Wound, Ostomy, and Continence Nurses Society (WOCN®)

IPCaRe - Interventions Post Catheter Removal

Funded by an unrestricted education grant from
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Acknowledgement

Glossary

References

Resources

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How to Use This Guide

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Algorithm Introduction

Despite recent advances in continence management for adults, evidence guiding bladder management strategies following discontinuation of an indwelling urinary catheter in the acute care setting is particularly sparse.  To address this gap and guide best-practice, the WOCN Society has developed a consensus-based algorithm for acute care settings focusing on patient assessment and the selection and use of bladder management strategies after indwelling urinary catheter removal. This algorithm will fill the gap in evidence available for first-line and WOC specialty practice nurses and guide optimal bladder management following the removal of an indwelling urinary catheter.

To learn more about the algorithm’s development, we invite you to read the accompanying article, "Interventions Post Catheter Removal (iPCaRe) in the Acute Care Setting: An Evidence- and Consensus-Based Algorithm", published in the Journal of Wound, Ostomy and Continence Nursing: November/December 2020 - Volume 47 - Issue 5 - p 601-618

The electronic version of the algorithm will guide you through a series of assessments. Click on the appropriate orange box to move on to the next step of the algorithm. When you reach the end of your pathway, the final result will be displayed in an orange box.

This algorithm is written for acute care but may be adapted to post-acute care.

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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
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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
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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

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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).

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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.
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Air Fluidized Feature

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

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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.

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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
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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.

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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
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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
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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
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Repeatedly Washed Silk-Like Polyester (Magnified)

Silk-Like Polyester

  • Fibers remain unchanged
  • Continuous fibers reduce friction ahd shear

Repeatedly Washed Traditional Polyester/Cotton Blend (Magnified)

Polyester/Cotton Blend

  • Broken fibers create a "rough surface"
  • Creates additional friction and shear

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

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Female Pouch

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

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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.

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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.

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Acknowledgement

Thank you to the dedicated developers of the Interventions Post Catheter Removal (iPCaRe) Clinical Tool:

Sandra Engberg, PhD, RN, CRNP, FAAN
University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania

Terrie Beeson, MSN, RN, CCRN, ACNS-BC
Indiana University Health, University Hospital, Indiana

Dea Kent, DNP, RN, NP-C, CWOCN
Indiana University- Kokomo, School of Nursing, Kokomo, Indiana

Dianne Mackey, MSN,RN,CWOCN
Kaiser Permanente, San Diego, California

Laurie McNichol, MSN, RN, CNS, GNP, CWOCN, CWON-AP, FAAN
Cone Health, Greensboro, North Carolina

Donna L. Thompson, MSN, CRNP, FNP-BC, CCCN-AP
Division of Urogynecology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania

Mikel Gray, PhD, RN, FNP, PNP, CUNP, CCCN, FAANP, FAAN
Department of Urology, University of Virginia, Charlottesville, Virginia

The WOCN Society does not endorse any specific brands or products.

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Resources

The WOCN Society does not endorse any specific brands or products.

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References

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  2. AUGS. Urinary incontinence in women. Practice Bulletin No. 155. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015; 126:e66–81.

  3. Averch D, Stoffel J, Goldman HB, Griebling TL, Lerner L, Newman DK, Peterson AC. Catheter-Associated Urinary Tract Infections: Definitions and Significance in the Urologic Patient. 2014; AUA Guideline.https://www.auanet.org/guidelines/catheter-associated-urinary-tract-infections Accessed October 27 2019.

  4. Ayello EA, Baranoski S, Lyder C, Cuddigan J. Pressure ulcers. In: Baranoski S, Ayello EA, eds. Wound Care Essentials: Practice Principles. Philadelphia, PA: Lippincott Williams & Wilkins; 240-70. 2004.

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  6. Black, JM, Gray, M, Bliss, D, et al. MASD part 2: incontinence-associated dermatitis and intertriginous dermatitis: a consensus. J Wound Ostomy Continence Nurs. 2011;38(4),359-370. doi: 10.1097/WON.0b013e31822272d9

  7. Byun SS, Kim HH, Lee E, Paick JS, Kamg W, Oh SJ. Accuracy of bladder volume determinations by ultrasonography: are they accurate over entire bladder volume range? Urology. 2003 Oct;62(4):656-60.

