Indications for Referral

Consider referral to a continence nurse/APRN specialist (e.g. WOC Nurse, Urologic Nurse, Rehabilitation Nurse), or other continence specialist if:

• Difficulty identifying optimal bladder management strategy
• In and Out catheterization is recommended but staff is unable to perform
• Dual incontinence (urine and fecal) with unsuccessful management plan
• Patient, family, caregiver request

Indications for Referral

Consider referral to a wound care nurse/APRN specialist (e.g. WOC Nurse, Wound Treatment Associate (WTA), Urologic Nurse, Rehabilitation Nurse), or other wound care specialist when any of the following are not addressed by or responsive to facility protocol:

• Medical Device Related Pressure Injury (MDRPI) of skin or mucosa related to an external collection device
• Medical Adhesive-Related Skin Injury (MARSI) related to an external collection device
• Moisture Associated Skin Damage (MASD), including Incontinence Associated Dermatitis (IAD) and Intertriginous Dermatitis (ITD)
• Friction skin injury

Portable Bedside Ultrasound

• Techniques for portable bedside ultrasound assessment vary based on manufacturer; refer to facility protocol or manufacturer's instructions
• The following principles should be used when completing a portable bedside ultrasound:
  • Place the patient in a supine position, the head may be supported on a single pillow
  • Expose the suprapubic area, at the midline and below the umbilicus for scanning
  • Apply ultrasound gel to the suprapubic skin, do not use other lubricating gels
  • Follow facility protocol or manufacturer’s directions to determine bladder volume
• Portable bedside ultrasound assessment accuracy may be compromised by:
  • Fluid filled abdominal mass (Cystic masses)
  • Ascites
  • Large uterine fibroids
  • Morbid obesity
  • Large pannus
  • Late stage pregnancy

Per Facility Protocol

This algorithm contains specific recommendations related to patient care post-indwelling urinary catheter removal. There are instances where empirical data is given as a guide; however, it is recommended that the user refer to facility protocol that may exist for that particular information. Facility protocols and guidelines exist to close the gap between literature recommendation and practice, and these protocols and guidelines vary from agency to agency. This tool is meant to provide guidance and not supersede facility protocol (Kredo et al, 2016).

Skin Care Guidelines

• Cleanse the skin and protect it with one or more moisture barrier products after each incontinent episode.
• Apply and remove moisture barrier products (e.g. creams, ointments, pastes, liquid barrier films) per manufacturer instructions.
• Consider the reduced absorbent capacity of underpads or body worn absorbent products and potential for increased friction when applying a thick layer of ointment or zinc oxide based moisture barrier product.
• Consider the potential for increased friction between the patient’s skin and underpad, body worn absorbent product, external collection device.

Air Fluidized Feature

Support surfaces with air fluidized features are usually used for patients undergoing skin flap or other plastic surgery procedures.

Critical Thinking Point
Urinary Incontinence as a Sign of a Urinary Tract Infection

Classic signs and symptoms of urinary tract infection (UTI) are dysuria, suprapubic pressure or pain, frequent urination with or without fever and hematuria. Urinalysis reveals pyuria and bacteriuria, and urine culture reveals 10⁵ CFU of bacteria. However, few individuals managed by intermittent catheterization will experience these symptoms and more than 50% will have bacteriuria and pyuria on urinalysis. Instead, look for these indicators of UTIs in patients managed with intermittent catheterization:

• New onset of involuntary voiding between catheterizations
• Increased spasticity in patients with spinal cord injuries or other paralyzing spinal disorders
• Malaise
• Cognitive changes such as delirium

Therefore, when a patient managed by intermittent catheterization begins to experience involuntary spontaneous voiding between catheterization, assess for a urinary tract infection before reducing or discontinuing intermittent catheterizations.

Critical Thinking

Feasibility of In and Out or Intermittent Catheterization

• In and Out catheterization is a standard of care in the acute care setting
• For patients with ongoing urinary retention (incomplete bladder emptying), intermittent catheterization is a preferred alternative to indwelling catheterization in the acute care setting.

