Attention: This article is no longer being updated. The information has proven so popular and useful, though, that we have decided to keep it in place as reference material.
In 2005, The Center for Medicare and Medicaid Services' (CMS) revised FTag 315 and issued regulations related to the assessment and screening of nursing home residents with urinary incontinence (UI) or an indwelling urinary catheter. (Newman, 2006)
The goal is to maintain and improve bladder function whenever possible and reduce the use of indwelling catheters in this population.
The responsibility for this assessment, which includes evaluation for such reversible conditions as urinary retention and urinary tract infections, rests with long-term care facilities (e.g. nursing homes) and their nursing staff.
Determining a post-void residual (PVR) is an integral part of assessing bladder volume in patients with suspected urinary retention and in distinguishing among the three most common conditions seen in nursing home residents: urinary incontinence, urinary retention and urinary tract infections. The most acceptable and non-invasive method for determining bladder emptying is the use of a portable, ultrasound instrument called the BladderScan®. Nurses at the bedside can easily evaluate bladder function as recommended with this technology without using invasive instrumentation such as catheterization that may cause infections. Using ultrasonography to determine PVR has become the standard of nursing practice in all clinical settings.
Three Related Bladder Disorders
Urinary incontinence (UI), urinary retention or incomplete bladder emptying, and urinary tract infections (UTIs) can be chronic or even life-threatening conditions, especially in nursing homes. Staff may hang on to the outdated belief that urinary incontinence is a normal and expected part of aging and they may not realize that, in some cases, the condition can be improved (Fantl, et al.1996). In many situations, these three disorders are related. For example, the first sign of urinary retention might be UI, or a transient case of UI may be secondary to a bowel impaction or other bowel disorders, or it may be due to urinary retention or a UTI (Fantl, Newman et al., 1996; Newman, 2007; Lekan Rutledge & Colling, 2003). It is therefore important for nursing staff to understand these three disorders, especially in the nursing home setting.
One of the measures of quality of nursing care in the extended care setting is the prevalence of UI (Zimmerman, et al., 1995). At least 55% of nursing home residents exhibit urinary incontinence (AMDA, 2005, Gabrel, 1995), which is a leading cause of institutionalization of the elderly. According to a report by CMS in 2000, more than a third of nursing home residents experienced some form of UI all or most of the time. UI in elderly nursing home residents is associated with such other medical problems as falls, bone fractures, pressure ulcers, UTI's and depression (Brown, et al., 2000; Newman, 2002, Ouslander, et al., 1993). It is often the cause of social isolation and accompanied depression and other psychological conditions. In many of these residents, small frequent bladder contractions create a sense of urgency that leads to overactive bladder with incontinence. The result is an abrupt urge to urinate before the bladder is full (Newman 2007) known as urge urinary incontinence (UUI). The contractions, over which the patient has no control, cause urine to leak. The nursing staff sometimes resorts to the use of an indwelling catheter as a way to manage the resulting wetting (Newman, 2005).
In 2005, CMS issued a new guidance for surveyors related to incontinence and urinary catheters that collapses older Tags F315 and F216 into one Tag (F315) and outlines a new Investigative Protocol, new Interpretive Guidelines, and a new compliance and severity guidance (CMS, 2005).
Urinary Tract Infection
Nursing homes show high rates of urinary tract infections among their residents, ranging from 12 to 30% (O'Donnell, 2002). Bacteria that cling to the lining of the urethra (urethritis), multiply and travel up the urethra to the bladder (cystistis), ureters (ureteritis), and /or kidneys (pyelonephritis), are the cause of urinary tract infections. (Newman, 2006) Lower urinary tract UTIs involve the urethra and bladder, but infections are called upper tract UTIs when the ureters and kidneys are involved. Most nursing home residents with UTIs exhibit no symptoms, but the rate of bacteria in their urine (bacteriuria) is 25% to 50% (Nicolle, 1999). UTIs are the reason given for transfer of patients from nursing homes to acute care facilities 8-30% of the time (Nicolle, 2001).
Bladder infections are more common in women due to the shorter length of the urethra (less of a barrier to bacteria) and to the short distance between the anus and the urinary meatus, which allows easy contamination with fecal material. Elderly women have lower estrogen levels and are slower at emptying the bladder, both of which contribute to an increased risk of incomplete bladder emptying that often leads to stasis and infection.