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  10. Colwell, J, Ratliff, C, Goldberg, M, et al. MASD part 3: peristomal moisture– associated dermatitis and periwound moisture–associated dermatitis: a consensus. J Wound Ostomy Continence Nurs. 2011;38(5),541- 553. doi: 10.1097/WON.0b013e31822acd95

  11. Cottenden A. Fader M. Beeckman D. et al. Management using continence products. In: Abrams, P, Cardozo, L, Wagg, A, et al. ed. Incontinence. 6th ed. ICS/ICUD;2017: 2303-2426.

  12. D’Ancona CD, Haylen BT, Oelke M, Herschorn S, Abranches-Monteiro L, Arnold EP, Goldman HB, Hamid R, Homma Y, Marcelissen T, Rademakers K, Schizas A, Singla A, Soto I, Tse V, de Wachter S. An International Continence Society (ICS) Report on the Terminology for Adult Male Lower Urinary Tract and Pelvic Floor Symptoms and Dysfunction. Neurourol Urodyn. 2019 DOI: 10.1002/nau.23897

  13. Diaz, DC Robinson, D. Bosch, R, Costantini, E, Cotterill, N Espuna-Pons, M, Kocjancic, E, Lemos, N, Tarcan, T, Yoshida, M. Initial assessment of urinary incontinence in adult male and female patients. In Abrams, P, Cardozo, L, Wagg, A, Wein A. eds Incontinence 6th ed ICS/ICUD.2017; 497-540.

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  15. Edsberg, L. E., Black, J. M., Goldberg, M., McNichol, L., Moore, L., & Sieggreen, M. (2016). Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System: Revised Pressure Injury Staging System. Journal of Wound, Ostomy, and Continence Nursing: official publication of The Wound, Ostomy and Continence Nurses Society, 43(6): 1-13.

  16. *Edsberg LE, Black JM, Goldberg M, McNichol L, Moore L, Sieggreen M. Revised national pressure ulcer advisory panel pressure injury staging system. J Wound Ostomy Continence Nurs 2016;43(6):585-597.

  17. Ferrarin M, Ludwig N. Analysis of thermal properties of wheelchair cushions with thermography. Med Bio Eng Comput 2000;38(1):31-34

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  19. Gerhardt LC, Strassle V, Lenz A, Spencer ND, Derler S. Influence of epidermal hydration on the friction of human skin against textiles. J.R.Soc. Interface (5), 1317-1328, 2008.

  20. Gormley, Em, Lightner, DJ, Burgio, KL, Chai, TC, Clemens, JQ, Culkink DJ, Das, K, Foster, HE, Scarpero, HM, Tessier, CD, Vasvada, SP. Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU Guideline. 2014

  21. Gray, M, Black, JM, Baharestani, M, et al. Moisture-associated skin damage overview and pathophysiology. J Wound Ostomy Continence Nurs. 2011;38(3), 233-241. doi: 10.1097/WON.0b013e318215f798

  22. Gray M, Kent D, Ermer-Seltun J, McNichol L. Assessment, selection, use, and evaluation of body-worn absorbent products for adults with Incontinence. J Wound, Ostomy Continence Nurs. 2018;45(3):243-264.

  23. Gray M, Skinner C, Kaler W. External Collection Devices as an Alternative to the Indwelling Urinary Catheter. Journal of Wound, Ostomy and Continence Nursing 2016; 43(3): 301-7.

  24. Hagedorn JC, Wessels H. A contemporary update on Fournier's Gangrene. Nature Reviews in Urology 2017; 14: 205-14.

  25. Haylen BT et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourol Urodyn 2010; 29:4–20.

  26. Haylen BT, Frazer MI, MacDonald JH. Assessing the effectiveness of different urinary catheters in emptying the bladder: an application of transvaginal ultrasound. Br J Urol. 1989 Oct;64(4):353-6.

  27. Irion, G. Etiologies of common wounds. In: Comprehensive Wound Management. 2nd ed. Thoroughfare, NJ:Slack; 2010:73-148.