In and out or Intermittent Catheterization may not be feasible due to:

• Difficult urethral anatomy
• Significant pain with catheterization
• Recent urologic or urogynecologic surgery
• Agitation provoked by attempt to catheterize
• Artificial urinary sphincter (Look for Medical Alert ID)

Use caution or consult provider in patients with

• Recent urologic or urogynecologic surgery of the bladder or urethra
• Painful genital lesions
• Significant genital edema creating difficulty visualizing the urethral meatus

Critical Thinking Point

For example, a patient who has a Braden score of 17 (at risk) and has a Stage 1 or 2 pressure injury on their sacrum or trunk and are able to turn side to side, may not need a different level support surface.

Persons with multiple Stage 2, or large (of sufficient size to compromise a turning surface) or multiple Stage 3 or 4 pressure injuries on the trunk or pelvis involving more than one available turning surface should be placed on a support surface with a low air loss feature or an air fluidized feature.

If a medical condition prohibits turning side to side (e.g. shortness of breath, cardiac rhythm changes, device in place, etc.) and therefore only one turning surface is available, the patient should be placed on a higher level support surface to ensure adequate pressure redistribution.

Support surfaces cannot provide sufficient envelopment to protect patients who have been identified at risk for a pressure injury to the heels. Initiate interventions to elevate the patient’s heels off the bed or chair surface.

Critical Thinking Point

Consider the additional use of an External Collection Device (ECD) if patient is incontinent and:

• Unable to engage in a toileting program
• Require an adjunct to a toileting program
• Needs more accurate estimate of output

Critical Thinking Point

Consider a Body Worn Absorbent Product (BWAP) if patient is incontinent and:

• Cannot be managed by an external collection device (Genital edema or skin in contact with device is not intact)
• During ambulation, therapy or when off-unit in order
• Confused/combative
• To preserve dignity/privacy, prevent falls and reduce environmental contamination
• Patient preference

Using a Coudé Tipped Catheter

• Follow facility procedures for catheterization
• Generously lubricate the catheter prior to insertion in females. In males, insert 10 ml of lubricating gel into the urethra prior to insertion.
• Coudé catheters have a notch, elevated bump or stripe to assist with orientation of the catheter. Insert the catheter so the notch or stripe is facing upward, this will ensure the tip faces upward assisting insertion.
• Use slow steady pressure to minimize discomfort while moving the catheter through the urethra and into the bladder
• Resistance is commonly encountered as the catheter passes through the striated sphincter muscle located just below the prostate in males and mid-urethra in females
• Stop the insertion when you observe urine draining through the catheter
• When drainage stops, slowly withdraw the catheter approximately 1 inch and see if drainage restarts, wait until drainage stops again, this procedure may be repeated several times until the bladder is empty
• Remove and dispose of the catheter using your facility’s procedures

Condom external collection devices - Select a size appropriate device based on manufacturer’s sizing tool and recommendations.

Female Pouch

Independent Toileting
The ability to recognize, respond to and act upon the desire to urinate in a socially appropriate manner.

Strict Intake and Output
Quantitative measurement of fluid intake by mouth, feeding tube or parenteral routes, along with quantitative measurement of liquid output from the urinary bladder and other drainage devices. Intake and output are measured over a 24-hour (daily) period and typically expressed in ml.

Coefficient of Friction (CoF) Dry or Wet
Measures the relative ratio between the force necessary to move one surface (eg. a patient’s skin) over another surface (e.g. an underpad) and the pressure between the two surfaces.

The CoF of fabrics against the skin is mainly influenced by:

• The nature of the fabric; e.g., rougher fabrics produce higher coefficients of friction
• Skin moisture content, Moisture vapor transfer rates (MVTR), and surface wetness, which increase the CoF and are particularly relevant in the clinical context where skin may be damp from perspiration or incontinence
• Ambient humidity, in that high humidity may increase skin moisture content or induce sweating and therefore increase CoF

A measurement of the amount of friction existing between two surfaces.

Indwelling Catheter has been removed

Did the patient void spontaneously within 6 hours?

Indwelling Catheter has been removed

Was post void residual volume ≤ 200 ml or per facility protocol?

Indwelling Catheter has been removed

Is total bladder volume < 400 ml or per facility protocol?