CMS Tag F315 defines the number of bacteria required for laboratory confirmation of a symptomatic UTI (See Table 1). Ninety-five percent of all UTIs are caused by a single bacterial agent, and of these, 80% are caused by Escherichia coli (E. coli). The presence of bacteria in the bladder can irritate its lining (mucosa) and the result is typically overactive bladder, frequency and urgency.
The main impact of UTIs on long-term care facilities is their treatment cost and effect on patient outcomes. A good way to lower their prevalence is to eliminate or diminish the use of catheters which tend to introduce urethral and introital organisms into the bladder (Warren, 2001).
Urinary retention is the failure to empty the bladder while voiding and can be due in aging men to prostate disorders (e.g., prostatitis, BPH) and in aging women to pelvic organ prolapse (e.g., cystocele). Neurogenic bladder, where innervation between the brain and the bladder is interrupted by a lesion of the central or peripheral nervous system, can cause retention. However, this diagnosis is sometime inappropriately used to justify use of an indwelling catheter. Nerve damage anywhere along the nerve pathways can impair bladder function and lead to incomplete bladder emptying. Newman 2007) Diffuse nerve damage, as seen in a variety of conditions (e.g., Parkinson's, MS, spinal cord injuries), can cause problems with initiating and completing bladder voiding. Typically, residents maintain some ability to void, but when they consistently exhibit high post-voiding residual (PVR) urine volumes, they are at risk for acute urinary retention, UTIs, or such upper tract problems as pyelonephritis, hydronephrosis or renal insufficiency (Gray, 2000a).
Causes of urinary retention are:
- Areflexic - diseases of the spinal cord
Areflexic, or lower motor neuron bladder, occurs when the injury is at the sacral voiding center itself. This results in a flaccid bladder. No awareness of bladder filling is present and the person is unable to initiate a void. Urinary retention often results.
- Hyperreflexic Bladder
The second type of neurogenic bladder is the hyperreflexic (spastic) or upper motor neuron bladder. This type of bladder results when the spinal cord is injured above the level of the sacral (S2 to S4) voiding center. This also results in urinary retention.
- Sensory and/or Motor Paralytic Bladder
Disease of the peripheral nervous system can attack the local nerve supply to the bladder. This is especially common in patients with diabetic mellitus, which can affect both sensory and motor pathways. Even if sensation alone is deficient, the bladder may become over-distended since an adequate cue to toilet is never experienced. Motor damage leads to inefficient bladder emptying and overflow incontinence can develop. Similarly, extensive pelvic surgery can disrupt peripheral nerves.
- Other Causes of Urinary Retention
Chronic urinary retention increases with age in both men and women. The bladder muscle loses its flexibility and does not completely empty with each voiding. The elderly have chronic illnesses (e.g. diabetes, Parkinson's) that affect normal bladder function. Retention can also be secondary to obstruction of urinary flow caused by an anatomic lesion. An enlarged prostate (e.g. prostatitis, BPH) in men can lead to urinary retention. Pelvic organ prolapse (e.g. cystocele, uterine prolapse) in women can cause a mechanical obstruction of the urethra at the bladder neck leading to urinary retention. Medications can also contribute to incomplete bladder emptying.
CLASSIFICATION DRUG NAME Anticholinergics and Antispasmodics Atropine
Tricyclic antidepressants Amitriptyline
Other antidepressants (reduced risk) Bupropion
Calcium channel blockers (when combined with other agents) Nifedipine
Narcotic analgesics (when combined with other agents) Morphine
Anesthetic agents General anesthesia
Recreational drugs Cannabis
PVR urine volume is used to diagnose urinary retention (Colling, et al., 2003, Gray, 2000b, Newman, 2007) and is defined as the amount of urine remaining in the bladder within 20-30 minutes after voiding (See Table 1 below for parameters). Chronic urinary retention is characterized by an ongoing inability to completely empty the bladder during voiding.
Urinary retention is determined by measuring the post-void residual (PVR) urine volume 10 to 20 minutes after the person has voided. A PVR volume of greater than 100 mLs is generally accepted as the criterion to define incomplete bladder emptying. In elderly patients, however, a PVR of 150 to 200 mLs or greater (measured on 2 separate occasions) indicates incomplete bladder emptying. This is the reason why the elderly need to void often in small amounts (urinary frequency). Urine remaining in the bladder after the person has voided can become colonized with bacteria, hence, there is an increased incidence of UTI.
