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## Complete Summary

#### GUIDELINE TITLE

Urinary incontinence (UI) in older adults admitted to acute care. In:
Evidence-based geriatric nursing protocols for best practice.

#### BIBLIOGRAPHIC SOURCE(S)

Dowling-Castronovo A, Bradway C. Urinary incontinence (UI) in older
adults admitted to acute care. In: Capezuti E, Zwicker D, Mezey M,
Fulmer T, editor(s). Evidence-based geriatric nursing protocols for best
practice. 3rd ed. New York (NY): Springer Publishing Company; 2008. p.
309-36. \[45 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Dowling-Castronovo A, Bradway
C. Urinary incontinence. In: Mezey M, Fulmer T, Abraham I, Zwicker DA,
editor(s). Geriatric nursing protocols for best practice. 2nd ed. New
York (NY): Springer Publishing Company, Inc.; 2003. p. 83-98. \[26
references\]

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Urinary incontinence

#### GUIDELINE CATEGORY

Evaluation\
Management\
Prevention\
Risk Assessment\
Treatment

#### CLINICAL SPECIALTY

Geriatrics\
Nursing\
Urology

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Health Care Providers\
Hospitals\
Nurses\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

To provide a standard of practice protocol for management of urinary
incontinence by nurses in practice settings

#### TARGET POPULATION

Older adults hospitalized for acute care

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Evaluation**

1.  Documentation of presence/absence of urinary incontinence (UI) on
    admission

2.  Determination of presence/absence of indwelling catheter and
    appropriate catheter use

3.  Assessment for type of UI and its possible etiologies

**Treatment/Management**

1.  General prevention and management

    -   Identification and treatment of causes

    -   Individualized plan of care

    -   Avoidance of contributing factors: medications, indwelling
        urinary catheters, bladder irritants, hydration status,
        overweight, environmental factors

    -   Prevent skin breakdown

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2.  Strategies for specific problems (stress, urge, overflow, and
    functional UI)

    -   Pelvic floor muscle exercises (PFMEs)

    -   Toileting assistance and bladder training

    -   Referral for pharmacological, surgical, or physical therapies

    -   Bladder training

    -   Information on urge inhibition

    -   Sufficient voiding time

    -   Double voiding and Crede\'s maneuver

    -   Sterile intermittent catheterization

    -   Scheduled or prompted voiding

    -   Adequate fluid intake

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3.  Patient education regarding urinary incontinence

4.  Follow-up monitoring

#### MAJOR OUTCOMES CONSIDERED

-   Episodes of urinary incontinence

-   Urinary tract infection

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Although the AGREE instrument (which is described in Chapter 1 of the
original guideline document) was created to critically appraise clinical
practice guidelines, the process and criteria can also be applied to the
development and evaluation of clinical practice protocols. Thus the
AGREE instrument has been expanded for that purpose to standardize the
creation and revision of the geriatric nursing practice guidelines.

**The Search for Evidence Process**

Locating the best evidence in the published research is dependent on
framing a focused, searchable clinical question. The PICO format---an
acronym for population, intervention (or occurrence or risk factor),
comparison (or control), and outcome---can frame an effective literature
search. The editors enlisted the assistance of the New York University
Health Sciences librarian to ensure a standardized and efficient
approach to collecting evidence on clinical topics. A literature search
was conducted to find the best available evidence for each clinical
question addressed. The results were rated for level of evidence and
sent to the respective chapter author(s) to provide possible
substantiation for the nursing practice protocol being developed.

In addition to rating each literature citation to its level of evidence,
each citation was given a general classification, coded as \"Risks,\"
\"Assessment,\" \"Prevention,\" \"Management,\"
\"Evaluation/Follow-up,\" or \"Comprehensive.\" The citations were
organized in a searchable database for later retrieval and output to
chapter authors. All authors had to review the evidence and decide on
its quality and relevance for inclusion in their chapter or protocol.
They had the option, of course, to reject or not use the evidence
provided as a result of the search or to dispute the applied level of
evidence.

