Unit 4222-224 Support individuals to manage continence
(HSC 2016)
Assessment Criteria

Outcome 1 Understand factors that affect the management of continence
The learner can:

1. explain how difficulties with continence can affect an individual??™s self esteem, health and their day to day activities

Incontinence can affect you mentally as well as physically. The negative effect on your self-esteem, dignity and independence can lead to restrict employment, educational and leisure opportunities, and lead to social embarrassment, isolation, distress and depression. According to continence nurses, as many as 70% of people with incontinence are affected by depressive illnesses. It is vital that people who are incontinent are given every opportunity to regain their continence. Individuals may avoid getting treatment for incontinence because they are too embarrassed to discuss their problem. It can severely restrict their social life and contact with others. Having had an embarrassing, humiliating experience of an ???accident??™ in public they live in constant fear of it happening again. Many people will stop going out because of this fear. It is also one of the reasons many individuals come into care because either they or their carer??™s are unable to cope with their incontinence. Individuals may be inclined to reduce their intake of liquids or food to alleviate their incontinence but this can result in their urine becoming concentrated, which in turn can irritate the bladder and cause a greater sense of urgency or result in infection or inflammation. This can also cause constipation, which in turn can weaken the pelvic floor muscles through straining to pass a constipated stool.

2. list common causes of difficulties with continence

There are different types of incontinence and different causes

Urinary incontinence

Overactive bladder ??“ bladder contractions cause bladder to think it is full when it is not

* Parkinsons disease and stroke affect the brain and can cause the bladder to become overactive.
* Anxiety and worry can cause a need for urgency ??“ if an older person is worried about wetting themselves it can make the situation worse
* Constipation can cause hard faeces to push on the bladder and irritate it therefore treating the constipation can cure an overactive bladder
* Infection makes an irritable bowel more irritable
* Medication can make urgency worse

Underactive bladder ??“ bladder fails to empty properly

* Brain damage after stroke or head injury and diabetes can cause an underactive bladder.
* Severe constipation in lower bowel
* Enlarged prostrate (in men)
* Spinal cord damage
* Multiple sclerosis and Parkinson??™s disease

Stress continence

An involuntary loss of urine that occurs during activities that increase intraabdominal pressure, such as coughing, sneezing, laughing or exercise. Most common in women. This is because of several reasons. First men have two valves to hold urine in the bladder and women only have one. This urethra becomes less effective after the menopause due to a shortage of oestrogen. The pelvic floor muscles are weakened by childbirth.

Functional incontinence

Common in people with advanced dementia and head injury. People have normal bladder function but are unaware that they have passed urine or are wet.

Other factors

* Stress – Moving to a new place such as into residential home
* Medicines ??“ Diuretics stimulate the kidneys and increase amount of urine. Sleeping tablets cause drowsiness
* Difficulty walking ??“ unable to make the toilet
* Confusion ??“ may need reminding to go to the toilet
* Untreated, symptomatic urinary tract infections must be identified and treated.
* Urinary frequency and urgency may be due to undiagnosed diabetes. Urine testing is essential.
* Incomplete bladder emptying may be a complication of diabetes, diabetics experiencing urinary tract infection or dribbling urine must have a post void bladder scan.
* Nocturia (passing large amounts of urine at night) may indicate heart failure or reduced secretion of the antidiuretic hormone. Medical assessment is required.
Bowel incontinence

The most common cause of faecal incontinence is constipation, it can also cause or worsen urinary incontinence. It can cause lethargy, nausea, loss of appetite and abdominal pain. The cause of bowel incontinence can be


* Laxatives
* Antibiotics ??“ given to treat infection
* Food poisoning ??“ poor hygiene
* Constipation ??“ hard dry faeces build up in rectum and further faeces gather behind and leak around the blockage. It can appear the person had diarrhoea but actually has severe constipation.

3. explain how an individual??™s personal beliefs and values may affect the management of Continence

Many factors will affect the level of assistance an individual may require with their continence depending on their age, medical condition, personal beliefs and preferences. You may have to deal with situations where the individuals choices and practices in connection with continence and hygiene are different to your own. You should not impose your own ideas. Religious beliefs may affect the help an individual accepts with their continence. For example a Hindu or Muslim would only accept assistance from a carer of the same gender. You may be faced with situations when an individual wants to wear clothes which are unsuitable given the nature of their condition. For example they may insist on wearing clothes which can only be dry cleaned.

4. describe ways to protect an individual??™s privacy whilst managing continence.