Assessment of Bladder Function
All nursing home residents who exhibit bladder symptoms should be assessed to determine whether (and which) pathophysiologic factors may be playing a role in the dysfunction (AMDA, 2005, CMS, 2005, Fantl, et.al., 1996). The "Bladder Function Checklist" in Table 1 is an aid in this process. The assessment should follow the Resident Assessment Protocol (RAPS) as required by CMS regulations. The RAP is a tool for critical problem solving, care plan development and treatment decisions that can play a large role in the quality of life for each nursing home resident. If this protocol shows that a resident is incontinent or has an indwelling catheter, further assessment will determine the situational factors, medical conditions, bowel function, abnormal laboratory values or neurologic condition that may contribute to the UI. Transient factors that may play a role should also be evaluated including urinary retention, urinary tract infection, medications, and environmental and medical factors.
Nursing homes will also be surveyed for compliance with the CMS interpretive guidance on F Tag 315 (CMS, 2005, Newman 2006) to ensure that:
- All residents who are found to have UI will be properly assessed and receive appropriate treatment and services to help maintain as much normal bladder function as possible;
- All uses of indwelling catheters are medically justified and the catheterization is discontinued as soon as the medical situation warrants;
- Services to restore or improve urinary function are provided after removal of the catheter; and
- All residents, regardless of the use of an indwelling catheter, receive the appropriate care and services to prevent urinary tract infections.
Assessment is the key component of this new guidance as a tool for discovering the underlying transient and persistent causes of UI. For many residents, the required tool for assessing urinary function is the post-void residual (PVR) (Newman, 2006). See Table 2 below for a list of resources available relevant to compliance with this requirement.
Assessment of Bladder Emptying Using New Technology
New technology exists to help nurses at the bedside determine PVR accurately, non-invasively and in compliance with both RAPS and the CMS F Tag 315 (Colling, 1996, Ouslander, et al., 1994). Verathon Medical, Inc., Bothell, Washington, manufactures a portable ultrasound machine designed specifically for measuring PVR.
The portable BladderScan instrument uses V-mode ultrasound technology to create a three-dimensional image of the bladder and calculate volume based on this image. To create the three-dimensional image, the BladderScan measures ultrasonic reflections on multiple planes within the resident's body to differentiate the bladder from surrounding tissues. A microprocessor within the instrument automatically calculates and displays bladder volume; the operator simply applies ultrasound coupling medium (ultrasonic gel), aims the scanhead, and initiates the scan. Noninvasive bladder volume measurement via the V-mode BladderScan is quick, easy, and very specific for determining elevated PVR. Portable ultrasounds have been found to have a specificity of 96.5% in detecting PVR 100 mLs in ambulatory women (Goode et al., 2000, Newman 2005).
Extended care residents present many uses for portable ultrasounds including the objective measurement of bladder volume, regular monitoring and avoidance of prolonged urinary retention, avoidance of unnecessary catheterizations and resultant nosocomial UTIs, and accurate measurement of bladder volume during attempted voiding or prompted voiding programs (Wooldridge, 2000; Newman, 2002).
Numerous studies have documented the accuracy of ultrasound scanning. Coombes et al. (1994) assessed the accuracy of two successive models of the portable bladder ultrasound device in determining PVRs in 100 patients. Ultrasound measurements were compared to post-scan bladder volumes obtained by catheterization and fluoroscopic screening in the same patients. The accuracy of the BladderScan (BVI 2500 model) was as good as catheter estimations of true residual volumes. The authors recommend BladderScan use as an alternative to catheterization for the determination of PVR volume. Ouslander (1994) used a portable ultrasound scanner (BladderScan BVI 2500) to determine the accuracy of PVR volumes in nursing home residents. Accuracy of the scanner ranged from 90 - 95% for volumes of 50 to 100 mLs to a rate of 69% for volumes greater than 200 mLs.
Because the uterus may resemble the bladder, the BladderScan® has a gender setting that excludes the uterus from measurements. The nurse simply selects the female setting when scanning a woman who has not had a hysterectomy, and proceeds with the exam. The gender setting helps to ensure optimum accuracy of measurement.
The BladderScan®; BVI 9400
While there are several BladderScan® models available, the latest model, incorporating NeuralHarmonics® technology, is the BladderScan® BVI 9400. It is a portable, 3D ultrasound instrument that is accurate and reliable. For example, the BVI 9400 has an accuracy specification of 0 - 999ml, ± 15% ± 15ml on a tissue equivalent phantom. The BVI 9400 is noninvasive, quick and easy to use. It can be transported to a patient or resident’s bedside via an optional mobile cart, and the exam takes just a few minutes to complete. The BVI 9400 offers exam results via the console screen, the onboard printer, and/or to your EMR system via computer/wireless hub. The BVI 9400 also integrates with Verathon Medical's ScanPoint™ online imaging and calibration service so users can view ultrasound images, save and print exam results, and calibrate their handheld scanner all online.