**Developing a Search Strategy**

Development of a search strategy to capture best evidence begins with
database selection and translation of search terms into the controlled
vocabulary of the database, if possible. In descending order of
importance, the three major databases for finding the best primary
evidence for most clinical nursing questions are the Cochrane Database
of Systematic Reviews, Cumulative Index to Nursing and Allied Health
Literature (CINAHL), and Medline or PubMed. In addition, the PsycINFO
database was used to ensure capture of relevant evidence in the
psychology and behavioral sciences literature for many of the topics.
Synthesis sources such as UpToDate® and British Medical Journal (BMJ)
Clinical Evidence and abstract journals such as Evidence Based Nursing
supplemented the initial searches. Searching of other specialty
databases may have to be warranted depending on the clinical question.

It bears noting that the database architecture can be exploited to limit
the search to articles tagged with the publication type
\"meta-analysis\" in Medline or \"systematic review\" in CINAHL.
Filtering by standard age groups such as \"65 and over\" is another
standard categorical limit for narrowing for relevance. A literature
search retrieves the initial citations that begin to provide evidence.
Appraisal of the initial literature retrieved may lead the searcher to
other cited articles, triggering new ideas for expanding or narrowing
the literature search with related descriptors or terms in the article
abstract.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence**

**Level I**: Systematic reviews (integrative/meta-analyses/clinical
practice guidelines based on systematic reviews)

**Level II**: Single experimental study (randomized controlled trials
\[RCTs\])

**Level III**: Quasi-experimental studies

**Level IV**: Non-experimental studies

**Level V**: Care report/program evaluation/narrative literature reviews

**Level VI**: Opinions of respected authorities/Consensus panels

Reprinted with permission from Springer Publishing Company: Capezuti,
E., Zwicker, D., Mezey, M. & Fulmer, T. (Eds). (2008) *Evidence Based
Geriatric Nursing Protocols for Best Practice*, (3^rd^ ed). New York:
Springer Publishing Company.

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Levels of evidence (**I -- VI**) are defined at the end of the \"Major
Recommendations\" field.

**Parameters of Assessment**

-   Document the presence/absence of urinary incontinence (UI) for all
    patients on admission (\"Assessment,\" 2000 **\[Level VI\]**).

-   Document the presence/absence of an indwelling urinary catheter.

    -   Determine appropriate indwelling catheter use: severely ill
        patients, patient with Stage III to IV pressure ulcers of the
        trunk, urinary retention unresolved by other interventions
        (Wound Ostomy Continence Nurse\'s Society, 1996 **\[Level
        VI\]**).

-   For patients with presence of UI:

> The nurse collaborates with interdisciplinary team members to:

-   Determine whether the problem is transient, established
    (stress/urge/mixed/overflow/functional), or both and document (Fantl
    et al., 1996 **\[Level I\]**; \"Assessment,\" 2000 **\[Level
    VI\]**); Johnson et al., 2001 **\[Level VI\]**).

-   Identify and document the possible etiologies of the UI (Fantl et
    al., 1996 **\[Level I\]**; \"Assessment,\" 2000 **\[Level VI\]**).

**Nursing Care Strategies**

-   General principles that apply to prevention and management of all
    forms of UI:

    -   Identify and treat causes of transient UI (\"Assessment,\" 2000
        **\[Level VI\]**).

    -   Identify and continue successful pre-hospital management
        strategies for established UI.

    -   Develop an individualized plan of care using data obtained from
        the history and physical examination, and in collaboration with
        other team members.

    -   Avoid medications that may contribute to UI (Kane, Ouslander, &
        Abrass, 2004 **\[Level VI\]**).

    -   Avoid indwelling urinary catheters whenever possible to avoid
        risk for urinary tract infection (UTI) (Dowd & Campbell, 1995
        **\[Level IV\]**; Bouza et al., 2001 **\[Level IV\]**; Madigan &
        Neff, 2003 **\[Level I\]**; Zimakoff et al., 1996 **\[Level
        IV\]**; Wong, 1981 **\[Level VI\]**).

    -   Monitor fluid intake and maintain an appropriate hydration
        schedule.