Indwelling Catheter has been removed

Does patient report suprapubic discomfort or urge to urinate?

Indwelling Catheter has been removed

Does spontaneous voiding occur?

Indwelling Catheter has been removed

Was post void residual volume ≤ 200 ml or per facility protocol?

Assess Toileting Ability

Is Patient able to toilet (Urinate into toilet, bedside commode, urinal, bedpan)?

• Able to recognize, respond to and act upon cues to urinate in a socially appropriate manner
• Has adequate mobility or dexterity to toilet with the assist of one caregiver
• Toileting does not cause intolerable pain or agitation

Assess Continence Between Toileting Episodes

Is the patient continent?

Assess Continence Between Toileting Episodes

Patient is incontinent.

Assess Continence Between Toileting Episodes

Does patient require strict monitoring of intake and output?

Assess Continence Between Toileting Episodes

Does patient require strict monitoring of intake and output?

Assess Toileting Ability

Clinical Decision Making to Determine Bladder Management

• External Collection Devices and Underpads are first line therapies for patients who are incontinent and unable to toilet and are often used in combination.
• External Collection Devices allow more accurate measurement of urine output than underpads.
• Consider a urine management wrap for males whose urinary incontinence is not adequately contained by underpads.
• Underpads allow for containment of urine not captured by External Collection Devices.
• Underpads are a good choice to contain fecal incontinence.

Toileting

Guidelines

Toileting should be the first line strategy for bladder management of any patient who is able to toilet independently or with assistance.

• Provide assistance with toileting and cue as needed at a fixed interval starting at every 2 hours when awake and individualize toileting schedules based upon patient needs (e.g. fluid intake, time of day, diuretic use and incontinence frequency)
• For patients who do not require cueing at fixed intervals, provide toileting assistance in a timely manner.
• Night time toileting should be based upon patient need and the goals of care
• Do not routinely awaken patient during the night for toileting
• Adequate pain management is an integral part of a toileting program
• Document toileting strategy and plan of care
• Include toileting plan and patient response during hand–off to ensure consistent implementation.
• The outcome of a successful toileting plan does not necessarily include absence of incontinence; goals for Successful Toileting Program include:
• Decrease in number of incontinence episodes
• Reduce risk for skin damage
• Improve patient satisfaction and preserve dignity
• Reduce agitation in cognitively impaired persons

Toileting

Special Considerations

• If needed, use an incontinence containment product that promotes as much toileting independence as possible.
• Consider patient preference related to choice of toileting method (toilet vs. bedside commode, urinal, bedpan, absorbent product, external collection device).
• Consider use of assistive aides to promote toileting; refer to occupational therapy or physical therapy as needed.
  • Walkers, canes
  • Clothing modification such as elastic waist pants
  • Raised toilet seat
  • Bedside commodes
  • Female or male urinals

Toileting - At time of Discharge to Home

Care is coordinated and communicated with the discharge planner (e.g. case manager, social worker), patient and family to promote a seamless transition of care for bladder management. This plan of care may include:

• Supplies and guidance on how to secure supplies
  • Toileting instructions for patient and caregiver
  • Body Worn Absorbent Products (BWAP) and source for obtaining additional product
  • External Collection Devices and source for obtaining additional product*
  • Support Surfaces (Prescription required)
  • Disposable medical supplies and source for obtaining additional product
  • Durable medical equipment (Prescription required)
    • 3 in 1 bedside commode, raised toilet seat
    • Grab bars (Resources for installation, usually installed by plumber or contractor)
    • Walker, cane, assistive aides
    • Portable suction machine if external suction collection devices used at home*
• Follow-up care referrals
  • Home care
  • Continence care provider
  • Occupational therapy and/or physical therapy
• Healthy Bladder Tips

Toileting - At time of Discharge to Post-Acute Care Facility

Care is coordinated and communicated with the discharge planner (e.g. case manager, social worker), patient and family to promote a seamless transition of care for bladder management. This plan of care should include:

• Toileting instructions for patient and caregiver
• Body Worn Absorbent Products (BWAP)
• Underpads
• External collection devices
• Support Surface

Underpads

Critical Thinking – Consider patient preference in relation to incontinence management