A printed copy of the scan assists providers who are billing the scan. ICD-9 diagnostic codes to use when billing for the scan include: 788.2 Urinary retention, or 788.21 Bladder, incomplete emptying.
In addition full documentation (manual, quick reference cards, etc.)as well as an in-service session, there is a 4-minute “onboard” video tutorial showing how to use the device.
When using this scanner, factors that can cause inaccurate readings include:
- Morbid obesity.
- Inadequate ultrasound gel. To ensure that this problem does not occur, Verathon Medical offers Sontac® ultrasound gel pads - small disposable discs of gel that are placed on the abdomen of the patient before scanning.
- Improperly aiming the scanhead so the bladder is partially or wholly outside its field of vision.To prevent this problem, nurses should aim the BladderScan® as indicated by icons on the scanhead. User's manuals and training videos also provide instructions on how to position the scanhead properly to obtain correct measurements.
- Moving the probe during the scan.
- Presence of an indwelling urethral catheter. However, such measurements still have clinical utility, as they enable the detection of a blocked catheter.
- Scar tissue, incisions, sutures, and staples can affect ultrasound transmission and reflection; nurses should use care when scanning patients who have had suprapubic or pelvic surgery.
Clinical Indications for the BladderScan®
There are several indications for use of the BladderScan®, which are detailed in the following table.
|Clinical Indications||Benefits of BladderScan®|
|Assessing PVRs to determine urinary retention or incomplete bladder emptying and the need for catheterization in those patients with risk factors (e.g. diabetes, suprapubic tenderness or distension, taking anticholinergics or other medications that interfere with bladder emptying).||Noninvasive procedure with a high-degree of accuracy. May enable patient to avoid intermittent catheterization.|
|To prevent the onset of urinary retention following indwelling catheter (Foley) removal post-hospitalization and to assist with bladder retraining by determining the need to void based on bladder volume. After removal of indwelling urinary catheter, scan four hours after removal until the patient voids with a post-void residual of less than 150 mLs.||Allows early removal of indwelling urinary catheter with the ability to assess for bladder volume (noninvasive).|
|To determine actual bladder volume in patients who have incomplete bladder emptying and who are on scheduled catheterization times to drain the bladder. Performing intermittent catheterizations based on actual volume instead of a specific schedule may avoid unnecessary catheterizations and reduce risk of infection.||To minimize instrumentation of patient while preventing bladder distension and additional complications such as infection.|
|To monitor a post-operative patient or in those patients unable to void (for example, spinal cord injury.)||Establishes a voiding schedule that is based on volume, not time.|
|To determine bladder volume in a patient with decreased urine output. Scan hourly in critical care and every four to six hours in general care.||Assessment of decreased urine volume: Is the patient dehydrated, obstructed?|
|To assist staff in implementing a toileting program by determining the amount of urine in the bladder when attempting to toilet a patient. As first sensation of bladder fullness occurs at 250 mLs, staff should encourage (prompt) the patient to void if scanned volumes were 200 mLs or greater.||Knowledge about bladder volume at any given time may help eliminate unnecessary toileting and allows for accurate assessment of the hydration state. This may be a helpful tool in the patient who has an obsession with frequent toileting.|
An Example of the Clinical Applications of Bladder Assessment Technology
The BVI3000 portable ultrasound scanner has been successfully used by CRISTA Nursing Center, a 176 bed long-term care facility located in North Seattle. CRISTA offers the full spectrum of care including a special unit for dementia. The purchase of the BVI3000 triggered the development of usage guidelines by staff and a plan to ensure that all staff members understood when and why to use the scanner as well as its proper use. A Case Manager was assigned the responsibility for identifying residents who would benefit from a scan and all staff members (RNs, LPNs, and CNAs) were trained in proper use of the scanner. The plan included regular continuing education and demonstrations of correct scanner use. CRISTA discovered that incorporating this new technology into daily practice and care plans took time.
To ensure accuracy of the PVR, the resident receiving the scan was assessed for voiding before the scan, for the inability to void, and for the presence of urinary incontinence. In order to increase efficiency and decrease the amount of time required, the resident was allowed to remain in bed or in a chair. Staff found that using a generous amount of ultrasound gel (two tablespoons or more) increased the accuracy of the readings.