    -   Limit dietary bladder irritants (Gray & Haas, 2000 **\[Level
        VI\]**).

    -   Consider adding weight loss as a long-term goal in discharge
        planning for those with a body mass index (BMI) greater than 27
        (Subak et al., 2005 **\[Level II\]**).

    -   Modify the environment to facilitate continence (Fantl et al.,
        1996 **\[Level I\]**; Jirovec, 2000 **\[Level VI\]**; Palmer,
        1996 **\[Level VI\]**).

    -   Provide patients with usual undergarments in expectation of
        continence, if possible.

    -   Prevent skin breakdown by providing immediate cleansing after an
        incontinent episode and utilizing barrier ointments (Ersser et
        al., 2005 **\[Level I\]**).

    -   Pilot test absorbent products to best meet patient, staff, and
        institutional preferences (Dunn et al., 2002 **\[Level I\]**),
        bearing in mind that diapers have been associated with UTIs
        (Zimakoff et al., 1996 **\[Level IV\]**).

-   Strategies for specific problems:

> **Stress UI**

-   Teach pelvic floor muscle exercises (PFMEs) (Bo, Talseth, & Holme,
    1999 **\[Level II\]**; Hay-Smith & Dumoulin, 2006 **\[Level I\]**;
    \"Assessment,\" 2000 **\[Level VI\]**).

-   Provide toileting assistance and bladder training as needed
    (\"Assessment,\" 2000 **\[Level VI\]**).

-   Consider referral to other team members if pharmacologic or surgical
    therapies are warranted.

> **Urge UI**

-   Implement bladder training (retraining) (\"Assessment,\" 2000
    **\[Level VI\]**; Teunissen et al., 2004 **\[Level I\]**).

-   If patient is cognitively intact and is motivated, provide
    information on urge inhibition (Gray, 2005 **\[Level VI\]**; Smith,
    2000 **\[Level VI\]**).

-   Teach PFMEs to be used in conjunction with bladder training or
    retraining (Flynn, Cell, & Luisi, 1994 **\[Level IV\]**).

-   Collaborate with prescribing team members if pharmacologic therapy
    is warranted.

-   Initiate referrals for those patients who do not respond to the
    above.

> **Overflow UI**

-   Allow sufficient time for voiding.

-   Discuss with interdisciplinary team the need for determining a
    post-void residual (PVR) (\"Assessment,\" 2000 **\[Level VI\]**;
    Shinoplous, 2000 **\[Level VI\]**; Weiss, 1998 **\[Level VI\]**)
    (see Figure 13.1 in the original guideline document)

-   Instruct patients in double voiding and Crede\'s maneuver (Doughty,
    2000 **\[Level VI\]**).

-   Sterile intermittent is preferred over indwelling catheterization as
    needed (Saint et al., 2006 **\[Level II\]**; Terpenning, Allada, &
    Kauffaman, 1989 **\[Level IV\]**; Warren, 1997 **\[Level VI\]**).

-   Initiate referrals to other team members for those patients
    requiring pharmacologic or surgical intervention.

> **Functional UI**

-   Provide individualized, scheduled toileting or prompted voiding
    (Eustice, Roe, & Paterson, 2005 **\[Level I\]**; Jirovec, 2000
    **\[Level VI\]**; Ostaszkiewicz, Johnston, & Roe, 2005 **\[Level
    I\]**).

-   Provide adequate fluid intake.

-   Refer for physical and occupational therapy as needed.

-   Modify environment to be conducive to maintaining independence with
    continence (Fantl et al., 1996 **\[Level I\]**; Jirovec, 2000
    **\[Level VI\]**; Jirovec, Brink, & Wells, 1988 **\[Level VI\]**);
    Palmer, 1996 **\[Level VI\]**).

**Follow-up Monitoring of Condition**

-   Provide patient/caregiver discharge teaching regarding outpatient
    referral and management.

-   Incorporate continuous quality improvement (CQI) criteria into
    existing program.

-   Identify areas for improvement and enlist multidisciplinary
    assistance in devising strategies for improvement.