Guidelines

• Assess prior history of bladder management strategies and use of absorbent products, including underpads.
• When ordering underpads, contact your supply chain management team to order the correct product(s) from the contracted manufacturer within your facility/department.
• Consider using silk-like bed linen system (sheets, underpad) with a low coefficient of friction (CoF) to prevent skin injury. Features include an absorbent core that rapidly contains moisture and disseminates it throughout the entire underpad and successfully prevents moisture strike-through.
• Consider using underpads with embedded technology that alert care providers to episodes of urinary incontinence.
• Minimize the number and type of layers (e.g. clothing, bed linens and underpads) between the patient and support surface.
• Do not use underpads for turning and repositioning patients with incontinence unless designed for that purpose.
• Underpads should be changed as soon as possible after an incontinent episode.

Special Considerations

Use a breathable (non-plastic back or silk-like linen) underpad on support surfaces with low air loss feature for patients with incontinence and a Braden Moisture subscale score of 2 (very moist) or 1 (constantly moist).

Consider a urine management wrap for males whose urinary incontinence is not adequately contained by underpads.

Underpads

Is the patient’s Braden mobility subscale score ≤ 2?

Support Surfaces

Guidelines

Support surfaces are not a stand-alone intervention for the prevention and treatment of pressure injuries but are to be used in conjunction with proper nutritional support, moisture management including incontinence, turning and repositioning, risk identification, and patient and caregiver education.

• A support surface with a low air loss feature may be indicated for a diaphoretic patient or a patient with copious wound drainage or incontinence not contained by dressings or absorbent products.
• Minimize the number and type of layers (underpads, clothing and linens) between the patient and the support surface.
• Support surfaces do not eliminate the need for turning and repositioning.
• When choosing a support surface, consider current patient characteristics and risk factors, including weight and weight distribution; fall and entrapment risk; risk for developing new pressure injuries; number, severity, and location of existing pressure injuries; as well as previous support surface usage and patient preference.
• The person who exceeds the weight limit or whose body dimensions exceed his or her current support surface should be moved to a bariatric support surface.
• For persons who are incontinent and are candidates for progressive mobility, consider a support surface that facilitates getting out of bed (egress) with the addition of a body worn absorbent product (BWAP) when ambulating out of the room.
• Consider a body worn absorbent product (BWAP) if patient is going off unit for procedures.
• Persons who have medical contraindications for turning should be considered for a support surface and frequent small shifts in positioning.
• For persons experiencing intractable pain, consider providing an alternative to the current support surface.
• Persons with a new myocutaneous flap on the posterior or lateral trunk or pelvis should be provided with a support surface per facility protocol.
• Consider concurrent use of a pressure redistribution seating surface along with use of any support surface.

Special Considerations

Consider fall risk when choosing between a support surface with a low air loss feature or a low bed. Patient safety is always the priority.

Consider an alternate support surface for patients who complain of noise, heat or discomfort related to use of support surface.

Click to learn more about the use of Support Surfaces for management of incontinence, https://algorithm.wocn.org/

Support Surfaces

Skin breakdown on the trunk/pelvis?

External Collection Devices

External Collection Devices - Male

Guidelines - Male

Use external collection devices for patients who are incontinent and:

• Unable to engage in a toileting program
• Require an adjunct to a toileting program
• Require monitoring of urine output

External collection devices should not be used for staff convenience.

• Devices
  • Condom catheter
  • Non-sheath glans adherent devices (sheath, Texas catheter)
  • Penis pouch (Retracted penis pouch)
• Device Selection
  • Consider a condom catheter in males with:
    • Intact penile skin
    • Adequate penile shaft length to accommodate device
  • Consider a non-sheath glans adherent device or penis pouch in males with:
    • Buried or retracted penis
    • Shorter penile shaft length
    • Do not use external female collection devices in males

