CNAs and floor nurse have
relative to the elimination needs of the older adult.
Additional Data
After removing the indwelling urinary catheter, Mrs. P became

incontinent. Rather than notify the RN, the CNA used a diaper
for management.
Question #3
What other data do you need to collect at this point?
1.
Is this new UI or old UI?

Since you have already collected further subjective data that
Mrs. P was independent in ADLs at home, you determine that
this is new-onset UI.
2.
What are the causes for new, transient, UI?

Using the mnemonic, TOILETED (visit
www.ConsultGeriRN.org and select Try This Series: UI
Assessment) to review potential reversible causes of UI. In
this case, restricted mobility due to hip fracture and repair,
use of narcotic analgesia causing constipation are all
important factors.
Question #3
3. Could this be iatrogenic UI?
Iatrogenic UI refers to a medically induced problem. In this
case, the catheterization could have led to the new onset of a
bacterial infection.
4. What additional objective data is needed?
Review the output and note how many voiding episodes
versus leaking episodes have taken place. Is Mrs. P moving
her bowels? A reassessment of the abdomen is needed to
assess for any supra-pubic tenderness and left lower quadrant
fullness or pain. These are signs of urinary or stool retention.
Assessment reveals a slight firmness in both the supra-pubic
region and the left lower quadrant.
Assessment and Plan of Care
After consulting with the NP, another abdominal assessment,

including a rectal exam is performed. Results show that soft
stool is present, the post-void residual (PVR) is 100 cc, the
urinalysis shows: + WBC, trace blood, +nitrates, culture
pending. The following is ordered:
MOM 30cc po X once at bedtime
Colace 100 mg po TID
Question #4
What should the nurse add to the plan of care?
Answer:
1. The nurse needs to learn from the CNA staff if Mrs. P has any
non-verbal or verbal cues that may help to determine the need to
toilet. A bladder record for a few days will assist in determining
Mrs. Ps individual elimination patterns so that an individualized
toileting schedule may be implemented. Emphasize to the CNA
staff the need to toilet according to Mrs. Ps patterns. Clearly
communicate that Mrs. P. did not have incontinence issues prior
to her hip fracture, and that part of her rehabilitation is to
maximize her continence in an effort to return to baseline.
Consider a bedside commode as an environmental modification
to promote continence.
2. The nurse should anticipate an antibiotic order for a urinary tract
infection (UTI). A PVR of 100cc needs to be carefully assessed,
in this case the treatment of the UTI improves Mrs. Ps
continence status.
Additional Information
During the remainder of her short term rehabilitation stay, Mrs.

P. and her daughter struggled to maintain continence. This was
challenged by a bout of diarrhea caused by a bacterial infection
in her bowel (e.g., clostridium difficile). She was discharge after
one-month to her home wearing her own underwear and
maintaining a state of continence.
Discharge planning included regular toileting and use of a
bedside commode at night.
One Year Post-discharge
Mrs. P has done well. She continues to live at home with her
daughters family and the help of home attendants. She has had
two UTIs her first sign/symptom was UI. She now is
dependent with her ADLs, with the exception of feeding and at
times toileting. About 80% of the time she is continent, but at
night does not recognized the urge to void the daughter and
attendant use diapers at night and prompt to void during the
night at least once. This is all in an effort to balance continence
with sleep needs. In this case, not diapering means that the pad
and her Pajamas get wet and she is uncomfortable. However,
for now she is still diaper free during the day and attends a
social adult day program three times a week.
Take Home Points
Urinary incontinence is a problem for both those experiencing it

(the older adult patient) and their caregivers. For the older adult
it can lead to embarrassment and frustration, and for caregivers
it can lead to anxiety when attempts to manage it fail. Fecal
incontinence is under addressed in clinical practice. In this
case, the staff was not prompted to determine the cause of the
diarrhea and, in fact, continued administering the stool
softener. Note that antidiarrheals are contraindicated with
concurrent C. difficile infection of the bowel.
UTIs can develop and complicate the care of an older adult
who also has functional limitations.
Take Home Points
Reduced mobility can lead to urinary retention and sluggish

bowel function, both of which contribute to urinary track
infections and to urinary incontinence
Older adults with dementia and impaired communication have
limitations in their ability to express pain. Non-verbal clues are
important to recognize so that appropriate management can
take place.
Urinary incontinence is often reversible, but its cause first needs
to be determined which only occurs when a proper assessment
takes place.

Incontinence Case Study

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Incontinence Case Study

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Urinary Incontinence Case Study

Author: Annemarie Dowling-Castronovo, RN, MA-GNP

Discuss the differences between transient and established

List essential elements of a focused history and physical

Develop an evidenced-based plan of care based on

List the appropriate indications for indwelling urinary catheter

Module 3: Atypical Presentation: Urinary Incontinence (UI)

Mrs. P. is a 69 year-old white widow who is status post an ORIF

On the initial encounter with Mrs. P on the sub-acute unit, she

Her daughter is present and appears very anxious,

When will my mothers urine tube come out? Dont those

My mom has not moved her bowels in three days, and

Subjective Data: Problem List

Review of Mrs. Ps medical records, discussion with the

What other subjective information specific to problem #2

What other subjective information specific to problem #2

It is essential for nurses to assess ALL patients continence

Additional Subjective &

Because there is no appropriate indication for the indwelling

Has a pain scale for the cognitively impaired been utilized

What were the components of pain management in the

What is Mrs. Ps response to activity? Given the current

Mrs. P daughter comes to you demanding to know why her

How do you respond to Mrs. P and what is your rationale?

After removing the indwelling urinary catheter, Mrs. P became

Is this new UI or old UI?

What are the causes for new, transient, UI?

Assessment and Plan of Care

After consulting with the NP, another abdominal assessment,

During the remainder of her short term rehabilitation stay, Mrs.

One Year Post-discharge

Take Home Points

Urinary incontinence is a problem for both those experiencing it

Take Home Points

Reduced mobility can lead to urinary retention and sluggish

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