  28. Johnson, E. The Condom Catheter: Urinary Tract Infection and Other Complications. Southern Medical Journal, Vol 76, NO. 5, May, 1983

  29. Kosiak M. Etiology and pathology of ischemic ulcers. Arch Phys Med Rehabil;40:62-9, 1959.

  30. Kredo, T., Berhardsson, S., Machingaidze, S., Young, T., Louw, Q., Ocodo, E., and Grimmer, K. (2016). Guide to clinical practice guidelines: the current state of play. Ing J Qual Health Care; 28(1): 122-128. doi: 10.1093/intqhc/mzv115

  31. Lucas, MG, Bedretdinova, D, Bosch, JIHR, Burkhard,F, Cruz, F, Nambiar, AK deRidder, DJMK, Tubaro, A, Pichard, RS. Guidelines on Urinary Incontinence. European Association of Urology 2013

  32. Maklebust J. Pressure ulcers: etiology and prevention. Nurs Clin North Am;22:359-77, 1987.

  33. McNichol L, Lund C, Rosen T, Gray M. Medical Adhesives and Patient Safety: State of the Science Consensus Statements for the Assessment, Prevention, and Treatment of Adhesive-Related Skin Injuries. J Wound Ostomy Continence Nurs 2013,40(4):365-380. doi: 10.1097/WON.0b013e3182995516

  34. McNichol L, Watts C, Mackey D, Beitz JM, Gray M. Identifying the right surface for the right patient at the right Time. J Wound Ostomy Continence Nurs. 2015;42(1):19-37.

  35. Middleton, J, Ramakrushnan, K, Cameron, I. Management of the Neurogenic Bladder for Adults with Spinal Cord Injuries. Chatswood, NSW Australia: Agency for Clinical Innovation. 2013.

  36. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler (Ed.).Cambridge Media: Osborne Park, Western Australia;2014,p.84.

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  38. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler (Ed.).Cambridge Media: Osborne Park, Western Australia;2014,p.326.

  39. National Pressure Ulcer Advisory Panel (NPUAP),European Pressure Ulcer Advisory Panel (EPUAP), Pan Pacific Pressure Ulcer Injury Alliance (PPPIA),. (2014). Prevention and Treatment of Pressure Ulcers: Clinical Practic Guideline. Washington, DC: NPUAP.

  40. Prentice, D., Sona, C., Wessman, B., Ablordeppey, E., Isakow, W., Arroyo, C. and Schallom, M. (2017). Discrepancies in measuring bladder volumes with bedside ultrasound and bladder scanning in the intensive care unit: A pilot study. Journal of the Intensive Care Society, 19(2), pp.122-126.

  41. Rew M, Lake H, Moore KB. The use of Tiemann tip catheters for male self-catheterization. British Journal of Nursing. 2018;27(9): S18-S25.

  42. Saint S; Krein SL; Fowler KE; Colozzi J; Ratz D; Lescinskas E; Chrouser K; Trautner BW. Condom Catheters versus Indwelling Urethral Catheters in Men: A Prospective, Observational Study. Journal of Hospital Medicine (Online). 14:E1-E4, 2019 Mar 20.

  43. Schade EB, Oliver-McNeil, S, Benkert T, George N. A quality improvement project to educate nurses on coudé catheter placement. Urologic Nursing. 2015; 35(4): 187-203.

  44. Tailly T. Denstedt JD. Fundamentals of urinary tract drainage. In: Wein A. Kavoussi LR. Partin A. et al. Urology. 11th ed. Philadelphia: Elsevier; 2016: 119-135.e7.

  45. Taylor D, Sierra T, Duenas-Garcia O et al. Accuracy of bladder scanner for the assessment of postvoid residual volumes in women with pelvic organ prolapse. Female Pelvic Med Reconstr Surg. 2018; 25(5):388-391.

  46. The Free Dictionary. Intake and output. Medical Dictionary for the Health Professions and Nursing, Farlex, 2012, https://medical-dictionary.thefreedictionary.com/intake+and+output , Accessed February 2 2020.

  47. Thornburn P, Fader M, Dean G, Brooks R, Cottenden A. Improving the performance of small incontinence pads: a study of “wet comfort”. J Wound Ostomy Continence Nurs 1997 Jul;24(4):219-25

  48. Tse, V, King, J, Dowling, C. English, S. Gray, K, Milard, R, O’Connell, H, Pillay, S, Thavaseelan, J. Conjoint Urological Society of Australia and New Zealand (USANZ) and Urogynaecological Society of Australasia (UGSA) Guidelines on the management of adult non-neurogenic overactive bladder. BJU Int 2016; 117: 34–47

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  50. Waites KB, Canupp KC, DeVivo MJ. Epidemiology and risk factors for urinary tract infection following spinal cord injury. Arch Phys Med Rehabil. 1993 Jul;74(7):691-5.