External Collection Devices - Male

Guidelines - Male

• When using a condom external collection device:
  • Inspect the skin of the glans penis and penile shaft for inflammation and integrity prior to initial application or device change.
  • Select an appropriately sized device based on manufacturer’s sizing tool and recommendations
  • Avoid use of condom external collection devices in patients with spina bifida of a history of hypersensitivity or allergy to latex.
  • Cleanse and dry the skin before application
  • Apply adhesive or securement mechanism based on manufacturer’s recommendations.
  • Do not apply additional adhesive securement products to the penis.
  • Expected wear time is 1 to 2 days.
• When applying a penis pouch (retracted penis pouch):
  • Inspect the penile and suprapubic skin adjacent to the penis for inflammation and integrity
  • Clip hair as needed
  • Cleanse and dry the skin before application
  • Place the penis through the pouch opening. Hold the adherent surface in place using gentle, warming hand pressure to activate the adhesive.
  • Do not apply additional adhesive or securement products to the penis or suprapubic skin.
  • The expected wear time is 1 to 2 days.

External Collection Devices - Male

Guidelines - Male

• When using non-sheath glans adherent external collection devices:
  • Inspect the glans penis and skin of the penile shaft for inflammation and integrity prior to initial application or device change.
  • Cleanse and pat dry before application or device change.
  • Follow manufacturer recommendations; gentle, warming hand pressure is essential to activate the adhesive.
  • Do not apply additional adhesive or securement products to the penis.
  • Expected wear time is 2 – 3 days.

External Collection Devices - Male

Special Considerations – Male

Consider use of an external collection device

• During procedures where the patient may have to lay still for a period of time such as:
  • Imaging procedures (MRI, CT)
  • Following cardiac catheterization or other endovascular procedure
• High volume urine production at night

External Collection Devices - Female

Guidelines - Female

Use external collection devices for patients who are incontinent and:

• Unable to engage in a toileting program
• Require an adjunct to a toileting program
• Require monitoring of urine output

External collection devices should not be used for staff convenience.

• Devices
  • External suction collection device
  • External pouch
• When applying external suction collection devices in females:
  • Inspect the skin of the genital area for inflammation, integrity and vaginal discharge.
  • Cleanse the patient’s genital area from front to back.
  • Visualize perineal area, gently separate the labia and position device with the tubing connection facing up
  • Ensure the device is touching the skin.
• Change device every 8 to 12 hours or when absorbent fabric is soiled with feces or body fluids other than urine.

External Collection Devices - Female

Guidelines - Female
External Suction Device

• Maintain a dedicated suction canister and tubing system.
• Do not place an external suction collection device for females into any body orifice.
• Remove external suction collection devices when patient is ambulating or leaves unit
• When transferring patients to a bedside chair:
  • Remove device
  • Position patient in chair with absorbent underpad
  • Reapply device only if able to ensure correct placement and adequate containment of urine and prevent medical device related pressure injury
  • Ensure appropriate suction and tubing length
  • Reassess device placement with routine repositioning, ensure suction tubing is not beneath patient
• Reevaluate the need for external suction collection devices as mobility and cognitive function improve.
• Maintain continuous suction; set minimum suction level of 40mmHg based on manufacturer recommendation. Safe maximum suction levels have not been determined; follow facility protocol.

External Collection Devices - Female

Guidelines - Female
External Suction Device

• Do not use External Suction Collection Devices in females who are:
  • Placed in prone position
  • Agitated, combative or uncooperative
  • Experiencing frequent episodes of bowel incontinence without adequate containment
  • Exhibiting inflammation, loss of skin or mucosal integrity, painful genital lesions or significant genital edema
  • Experiencing moderate/heavy menstruation and unable to use a tampon
  • Observed to have vaginal wall outside of the vagina (prolapse)
• When changing or removing external collection device follow manufacturers recommendations or facility protocol:
  • Verify suction is at 40mmHg
  • Gently displace device in a manner that avoids fecal contamination
  • Assess skin integrity and perform perineal care

External Collection Devices - Female

Guidelines - Female
Pouches

• When applying a pouch for urinary containment in a female:
  • Inspect the genital and suprapubic skin for inflammation and integrity
  • Clip hair as needed
  • Cleanse and dry the skin before application
  • Place the pouch opening over the urethral meatus and vaginal introitus. Hold the adherent surface in place using gentle, warming hand pressure to activate the adhesive.
  • Do not apply additional adhesive or securement products to the pouch or suprapubic skin.
  • The expected wear time is 1 to 2 days.

