Incontinence 101

Having spent 3 years in various wards, community areas, clinics etc., there has always been one problem which many of my patients have been affected by; incontinence!

Incontinence can be urinary, faecal or both. Incontinence is not a disease, rather a sign of a lifestyle problem, or a symptom of a medical condition. It affects between 3 and 6 million people (!!!!), and many do not seek help until much later. This needs to change!

Types of incontinence

Stress incontinence -not actually related to stress! It means that there is pressure on the bladder due to pregnancy, being overweight, sneezing, lifting heavy objects and some medical conditions (such as prostate cancer). It happens because the pelvic floor and urinary sphincter are weakened.

Overactive bladder- this is when you feel a strong urge to urinate, as your bladder is not relaxed. This means your bladder doesn’t like any amount of urine, so is constantly telling you to get rid of it! This can be caused by the type of fluids you drink, like caffeine or alcohol. It may be due to dehydration, as small concentrated amounts of urine in the bladder will irritate it. A urinary tract infection (UTI) can also cause an overactive bladder, but this is easily ruled out through a urine dip.

incontinence

Functional incontinence- This means that the incontinence is occurring as they are unable to reach the toilet on time, often due to immobility but also caused by Dementia or other physical/mental illnesses.

Mixed incontinence- As the name suggests, this is when there are two causes of incontinence. For example, a mix of stress and overactive bladder. Very common in women!

Total incontinence- This is the most severe, as there is no control over the bladder so there is constant leakage. This can be due to bladder abnormalities, spinal cord damage or bladder fistulas.

Faecal incontinence

Faecal incontinence can be harmless or serious, so it’s important to know all the details! Diarrhoea and constipation are the most common causes. Chronic constipation can lead to a weakening of rectal and intestinal muscles, causing faecal leakage. This is common in people with Parkinson’s.

How can you prevent incontinence?

  • Avoid/cut down on “bladder unfriendly” things such as caffeine, alcohol and spicy/acidic foods
  • Regular exercise (the answer to everything!)
  • Regular pelvic floor exercises
  • Treat any constipation and diahorrea quickly
  • Don’t strain during bowel movements, as this can weaken the muscles which control your bowel movements and only allow small amounts of faeces to pass

Treatments

There are so many options, and it depends upon the persons health and mental capacity, as well as the type of incontinence they have.

Pelvic floor exercises– These strengthen the pelvic floor muscles, which is the most effective treatment for stress or childbirth related incontinence. They are undertaken for 12 weeks, and must be completed 3 times a day (8 contractions each time).

Bladder training- This is a method I’ve been doing accidentally in all my years as a waitress/student nurse (2 professions where emptying you bladder needs to be precisely scheduled with your many other tasks). It involves delaying the passing of urine for 5-10 minutes, in order to force the bladder to wait. Techniques to achieve this include crossing you legs, standing on your toes, distracting yourself or applying pressure to your perineum.

Medicinal- I won’t go too far into detail, as I’m not an expert just a keen observer. Medicinal treatment of incontinence only works for overactive or mixed incontinence, and it is not the first-line of treatment (in nurse-led services). Drugs such as Oxybutynin, Tolterodine, Darifenacin and Festoterodine. These drugs are either immediate or extended release, with extended release causing less side effects but interacting with more drugs. They work by inhibiting the parasympathetic nerve impulses, relaxing your bladder. However, it is highly important to educate your patients about the possibility of urinary retention with these drugs, and a bladder scan is required 4 weeks after starting these treatments.

So that’s your one stop blog about continence! I can highly recommend spoking with your local continence service, whether in hospital or community, as you learn so much!

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Student Nurse Advocate

images.jpegAdvocating for patients, in my opinion, is one of our most privileged roles and one we should take very seriously. I have often found, our position as Student Nurses affords us a certain advantage when it comes to patient’s openness right from day 1. Because we are often very hands-on, we know our patients very intimately and they feel more able to open-up to us about smaller concerns they may not feel were important enough to raise with their doctor or consultant for example. This carries a responsibility for us to make sure we take all patient’s concerns seriously and act on/escalate anything that, using our theoretical knowledge, may be of importance to their care. This also takes a pinch of courage to have confidence in your instincts and “back yourself” as we say on the Rugby pitch.

Last week while assisting a patient with his wash (which is often a time when I learn the most about a patient) he told me he hadn’t slept well that evening as he had visited the bathroom over 10 times in the night. This patient was due for discharge in the coming days so this was concerning for me. As an elderly gentleman with hypertension, heart disease and other comorbidities, he was at risk of Falls and if he is going up and down to the bathroom so regularly, especially in the night, he may sustain a serious injury such as a fractured neck of femur. I looked through his drug kardex and found he was on very high doses of furosemide, a loop diuretic that is often prescribed to patients with Heart failure to prevent oedema.Renal_Diuretics.gif

I asked the patient if he was happy for me to discuss this with his doctors and a specialist continence nurse to see if something could be done to help either reduce this frequency or make provisions for his discharge so he isn’t at an increased falls risk, he agreed and I approached his doctor.

This encounter wasn’t entirely successful. When I proposed reducing his diuretics to the doctor, initially his response was “Do you want him to die of heart failure?” – in front of the patient…

keep-calm-and-back-yourself-4Not exactly the response I was hoping for, but I explained my concerns from a Nursing point of view and emphasised I am aware that his furosemide was prescribed for a reason and it is entirely his decision, I just wanted to advocate my patient’s best interests.