Along with a policy and procedural guide that included physician orders, CHRISTA developed a set of criteria for deciding when to scan a resident:
- To properly diagnose a resident's bladder function to determine incomplete bladder emptying through the measurement of the bladder volume and PVR.
- To determine actual bladder volume in residents who have incomplete bladder emptying and who are on scheduled urinary catheterization times to drain the bladder. The staff felt that performing intermittent catheterizations based on actual volume instead of a specific schedule may avoid unnecessary catheterizations and reduce risk of infection.
- To prevent the onset of urinary retention following indwelling catheter (Foley) removal post-hospitalization and to assist with bladder retraining by determining the need to void based on bladder volume.
- To determine urinary retention or incomplete bladder emptying and the need for catheterization in those residents with risk factors for developing urinary retention (e.g. diabetes or other neurologic diseases, spinal cord injury, men with prostate disorders, suprapubic tenderness or distension, taking anticholinergics or other medications that interfere with bladder emptying).
- To assist staff in implementing a toileting program by determining the amount of urine in the bladder when attempting to toilet a resident. As first sensation of bladder fullness occurs at 250 mLs, staff were told to encourage (prompt) the resident to void if scanned volumes were 200 mLs or greater. Knowledge about bladder volume at any given time may help eliminate unnecessary toileting and allows for accurate assessment of the resident's hydration state (Woolridge, 2000, Newman 2005). This may be a helpful tool in the resident who has an obsession with frequent toileting.
CRISTA developed a pre-scan assessment (See Form 1) that was used on all residents identified as at-risk. The form follows the RAP guidelines for assessment of residents with new onset or worsening incontinence and allows for determination of possible causes of transient incontinence. As a means to determine medical necessity, CRISTA also developed a protocol for scanning residents that outlined indications, scanning procedure and parameters, and specific documentations (See Form 2). Part of the protocol was the requirement for physicians to order the scan and also list the criteria before performing the scan that deemed it a medical necessity (e.g. indications such as urinary retention), the frequency (e. g., three times a day) and the duration of the scans (e. g., two weeks).
Staff reviewed the scan results daily to provide ongoing assessment of medical necessity, evaluate findings, and update care plans. Once the scan was finished, an assessment of the resident was done (See Form 3) and the resulting report was signed by the physician and placed in the resident's medical record. In addition, the scan printout was affixed to a paper, copied and placed in the laboratory reports section of the medical record.
The following are case studies of CRISTA residents whose bladder disorder resolved through the appropriate use of the BladderScan.
Case Study 1: Male resident with history of urinary frequency, UTIs, and falls secondary to self-toileting needs. Bladder scanning revealed urinary retention with PVRs ranging from a low of 53 mLs to a high of 446 mLs. Average scan volume was 330 mLs. A total of forty scans were completed. Resident was referred to a local urologist who diagnosed BPH (benign prostatic hypertrophy) and severe prostatitis. The enlarged prostate was causing urethral obstruction leading to incomplete bladder emptying with overflow incontinence. Urologist prescribed terazosin, an alpha adrenoreceptor blocking agent that shrinks the size of the prostate. Urinary incontinence decreased and residents' comfort increased. Quality of life increased with the addition of a six week course of antibiotic treatment for the prostatitis. Nursing staff felt that urinary retention would have gone unnoticed and UI accepted as being unable to be changed had it not been for analysis of two weeks of bladder volume measurements.
Case Study 2: Female resident with history of chronic urinary retention of approximately 3,000 mLs necessitating the insertion of an indwelling (Foley) catheter. Resident had an extensive history of mental illness with episodic delusions and paranoia. Assessment indicated that resident would not tolerate invasive measuring of PVR with intermittent catheterizations. An indwelling catheter remained in place for approximately one year. With the ability to do noninvasive PVRs with the bladder scanner, the indwelling catheter was discontinued and routine bladder scanning was started. Scan results revealed incomplete bladder emptying with PVRs ranging from 277 mLs to 360 mLs in the first several days but then normal bladder function returned by the end of two weeks (PVRs from 53 mLs to 198 mLs). Resident tolerated bladder scanning well. She was less restless and more comfortable without the indwelling catheter. More importantly, resident's quality of life improved.
Case Study 3: Female resident with ten year history of intermittent self-catheterization secondary to urinary retention following bladder surgery and urinary incontinence. Bladder scanning started to frequently measure PVR's for two weeks to establish current bladder function. Scanning revealed PVR's within normal limits. Resident also started initially on anticholinergics medication for overactive bladder, oxybutynin, which was later, changed to tolterodine and urinary incontinence decreased. Resident no longer needs to self catheterize thus improving her quality of life. Without the bladder scanner, this resident could have feasibly continued with self-catheterization indefinitely.