External Collection Devices - Female

Special Considerations - Female

• Mesh briefs may be worn as a securement device. Do not apply additional adhesive or other securement products.
• When using an external suction urine collection device in patients with dual incontinence, consider the use of fecal containment options such as small anal pads, external pouches or internal containment devices.
• Consider nighttime use of external suction collection devices to maximize sleep in patients unable to engage in a toileting program.
• Consider use of an external suction collection device
  • During procedures where the patient may have to lay still for a period of time such as:
    • Imaging procedures (MRI, CT)
    • Following cardiac catheterization or other endovascular procedure
  • High volume urine production at night

External Collection Devices

At time of Discharge to Home (Male and Female)

Care is coordinated and communicated with the discharge planner (e.g. case manager, social worker), patient and family to promote a seamless transition of care for bladder management. This plan of care may include:

• Supplies and guidance on how to secure supplies
  • External Collection Devices and source for obtaining additional product*
  • Absorbent products (underpads and body worn) and source for obtaining additional product
  • Toileting instructions for patient and caregiver
  • Support Surfaces (Prescription required)
  • Disposable medical supplies and source for obtaining additional product
  • Durable medical equipment (Prescription required)
    • 3 in 1 bedside commode, raised toilet seat
    • Grab bars (Resources for installation, usually installed by plumber or contractor)
    • Walker, cane, assistive aides
    • Portable suction machine if external suction collection devices used at home*
• Follow-up care referrals
  • Home care
  • Continence care provider
  • Occupational therapy and/or physical therapy
• Healthy Bladder Tips

External Collection Devices

At time of Discharge to Post-Acute Facility (Male and Female)

Care is coordinated and communicated with the discharge planner (e.g. case manager, social worker), patient and family to promote a seamless transition of care for bladder management. This plan of care should include:

• At time of discharge from acute care facility
• External collection devices
• Absorbent products (underpads and body worn)
• Toileting instructions for patient and caregiver
• Support Surface
• Disposable medical supplies

In and Out Catheterization

Guidelines

• Assess history of intermittent catheterization.
• Use sterile technique.
• Choose the smallest possible size catheter (14 – 16 French).
• Avoid use of in and out catheters containing latex in patients with spina bifida or history of hypersensitivity or allergy to latex
• Coudé tipped catheters should be available for men with prostate enlargement or other patients who are difficult to catheterize with a straight-tipped catheter.
• Catheterize at least every 6 hours in patients with normal renal function and urine output.
• Consult provider if residual volumes are < 200 ml in the presence of a pattern of spontaneous voiding or per facility protocol?

Contraindications

• Active urethral bleeding, genital trauma
• Fournier’s Gangrene (Necrotizing Fasciitis) of the genital area

In and Out Catheterization

Special Considerations

• In patients with high urine output due to edema, heart failure, kidney disease, etc. perform portable bedside ultrasound before in and out catheterization and consider more frequent catheterizations
• Perform portable bedside ultrasound in patients who exhibit signs of bladder fullness (agitation, restlessness, elevated blood pressure, midline lower abdominal discomfort and distention) and, if needed, alter intermittent catheterization schedule
• If patient experiences urinary incontinence between catheterizations, consider:
  • Portable bedside ultrasound prior to next scheduled catheterization to assess bladder volume and increase intermittent catheterization interval for volumes ≥ 400 ml or discontinue in and out catheterization when spontaneous voiding returns and residual volumes are < 200 ml or per facility protocol.
  • Urine Culture and Sensitivity for urinary tract infection (in consultation with provider)
  • Other interventions for urinary incontinence
  • Preventive interventions for Incontinence Associated Dermatitis (IAD)

Is In and Out Catheterization feasible?

In and Out Catheterization

Does spontaneous voiding occur within 24 hours AND is residual volume ≤ 200 ml or per facility protocol

Is there a facility protocol that allows Intermittent Catheterization?

In and Out Catheterization

Indwelling catheter reinserted?