  51. Yates, S., McNichol, L., Heinecke, S. B., & Gray, M. (2017). Embracing the Concept, Defining the Practice, and Changing the Outcome: Setting the Standard for Medical Adhesive-Related Skin Injury Interventions in WOC Nursing Practice. J Wound Ostomy Continence Nurs. official publication of The Wound, Ostomy and Continence Nurses Society, 44(1): 13-17.

  52. Zhong, W., Xing, M.M.Q., Pan, N.& Maiback, H.I., Textiles and Human Skin, Microcliomate, Cutaneous Reactions: An Overview, Cutaneous and Ocular Taxicology, (25), 23-29, 2006.

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Glossary

Bladder Management Program

A bladder management program is a set of interventions that assist patients with any type of voiding dysfunction to adequately empty the bladder and minimize adverse effects. Voiding dysfunction includes urinary retention and urinary incontinence.​

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.

Condom Catheter (Sheath/Texas Catheter)

External urinary catheter collection device, which is a sheath that is rolled over the penile shaft, then secured with adhesive or non-adhesive methods. The device is connected to a urinary drainage bag by attaching the distal end of the sheath to a urinary drainage bag.

Coudé Tipped Catheter

A coudé tipped catheter (sometimes referred to as Tiemann tip) has a slight bend or angle in it that enhances insertion (catheterization) in some individuals. The most common indication for a coudé tipped catheter is a male with an enlarged prostate; clinical experience strongly suggests that it is useful for a variety of situations where catheter insertion with a straight tip (sometimes referred to as a Nealton catheter) is difficult.

Dependent Toileting

The need for assistance and/or prompting from a care provider to toilet.

External Collection Devices

External Collection Devices: a group of devices that adhere to the external genitalia or pubic area and collect urinary output; they are further divided into the following categories: condom catheters, reusable body-worn urinals, non-sheath glans adherent and suction devices.

Friction (frictional force)

Friction is the adherent force resisting shearing movement of the skin, which may result in denuded areas of the dermis through repeated epidermal shedding or avulsion of layers of epidermis.

Prolonged exposure to moisture (perspiration, urinary/fecal incontinence or friction (directly) and shear forces (indirectly) wound exudates increases:

  • Adverse effects of friction and shear forces on tissue by further weakening the intercellular bonds in the epidermal layers, causing maceration and epidermal ulceration.
  • The resistance to motion in a parallel direction relative to the common boundary of two surfaces.

Friction Skin Injury

External forces applied to skin resulting in separation of skin layers. This resultant injury may be either partial or full thickness in severity.

In and Out Catheterization

In and Out catheterization is often called straight catheterization or single catheterization; it is a one time insertion and removal of a catheter for the purpose of bladder emptying or evaluation of post void residual.​

Independent Toileting

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

Intermittent Catheterization

Intermittent catheterization (IC) is the act of passing a catheter into the bladder to drain urine or maintain stricture patency via the urethra or a catheterizable channel such as a Mitrofanoff diversion. Urine is drained and the catheter removed until the next indicated time.

Intertriginous Dermatitis

An inflammatory condition of skin folds, induced or aggravated by heat, moisture, maceration, friction, and lack of air circulation, and characterized by moist erythema, malodor, weeping, pruritus, and tenderness.

Moisture Associated Skin Damage (MASD)

Moisture-associated skin damage (MASD) is caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, saliva, and their contents.

MASD is characterized by inflammation of the skin, occurring with or without erosion or secondary cutaneous infection. Multiple conditions may result in MASD; 4 of the most common forms are:

  • Incontinence-associated dermatitis (IAD)
  • Intertriginous dermatitis (ITD)
  • Periwound moisture-associated dermatitis (PWMASD)
  • Peristomal moisture-associated dermatitis (PMASD)

Resultant skin damage is attributable to multiple factors, including chemical irritants within the moisture source, its pH, mechanical factors such as friction, and associated microorganisms.​

Medical Adhesive-Related Skin Injury (MARSI)

Medical adhesive-related skin injury (MARSI) occurs when erythema or other forms of skin injury persist for 30 minutes or longer after removal of an adhesive device; common forms of MARSI include epidermal stripping, tension injuries or blisters, skin tears, irritant contact dermatitis, allergic dermatitis, maceration, and folliculitis.​

Medical Device Related Pressure Injury (MDRPI)

Medical device related pressure injuries (MDRPI) result from the use of devices designed and applied for diagnostic or therapeutic purposes.