Case Study 4: An 89-year-old female with diagnosis of an anxiety disorder was identified as a candidate for a nursing rehab toileting program. During the assessment process, CNA reported, "You don't need to do that, she's in the bathroom every 5 minutes!" Care manager assessed resident to be appropriate for bladder scanning to measure PVR's. Scans revealed urinary retention with PVRs of 218 mLs to 956 mLs. Medications evaluated and changes made in an attempt to lower PVR's. Scanning continued but nursing found that readings continued to be elevated (averaged 981 mLs to 998 mLs). Resident was prescribed hydroxyzine 25 mg TID for her anxiety. Medication was discontinued and indwelling (Foley) catheter was inserted. It was noted that elevated PVR's and the placement of an indwelling catheter only exacerbated resident's existing anxiety disorder. After two weeks and a tapering of oxycontin and the addition of neurontin, the catheter was discontinued. Bladder scanning initiated again for three days to measure PVR's. PVR's found to be WNL. Impact on quality of life was tremendous. Bladder scanning allowed noninvasive diagnosis and resolution of urinary retention, which significantly decreased resident's anxiety and increased comfort and psychosocial well being.
In the past, catheterization was a standard process for determining PVR, which resulted in higher than necessary UTIs in the nursing home population. Ultrasonography, especially with portable devices, changed the standard and is being used extensively in acute and rehabilitation care settings to properly diagnose, treat and manage bladder disorders (Wagner & Schmid, 1997; Resnick, 1995; Lewis, 1995). Using portable ultrasonography helps ensure that the facility is providing the best possible care to its residents as well as maintaining their dignity, self-respect and quality of life.
- Source: Karch AM. 1997 Lippincott’s Nursing Drug Guide. Philadelphia: Lippincott-Raven;1997.
American Medical Directors Association (2006) Urinary Incontinence Clinical Practice Guideline, AMDA, Maryland.
Brown, J., Vittinghoff, E., Wyman, J., Stone, KL., Nevitt, MC., Ensrud, KE, et al. (2000) Urinary Incontinence: does it increase risk for falls and fracture? Journal of American Geriatrics Society 48:721-725.
Centers for Medicare and Medicaid Services, (2000) Nursing Home Data Compendium. Centers for Medicare and Medicaid Services, Survey & Certification Group, Division of Nursing Homes.
CMS Manual System, Department of Health & Human Services (DHHS, Centers for Medicare & Medicaid Services (CMS), Pub. 100-07 State Operations Provider Certification, June 28, 2005 Urinary Incontinence Tags F315 and F316.
Colling, JC., Owen, TR., McCreedy, M., Newman, DK. (2003) The Effects of a Continence Program on Frail Community-Dwelling Elderly Persons. Urologic Nursing, 23(2), April,117-122,127-131.
Colling J. (1996) Noninvasive techniques to manage urinary incontinence among care-dependent persons. JWOCN 23(6):302-308.
Coombes, G. M.& Millard, R. J. (1994) The accuracy of portable ultrasound scanning in the measurement of residual urine volume. Journal of Urology 152: 2083-2085.
Fantl, JA, Newman, DK, Colling, J., et al. (1996) Urinary Incontinence in Adults: Acute and Chronic Management Clinical Practice Guideline, No 2, Update, Rockville, MD: US Department of Health and Human Services. Public Health Service, Agency for Health Care Policy and Research, AHCPR Publication No. 96-0682. March.
Gabrel CS JA. The National Nursing Home Survey: 1995 summary. National Center for Health Statistics. Vital Health Statistics. 13 April 2000; 1-83.
Goode, PS., Locher, JL., Bryant, RL., Roth., DL., & Burgio, KL (2000) Measurement of postvoid residual urine with portable transabdominal bladder ultrasound scanner and urethral catheterization. Int Urogynecol J 11(5): 296-300.
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Gray, M. (2000b) Urinary retention management in the acute care setting (Part 2) August 100(8): 36-44.
Lekan-Rutledge D, & Colling, J. (2003) Urinary incontinence in the frail elderly. AJN; [Suppl] March:36-46.
Lewis, N. A. (1995) Implementing a bladder ultrasound program." Rehabilitation Nursing Jul/Aug;20(4): 215-217.