Intermittent Catheterization

Guidelines

• Assess history of intermittent catheterization.
• Use sterile technique.
• Choose the smallest possible size catheter (14 – 16 French).
• Avoid use of in and out catheters containing latex in patients with spina bifida or history of hypersensitivity or allergy to latex
• Coudé tipped catheters should be available for men with prostate enlargement or other patients who are difficult to catheterize with a straight-tipped catheter.
• Catheterize at least every 6 hours in patients with normal renal function and urine output.
• Consult provider regarding reduction or discontinuation of intermittent catheterization frequency if residual volumes are consistently < 200 ml in the presence of an onset of spontaneous voiding (persisting for more than 24 hours); consider the possibility of a UTI.

Intermittent Catheterization

Special Considerations

• In patients with high urine output due to edema, heart failure, kidney disease, etc. perform portable bedside ultrasound before intermittent catheterization and consider more frequent catheterizations
• Perform portable bedside ultrasound in patients who exhibit signs of bladder fullness (agitation, restlessness, elevated blood pressure, midline lower abdominal discomfort and distention) and, if needed, alter intermittent catheterization schedule
• If patient experiences urinary incontinence between catheterizations, consider:
• Portable bedside ultrasound prior to next scheduled catheterization to assess bladder volume and increase intermittent catheterization interval for volumes ≥ 400 ml or discontinue intermittent catheterization with spontaneous voiding and residual volume < 200 ml or per facility protocol.
• Urine Culture and Sensitivity for urinary tract infection (in consultation with provider) Other interventions for urinary incontinence
• Preventive interventions for Incontinence Associated Dermatitis (IAD)

Intermittent Catheterization

Consult provider regarding alteration or discontinuation of intermittent catheterization program if residual volumes are consistently < 200 ml in the presence of a pattern of spontaneous voiding (greater than 24 hours).

Did provider discontinue intermittent catheterization or reduce frequency to once or twice daily?

Intermittent Catheterization

At time of Discharge to Home

Care is coordinated and communicated with the discharge planner (e.g. case manager, social worker), patient and family to promote a seamless transition of care for bladder management. This plan of care may include:

• Supplies and guidance on how to secure supplies
  • Catheter type (French size, straight vs. Coudé tip) and catheterization frequency
  • Toileting instructions for patient and caregiver
  • Body Worn Absorbent Products (BWAP) and source for obtaining additional product
  • External Collection Devices and source for obtaining additional product
  • Support Surfaces (Prescription required)
  • Disposable medical supplies and source for obtaining additional product
  • Durable medical equipment (Prescription required)
    • 3 in 1 bedside commode, raised toilet seat
    • Grab bars (Resources for installation, usually installed by plumber or contractor)
    • Walker, cane, assistive aides
    • Portable suction machine if external suction collection devices used at home
• Follow-up care referrals
  • Home care
  • Urologist and continence care provider
  • Occupational therapy and/or physical therapy
• Healthy Bladder Tips

Clean Intermittent Catheterization Discharge Instructions – Male

Clean Intermittent Catheterization Discharge Instructions – Female

Intermittent Catheterization

At time of Discharge to Post-Acute Care Facility

Care is coordinated and communicated with the discharge planner (e.g. case manager, social worker), patient and family to promote a seamless transition of care for bladder management. This plan of care may include:

• Catheter type (French size, straight vs. Coudé tip) and catheterization frequency
• Underpads
• Support Surfaces
• External collection devices
• Body Worn Absorbent Products (BWAP)
• Disposable medical supplies

Body Worn Absorbent Products (BWAP)

Guidelines

• In the acute care setting, body worn absorbent products (BWAP) should be used for patients with incontinence who cannot be managed by an external collection device during ambulation, therapy or when off-unit in order to preserve dignity/privacy, prevent falls and reduce environmental contamination.
• Body worn absorbent products (BWAP) should not be used for staff convenience.
• Change times of absorbent products should not be based on routine and staff convenience.
• When assessing incontinent patients for selecting an absorptive product, consider the following factors:
  • Gender
  • Waist or hip circumference, if these cannot be measured, use BMI as a reference
  • Mobility and Dexterity
  • Patient preference and acceptability and goals of care
  • Cognition
• Assess incontinence severity (light or moderate/heavy) and timing (nighttime vs daytime) in order to assist in the selection of Body Worn Absorbent Products (BWAP).