**Definitions**:

**Levels of Evidence**

**Level I**: Systematic reviews (integrative/meta-analyses/clinical
practice guidelines based on systematic reviews)

**Level II**: Single experimental study (randomized controlled trials
\[RCTs\])

**Level III**: Quasi-experimental studies

**Level IV**: Non-experimental studies

**Level V**: Care report/program evaluation/narrative literature reviews

**Level VI**: Opinions of respected authorities/Consensus panels

Reprinted with permission from Springer Publishing Company: Capezuti,
E., Zwicker, D., Mezey, M. & Fulmer, T. (Eds). (2008) *Evidence Based
Geriatric Nursing Protocols for Best Practice*, (3^rd^ ed). New York:
Springer Publishing Company.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=13163)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for selected
recommendation.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

**Patient**

-   Fewer or no episodes of urinary incontinence (UI) or complications
    associated with UI

**Nurse**

-   Documentation of assessment of continence status at admission and
    throughout hospital stay. If UI is identified, documentation and
    determination of type of UI

-   Use of interdisciplinary expertise and interventions to assess and
    manage UI during hospitalizations

-   Inclusion of UI in discharge planning needs and referral as needed

**Institution**

-   Decreased incidence and prevalence of transient UI

-   Hospital policies that require assessment and documentation of
    continence status

-   Improved administrative support and ongoing education regarding
    assessment and management of UI for staff

#### POTENTIAL HARMS

Indwelling urinary catheters are associated with the risk of urinary
tract infection (UTI).

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Resources

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness\
Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Dowling-Castronovo A, Bradway C. Urinary incontinence (UI) in older
adults admitted to acute care. In: Capezuti E, Zwicker D, Mezey M,
Fulmer T, editor(s). Evidence-based geriatric nursing protocols for best
practice. 3rd ed. New York (NY): Springer Publishing Company; 2008. p.
309-36. \[45 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2003 (revised 2008)

#### GUIDELINE DEVELOPER(S)

Hartford Institute for Geriatric Nursing - Academic Institution

#### GUIDELINE DEVELOPER COMMENT

The guidelines were developed by a group of nursing experts from across
the country as part of the Nurses Improving Care for Health System
Elders (NICHE) project, under sponsorship of The John A. Hartford
Foundation Institute for Geriatric Nursing.

#### SOURCE(S) OF FUNDING

Supported by a grant from The John A. Hartford Foundation

#### GUIDELINE COMMITTEE

Not stated

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Primary Authors*: Annemarie Dowling-Castronovo, Christine Bradway

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Dowling-Castronovo A, Bradway
C. Urinary incontinence. In: Mezey M, Fulmer T, Abraham I, Zwicker DA,
editor(s). Geriatric nursing protocols for best practice. 2nd ed. New
York (NY): Springer Publishing Company, Inc.; 2003. p. 83-98. \[26
references\]

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [Hartford Institute for Geriatric
Nursing Web
site](http://consultgerirn.org/topics/urinary_incontinence/want_to_know_more).

Copies of the book *Geriatric Nursing Protocols for Best Practice*, 3rd
edition: Available from Springer Publishing Company, 536 Broadway, New
York, NY 10012; Phone: (212) 431-4370; Fax: (212) 941-7842; Web:
[www.springerpub.com](http://www.springerpub.com/).

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Urinary incontinence assessment in older adults part I---transient
    urinary incontinence. Try this: best practices in nursing care to
    older adults. 2007. Electronic copies available from the [Hartford
    Institute for Geriatric Nursing Web
    site](http://consultgerirn.org/uploads/File/trythis/issue11-1.pdf).

-   Urinary incontinence assessment in older adults part
    II---established urinary incontinence. Try this: best practices in
    nursing care to older adults. 2007. Electronic copies available from
    the [Hartford Institute for Geriatric Nursing Web
    site](http://consultgerirn.org/uploads/File/trythis/issue11-2.pdf).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on February 2, 2004. The information
was verified by the guideline developer on February 26, 2004. This NGC
summary was updated by ECRI Institute on November 13, 2008. The updated
information was verified by the guideline developer on November 20,
2008.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

#### NGC DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 12/8/2008