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Posted January 2007
Updated September 2009
- Identification of all primary and secondary medical problems to determine impact on lower urinary tract system.
- Symptoms (e.g., urgency, frequency, nocturia, dysuria, episodes of urine leakage).
- Type and pattern of urinary incontinence.
- Mental Status:
o Ability of resident to recognize bladder fullness (urge sensation).
o Ability to recall location of toileting facility (bathroom).
o Motivation for self-toileting and maintaining continence.
- Bowel History:
o Symptoms of constipation, diarrhea, fecal incontinence, abdominal bloating
o Type of laxatives, stool softeners, suppositories, enemas used in the past.
o Previous problem with fecal impaction and intervention.
- Observation of resident toileting:
o Ability to suppress the urge long enough for the staff to arrive and offer toileting.
o Distance from the bed/chair to bathroom.
o Ability to self-toilet or with minimal assistance.
o Staff takes resident to the bathroom, assists the resident on the toilet and resident voids (positive response to a prompt to void).
o Use of a device such as a bedside commode, urinal.
o Use of absorbent incontinence product and ability to remove the product to self-toilet.
o Straining or apparent difficulty when voiding.
- Diet/fluid intake:
o Assess for the presence of dehydration.
o Total fluid intake in a 3 day period.
o Amount of daily caffeinated beverages and food intake.
- Relationship of bladder dysfunction to medical diagnoses:
o Neurologic diseases (e.g. diabetes, Parkinson's, MS, spinal cord injury)
o Prostate problems (cancer or BPH)
o History of chronic UTIs
o Psychiatric disorder.
- Review of current medications to determine secondary effect on bladder.
- Abdominal examination:
o Presence and quality of bowel sounds.
o Complaints of abdominal or suprapubic tenderness, discomfort, fullness.
o Percussion (dull sound, representing fluid) of the suprapubic areas (dullness of the bladder to the level of the umbilicus indicates at least 500 mLs of urine in the bladder, and bladders containing 1,000 mLs or more extend well above the umbilicus).
o Palpation reveals a mid-line mass extending upward from the suprapubic area. (e.g. enlarged bladder).
- Genitalia examination:
o In men, condition of foreskin and glans penis.
o In women, dryness, redness and thinning of perineum and vaginal introitus may indicate atrophic vaginitis.
o In women, structural abnormalities present such as pelvic organ prolapse.
- Rectal examination:
o Presence of fecal impaction.
o Assessment of rectal sphincter tone
o In men, size of prostate gland
o Obtain a "clean catch" urine specimen. Note urine characteristics: color, odor, presence of sediment.
o Perform a Dipstick urinalysis. If the Dipstick urinalysis is positive for leukocytes esterase indicating significant pyuria) and nitrites (indicating the presence of Enterobacteriaceae) and the resident shows signs and symptoms of a UTI, send a urine specimen for urine culture. A negative leukocyte esterase or the absence of pyuria strongly suggests that a UTI is not present. A positive leukocyte esterase test alone does not prove that the individual has a UTI.
- Urine culture and sensitivity (C&S)
- A urine culture results indicating >10,000 CFU/mL of a single predominant pathogen is sufficient for the microbiological diagnosis of UTI. The most common infecting organisms seen are E coli most common in female residents, Proteus mirabilis in male residents.
- In addition to a positive urine culture, the resident without an indwelling (urethral or suprapubic) catheter has to have at least three of the following signs and symptoms to treat for a UTI. Symptoms are:
- Fever (2.4 degrees Fahrenheit above the baseline temperature) or chills
- New or increased burning pain on urination, frequency or urgency
- New flank or suprapubic pain or tenderness
- Change in character of urine (e.g. new bloody urine, foul smell, or amount of sediment) or as reported by the laboratory (new pyuria which is increased leukocytes in the urine or microscopic hematuria)
- Worsening of mental or functional status i.e., confusion, decreased appetite, unexplained falls, incontinence of recent onset, lethargy, decreased activity.
- In addition to a positive urine culture, the resident with an indwelling (urethral or suprapubic) has to have at least two of the following signs and symptoms to treat for a UTI. Symptoms are:
- Fever (2.4 degrees Fahrenheit above the baseline temperature) or chills
- New flank pain or suprapubic pain or tenderness
- Worsening of mental or functional status.
- Local findings such as catheter obstruction, leakage, or mucosal trauma (may also be present.