Body Worn Absorbent Products (BWAP)

Guidelines for Males

• Moderate to heavy urinary incontinence or dual urinary and fecal incontinence
  • First line recommendation: Disposable pull ons with superabsorbent polymer technology.
  • Alternative recommendation: Disposable absorbent briefs with superabsorbent polymer technology.
    • When selecting products, consider the following:
      • Comfort
      • Containment effectiveness (absorbent capacity, location of absorbent surface, elastication and elastic leg gathers)
      • Odor control
      • Skin protection (pH, breathability/breathable side panels, pressure redistribution properties)
      • Aesthetics (noise control, absence of rustling, low profile beneath clothing, and other aesthetic elements such as color, design, and appearance)
  • Change frequency:
  • Optimal change time after urinary incontinence varies based on urine elimination patterns, sleep-wake patterns, absorbent product properties, and perceptions of wet comfort.
  • Change times should be patient centered and not based on routine and caregiver convenience.

Body Worn Absorbent Products (BWAP)

Guidelines for Females

• Moderate to heavy urinary incontinence or dual urinary and fecal incontinence
  • First line recommendation: Disposable pull ons with superabsorbent polymer technology.
  • Alternative recommendation: Disposable shape pads with superabsorbent polymer technology worn with close-fitting underwear.
• When selecting products, consider the following:
  • Comfort
  • Containment effectiveness (absorbent capacity, location of absorbent surface, elastication and elastic leg gathers)
  • Odor control
  • Skin protection (pH, breathability/breathable side panels, pressure redistribution properties)
  • Aesthetics (noise control, absence of rustling, low profile beneath clothing, and other aesthetic elements such as color, design, and appearance)
  • Change frequency:
    • Optimal change time after urinary incontinence varies based on urine elimination patterns, sleep-wake patterns, absorbent product properties, and perceptions of wet comfort.
    • Change times should be patient centered and not based on routine and caregiver convenience

Body Worn Absorbent Products (BWAP)

Special Considerations

• When constructing facility formulary, advocate for multiple designs (briefs, pull-ons, pads, shields and guards) and sizes of Body Worn Absorbent Products (BWAP) to manage incontinence.
• When ordering absorbent products, contact your supply chain management team to order the correct product(s) from the contracted manufacturer within your facility/department.
• Consider continued use of patient preferred Body Worn Absorbent Products (BWAP) for incontinence management. If preferred product is not available, consult with patient and family regarding the need for them to provide preferred absorbent products.
• Patients in toileting programs who are intermittently incontinent should be using a pull-on or an undergarment with a pad, guard or shield (vs absorbent brief).

Learn more about the use of Body Worn Absorbent Products (BWAP) for management of incontinence, https://bwap.wocn.org/

Body Worn Absorbent Products (BWAP)

At time of Discharge to Home

Care is coordinated and communicated with the discharge planner (e.g. case manager, social worker), patient and family to promote a seamless transition of care for bladder management. This plan of care may include:

• Supplies and guidance on how to secure supplies
  • Absorbent products (underpads and body worn) and source for obtaining additional product
  • Toileting instructions for patient and caregiver
  • External Collection Devices and source for obtaining additional product*
  • Support Surfaces (Prescription required)
  • Disposable medical supplies and source for obtaining additional product
  • Durable medical equipment (Prescription required)
    • 3 in 1 bedside commode, raised toilet seat
    • Grab bars (Resources for installation, usually installed by plumber or contractor)
    • Walker, cane, assistive aides
    • Portable suction machine if external suction collection devices used at home*
• Follow-up care referrals
  • Home care
  • Continence care provider
  • Occupational therapy and/or physical therapy
• Healthy Bladder Tips

Body Worn Absorbent Products (BWAP)

At time of Discharge to Post-Acute Care Facility

Care is coordinated and communicated with the discharge planner (e.g. case manager, social worker), patient and family to promote a seamless transition of care for bladder management. This plan of care may include:

• Absorbent products (BWAP and underpads)
• Toileting instructions for patient and caregiver
• External Collection Devices
• Support Surfaces