This exchange I felt didn’t end on a particularly positive note, so later in the day I apologised to the doctor saying “I didn’t mean to question his treatment I just wouldn’t feel comfortable if I didn’t make you aware of his concerns to see if we could work together towards a solution”. The doctor was much more amicable and smiled and said he understood and would consider what could be done.

Not long after this, the same doctor stopped me and said he had written a letter to the patient’s GP to recommend reducing his diuretics in the community and observe his response. He felt changing his medications the day before discharge might impact on his fitness for discharge. He also suggested trialling Oxybutynin. When I recognised Oxybutynin as an anti-muscarinic (which would improve his feelings of urgency), his face lit up. I have a feeling, he may not have expected me to possess such knowledge.

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So many speech bubbles but 1 shared goal – patient’s wellbeing

Only upon writing this have I realised just how many units of study went into this encounter; Communications, Anatomy and Physiology, Pharmacology, Applied Pharmacology, Nursing Therapeutics, Recovery focused care and Medicines Management all informed my actions in this case. Reflecting on this scenario I am really pleased with the outcomes we achieved. Not only was the gentleman’s GP made aware of our concerns and recommendations but I managed to speak to the Trust’s continence specialist nurse and get her recommendations for interim provisions to help the patient transition into community. I fed all this back to the patient who was visibly relieved and so grateful we had pursued his concerns and formulated an action plan he understood and would work for him.

Advocating for patients is a vital part of the Nursing role and we can see advocacy in the NMC code in various different guises (see 3.4, 4.1, 8.6, 8.7 & 9.3).

Week 2 – DILP Questions Answered!

At the end of my second week working in a Sri Lankan hospital I am pretty exhausted. It’s been a really full on week; my first ever in A&E and it’s been absolutely invaluable. I’ve observed lots of amazing Nursing and care but can’t seem to keep myself from thinking “Oh, that’s not how we do it in England” every time something surprises me.

IMG_7797.JPGAfter last week’s post a few of you had some questions about the DILP and how myself and others went about it. Since I have organized my placement independently I referred to my friends currently working in Andhupura who have gone through Work the World for their DILP about their experiences too. They explaned that they chose Andhupura because it seemed to have a richer culture compared to Kandy and was near the beaches of Trincomalee which is one of Sri Lanka’s best preserved pieces of coast-line with clear blue waters and lots of snorkeling opportunities.

Firstly and often most crucially going abroad for this placement is an expensive undertaking. Going through an agency condenses all the costs however into one lump sum you pay directly to them to organize accommodation, flights etc. this can be paid in installments or in one go but the deadline is a couple of months before you fly. It has been known for people to fundraise to pay for their DILP but none of the lovely Ladies in Andhupura did but we were told by the DILP unit lead to expect to pay around £3000 through an Agency so fund raising may be a very good option.

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Our ECG machine – complete with metal suction cups

Since I organized mine independently it cost a lot less, around £1500 for flights, accommodation, visa’s, insurance and the cost of living whilst I’m here. Although recommending someone to go it alone abroad is much like recommending someone to do a home birth without alerting a midwife. It can be super rewarding and great but if something goes wrong – it can be really disastrous.

Work the World have been really wonderful with all the students who worked with them, really helpful and easy to contact which made the whole process very straightforward and stress-free. Also the students (who come from all over and include OTs and Medics) with Work the World all stay near to eachother which is nice to have a little support hub of people all going through the same thing.

People were curious about time off and whether or not we have the ability to actually experience the country and the culture whilst working 37.5 hours a week. We were unanimous in our answer of YES!! 7.5 hours a day with early starts does mean it’s not advisable to be staying up late every night having cocktails at a beach bar but there is always the weekends for that!

I’ve been working 8 hour shifts (excl. breaks) 7-3.30 each day which leaves me a big chunk of the afternoon to do as I please. With a coupe of 12 hour night shifts thrown in I’m finishing placement in 6 weeks (30 days) as opposed to the 7 weeks (33 working days excl. bank holidays) allocated by the university. This means I’ll have a week at the end of my placement exclusively for free time.

I’m lucky enough to be able to stay on for a while after placement is done to travel around the island a bit and holiday with my family and boyfriend which is a really nice goal to aim for when I’m missing home.

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“Difficulty walking, slurring speech, brain stem stroke”

The language barrier can be frustrating at times but all medical terms are spoken and written in English so you can spot quite easily what each case is about. Most of the Nurses I’ve encountered have a good grasp of English so if you ask questions, they will try their hardest to explain. The best thing about working abroad is the independence. You are relying on your Nursing instincts and knowledge, I’ve learnt a lot from my mentors and patients but I have taught them a lot as well. I’ve introduced a new standardized handover tool, which has been saving hours of staff time. I’ve been screenshot-ing and explaining tools such as the Bristol Stool Chart and the SBAR in an effort in increase the use of evidence based assessment tools. The staff are really keen to learn as am I which makes for a really engaging and exciting atmosphere in the ward.

Again any more questions you have about working abroad, working independently or the DILP in general please do comment on our Facebook page or email us at enhancingplacement@gmail.com