- Post void residual (PVR) urine:
o PVR volume must be measured no more than 20 minutes after the resident voids.
o PVR can be obtained by sterile in-and-out catheterization. The use of a portable ultrasonographic device permits noninvasive identification of clinically significant residual urine with an accuracy rate of more than 90%.
o Normal PVR is between 50 mL and 100 mL and findings of between 150 mL and 200 mL bear repeat measurement. Abnormal PVR is > 200 mL and those residents should be referred to the urologist.
Bladder & Bowel Record
- Assessment of voiding and defecation pattern through collection of a 3-day record or some other method.
Functional & Environmental Assessment
o Ability to toilet.
o Can devices such as a bedside commode or urinal be helpful?
o Ability for wheelchair bound resident to propel chair to the toilet in a timely fashion?
o Are restraints, physical or chemical, being used that are causing UI? Physical restraints include various straps and ties, as well as, "geri-chairs". In addition, sedating drugs can act as chemical restraints.
o Is equipment that can enhance mobility such as a cane, walker, and wheelchair available?
o Can improved access to toilets lessen UI?
o Are toilets at least 17 inches high with arms to assist the resident in lowering or rising?
o Are chairs designed for ease in rising?
o Are grab bars available and within the resident's reach when toileting?
Adapted with permission from:
Newman, D.K. (2002) Managing and Treating Urinary Incontinence Health Professions Press, Baltimore, MD. 81-83.
Newman, DK (2005) Bladder and Bowel Rehabilitation Program. SCA Personal Care, Philadelphia, PA.
CMS Manual System, Department of Health & Human Services (DHHS, Centers for Medicare & Medicaid Services (CMS), Pub. 100-07 State Operations Provider Certification, June 28, 2005 Urinary Incontinence Tags F315 and F316.
Newman, D.K. (2002). Managing and Treating Urinary Incontinence, Health Professions Press, Baltimore, Maryland.
Newman, DK (2005) Program of Excellence in Extended Care. Diagnostic Ultrasound, Corp, Bothell, WA.
Newman, DK (2005) Bladder and Bowel Rehabilitation Program. SCA Personal Care, Eddystone, PA.
|Primary Diagnosis ____________________ICD 9 Code:||
________788.2 Urinary Retention
|________788.21 Incomplete emptying of bladder|
|(CHECK ALL THAT APPLY)
|Age____ Male ____ Female ____||____Diruretics (e.g. Lasix, Burnex)|
|Hysterectomy ___yes ____no||____Sedative/Hypnotics
(e.g. Valium, Ativan, Xanax)
|____Urinary Incontinence||Meds with Anticholinergic properties:|
|____Urgency||____Antipsychotics (e.g. Haldol, Risperdal)|
|____Frequency||____Antidepressants (e.g. Trazadone, Elavil)|
|____Recurrent UTI||____Narcotics (e.g. Morphine, Darvon)|
|____Nocturnal Enuresis||____Parkinson's Meds (except Simemet, Deprenyl)|
|____Dysuria||____Antispasmodics (e.g. Donnatal, Bentyl)|
|____Nocturia||____Antihistamines (e.g. Benadryl)|
|____Hematuria||____Calcium Channel Blockers (e.g. Verapamil, Nifedipine)|
|____D/C of Foley||____Drugs affecting the sympathetic nervous system ( e.g. ephedrine, nose drops, prasolin)|
|____Falls r/t toileting|
|____Change in continence status|
|____Hx of urinary retention|
|____Suprapubic pain or discomfort|
|____Dx of neurogenic bladder|
|____Hx of constipation/fecal impaction|
|____Benign prostatic hypertrophy|
|____Hx of Prostrate CA|
|____Hx of Bladder CA|
|____Spinal Cord Disease|
|____Hx of pelvic radiation|
|____Prolapse: ___uterus ___bladder ___rectum|
|____Abnormal labs: ___________________|
MD ORDER: ______________________________________________________
____________________________________________LN Signature______________________ Date
|Resident Name____________ Physician_________________Admit #__________|
|© 2002 CHRISTA|
|Resident Name: ________________________________||Date: __________________________|
|Medical Record #: ______________________________||Time: __________________________|
PVR Amount: _________________ (Call MD for PVR > 250 cc)
|Prior to scan resident was: _______Toileted _______Incontinent ________Unable to void ______Other|
__Volume WNL, for resident
|__Changes in incontinence
__Incomplete emptying of the bladder
© 2002 CHRISTA
Follow up: ________________________________________________________________________
|Resident Name:_______________________ Doctor:______________________ Admit #:__________|
|© 2002 CHRISTA|