Long-Term Care Survey Alert

Published on Wed Apr 27, 2005 PDF

These simple strategies can do more for your QIs than you might think.

Improve residents' bowel health and regularity and watch your QIs follow, especially incontinence and pressure ulcers.

Facilities that feel overwhelmed by tackling a tough urinary incontinence (UI) problem can implement a bowel program and see how that impacts its UI rate, suggested Diane Newman, RNC, MSN, CRNP FAAN, co-director of the Penn Center for Continence and Pelvic Health in Philadelphia. Newman spoke on soon-to-be-released revised survey guidance at F315 (urinary incontinence/catheters) at the March 2005 American Association of Nurse Assessment Coordinators conference in Chicago.

Constipation can be tied to urinary incontinence and numerous other clinical problems. How so? "A full bowel pushes down on the bladder, reducing its capacity, which can cause urinary frequency - or even leakage, if the person's bladder sphincters are weak," says Kathleen Thimsen, MSN, RN, ET, APN, principal of RARE Consulting Group in Bella Vista, AR. "Stool in the rectum can cause bladder retention which leads to overflow incontinence."

Beware: Chronic constipation sometimes leads to fecal impaction, which is a sentinel health event in surveyors' books (one that should rarely, if ever, occur).

Don't be fooled: Fecal impaction may actually manifest as loose stools or fecal incontinence as the stool above the blockage squeezes around it, says Thimsen. "Nurses or physicians should thus do a rectal exam to check for fecal impaction when the resident has fecal soiling, loose stools or urinary incontinence," she adds.

A bowel program can also eliminate behavioral symptoms caused by painful constipation, prevent skin breakdown and improve residents' dignity and quality of life - not to mention staffing morale.

Work Wonders With 4 Strategies

Take these steps to improve residents' bowel regularity and continence:

1. Integrate best-practice dietary approaches to promote normal bowel patterns. One facility used dietary approaches alone to reduce fecal incontinence dramatically - and laxative use by 90 percent, Newman relayed. "The dietitian started by putting out fresh fruit for residents, who initially hoarded it, fearing a limited supply," said Newman.

Next the dietary department substituted higher-fiber brown rice for white. Residents protested an attempt to give up white bread for whole-grained varieties, so the facility abandoned that idea.

The facility also began to offer apricot juice, which is the highest fiber juice - and people tend to like it, said Newman. The dietitian implemented these dietary changes without increasing the facility's food budget.

Don't do this: The dietitian experimented with a cake recipe that tasted like carrot cake but was really made from prunes. "But the residents who ate it for dinner developed diarrhea because no one had stopped their laxatives," Newman said. Once residents adjusted to the dietary program and no longer needed laxatives, the facility used prune and raisin-based puddings and the prune cake.

2. Make sure residents receive fluid sufficient to prevent constipation. Poor hydration can cause or contribute to constipation. "While 1,500 ml per day is the recommended amount, a registered dietitian or physician should determine the resident's fluid needs based on his or her size and health status," said Michelle McDonald, RN, MPH, a DAVE clinical consultant during a Centers for Medicare & Medicaid Services' Webcast. "The general rule of thumb is 30 ml/kg per day," she relayed.

Drinking fluids with meals is probably most helpful to prevent constipation, says Charles Crecelius, MD, a certified medical director in St. Louis, MO. But ingesting an adequate amount of fluids overall is more important than timing, he adds.

Overcome this objection: Some people with bladder incontinence will severely limit fluids and oppose any suggestion to increase their fluid intake,  observes Nancy Holland, EdD, with the National Multiple Sclerosis Society. Yet, very concentrated urine irritates the bladder and causes hyperactivity of the detrusor muscle, she adds. "So the person urinates more frequently." Concentrated urine can also cause urinary tract infection and even bladder stones, especially in people who have some urine retention, Holland adds.

Solution: Educate cognitively intact residents about how fluid restriction actually aggravates their urinary problems. Work with the person to improve and manage her urinary incontinence so she feels comfortable drinking more fluid.

"People with nocturia or night-time incontinence can stop drinking fluids two to three hours before bed, but still drink an adequate amount during the day to ensure optimal bowel functioning," says Holland.

3. Assess and accommodate the resident's usual bowel routine. Pediatric settings have greatly reduced bowel incontinence in kids with neurological impairment due to spina bifida by encouraging them to use the bathroom at a regular time, noted Newman. Nursing facilities can apply the same principle to geriatric populations, including residents with cognitive impairment and reduced mobility.

Nursing staff at Minnewaska Lutheran Home track when the resident tends to have a bowel movement and then incorporate that time for toileting as part of the person's daily routine, reports Karen Johnson, RN, director of nursing at the Starbuck, MN, facility.

"Encouraging patients to toilet based on their usual pattern ... is in keeping with CMS' focus on resident-centered care," observes Karen Merk, RN, BS, CRNAC, clinical consultant with Briggs Corporation in West Des Moines, IA.

Talk to residents at admission to find out their usual elimination routine at home or in assisted living, Merk advises. "If the person has dementia, ask their previous caregivers and family for this information," she adds.

4. Get restorative nursing with the program. Exercise can really help bowel regulation, says Johnson. In her facility, "rehab and restorative nursing, along with the nursing assistants, help residents walk as much as possible," she relates.