The resultant pressure injury generally conforms to the pattern or shape of the device. This injury should be staged using the pressure injury staging system.

Moisture Strike Through

Measures the relative amount of liquid forced back through the top layer of an underpad, brief or pad when a saturated pad is placed under pressure. A lower re-wet value reflects product dryness.

Moisture Vapor Transmission Rate (MVTR)

The passage of water vapor through an underpad or support surface.

Any surface that comes into contact with the skin has the potential to alter the microclimate between the skin and the surface by changing the rate of moisture evaporation (and drying rate) and the rate at which heat dissipates from the skin.

The moisture vapor transmission properties of textile materials used in healthcare linens, such as underpads, can affect the moisture evaporation and drying rate from both the skin and the linens.

Non-sheath glans adherent

External urinary collection device that utilizes an adhesive which attaches to the small area of the glans penis around the meatus, providing a opening for diversion of urine into a collection pouch.

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.

Toileting Program

A toileting program involves assisting the patient to the toilet (toilet, bedside commode, urinal, bedpan) as well as assisting, as needed, with toileting related personal hygiene and clothing management.

Urinary Continence

No reported or observed involuntary loss of urine.

Urinary Incontinence

Complaint or observation of involuntary loss of urine.

Urinary Incontinence Management Strategies

Interventions used to treat or manage urinary incontinence

Wound Treatment Associate (WTA)

A non-WOC certified nurse, who has completed an educational program that focuses on providing optimal care for patients with acute and chronic wounds under the direction of a WOC specialty nurse, WOC advanced practice registered nurse (APRN), or physician.

Indwelling Catheter has been removed

Did the patient void spontaneously within 6 hours?

Yes No

Indwelling Catheter has been removed

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

Yes
No

Indwelling Catheter has been removed

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

Yes
No

Indwelling Catheter has been removed

Does patient report suprapubic discomfort or urge to urinate?

Yes
No

Indwelling Catheter has been removed

Does spontaneous voiding occur?

Yes
No

Indwelling Catheter has been removed

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

Yes
No

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
Yes No

Assess Continence Between Toileting Episodes

Is the patient continent?

Yes No

Assess Continence Between Toileting Episodes

Patient is incontinent.

Patient is able to independently toilet but there is urinary leakage between voluntary voids

Continue

Patient is dependent when toileting

Continue

Assess Continence Between Toileting Episodes

Does patient require strict monitoring of intake and output?

Yes No

Assess Continence Between Toileting Episodes

Does patient require strict monitoring of intake and output?

Yes No

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 an absorbent 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.
External Collection Devices Underpads

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
Continue

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
Ready for Discharge to Home Ready for Discharge to Post-Acute Facility

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
Start Over

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
Start Over

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 an absorbent wrap for males whose urinary incontinence is not adequately contained by underpads.

Continue

Underpads

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

Yes
No

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/

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Support Surfaces

Skin breakdown on the trunk/pelvis?

Yes No

External Collection Devices

Male Female

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.

Continue

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.
Continue

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.
Continue

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
Ready for Discharge to Home
Ready for Discharge to Post-Acute Facility

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
  • 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.
Continue

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.
Continue

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
Continue

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.
Continue

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
Ready for Discharge to Home
Ready for Discharge to Post-Acute Facility

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
Start Over

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
Start Over

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
Continue

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)
Continue

In and Out Catheterization

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
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Is In and Out Catheterization feasible?

Yes No

In and Out Catheterization

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

Yes No

Is there a facility protocol that allows Intermittent Catheterization?

Yes No

In and Out Catheterization

Indwelling catheter reinserted?

Yes - Start Over
No

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.
Continue

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)
Continue

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?

Yes No

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

Start Over

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
Start Over

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).
Continue

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.
Continue

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
Continue

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/

Ready for Discharge - Home
Ready for Discharge - Post-Acute

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
Start Over

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
Start Over