It is important to maintain an individual??™s dignity and privacy during any personal care. The toilet door should always be closed so the individual has privacy and you should not interrupt the individual or allow anyone else to do so. The door should have a lock should the individual wish to lock it but should have a safety mechanism outside the door. You should remain on hand incase they need further assistance and they should be aware that you are available and the way in which they can summons you e.g. by calling or pressing the buzzer. This should be discussed with the individual. The toilet should have a call bell in case of emergency. You should explain how this works to the individual before they use the bathroom. When talking to colleagues or the individual regarding their continence ensure the discussions are held in private as these are generally not matters individuals are happy for you to discuss in front of others. If an individual needs assistance with their continence and has agreed to this, you should offer assistance quietly and without a public announcement. If an individual is unable to get to the toilet facilities, but needs a commode or bedpan, a curtain around their bed, although not ideal, may be the most privacy you are able to offer. If an individual wears a catheter, ensure this remains discreet under clothing and not on show to others, which can cause the individual embarrassment.

Outcome 2 Be able to support individuals to manage their own

The learner can:
1. encourage an individual to express preferences and concerns about continence needs

Always work alongside the individual and encourage him or her to look for positive ways of managing continence. You should provide an atmosphere in which the individual can talk freely and openly about any difficulties. By doing this openly and without embarrassment it will allow the individual to be more willing to discuss options and alternative methods of treatment. Depending on the cause and severity of the incontinence the situation could be improved by

* Behavioural
* Devices
* Medication
* Surgery

You should discuss with the individual the type of toileting facilities which they feel able to manage and are comfortable with. Individuals need to feel they have easy access to facilities and assistance is readily available. No one should be incontinent because they are unable to obtain assistance. They should be given the means to call for assistance and help when using toilet facilities or incontinence aids. You will need to be sensitive to the embarrassment and distress that incontinence can cause the individual.

2. support the individual to understand the effects of lifestyle on continence

It is important to support the individual with incontinence and you can do this by establishing the cause of the incontinence and ways to improve it. Prevention is the preferable option, so you should discuss the following with them

Diet – can affect an individuals continence. Trial and error or sometimes the only way to establish which food contributes to bowel incontinence. Very spicy or hot foods can upset some people and foods rich in fibre can cause problems for individuals with poor control. A healthy diet should include fibre found in fruit vegetables, wholemeal bread and pasta. Eating fresh fruit and vegetables on a daily basis should be encouraged. You should encourage individuals to drink at least six cups or glasses of fluid per day. Tea and coffee and fizzy drinks should not be drank in large quantities as these can irritate the bladder and cause problems. Plain water, fruit juice and fruit and herbal tea are most beneficial and should be encouraged.

Exercise ??“ Is important for maintaining good digestive functions and will assist individuals with constipation. It will also improve general muscle tone and improve pelvic and anal muscles. Exercise should be appropriate to the individual. Sphincter exercises are useful for those experiencing problems of urgency. These are similar to pelvic floor muscle exercises but will strengthen the anal sphincter and assist in holding faeces in the back passage. Pelvic floor exercises are useful for both men and women by strengthening the pelvic floor muscles

Medication ??“ Several drugs are available to help with urge incontinence but there is very little to help with stress incontinence. Drugs such as anticholinergics and antispasmodics such as propantheline and oxybutynin work by relaxing the bladder muscles to stop abnormal contractions, however these have side effects such as dry mouth, blurred vision and constipation. If the cause of the incontinence is diarrhoea medication such as Imodium or codeine can be used to solidify the stools or reduce bowel contractions.

Daily routine ??“ Having regular meals and going to the toilet 20 ??“ 30 minutes after a meal is likely to develop a regular bowel habit. Regular toileting is important and you should remind individuals and provide support for them to access toilet facilities regularly. This is known as prompted voiding. People with incontinence during the night are recommended to stop drinking any beverages two to four hours before going to bed.

3. explain how and when to access additional guidance about support for continence

It is important to encourage and support the individuals to find the best way to manage and improve their condition. It is also important to know the type of incontinence you are dealing with and you should seek expert advice about the help that can be given. You are not a trained incontinent specialist so you should contact the individuals GP regarding specialist help as soon as a problem is noticed. Your GP or hospital can provide specialist incontinence advisers and you should encourage individuals to seek referral to the clinic for guidance about the support there is available and to provide advice on continence products, behavioural therapy, medication or surgery.

Outcome 3 Be able to support the use of equipment to manage

The learner can:
1. access information about continence equipment recommended for the individual

You will be able to access information about continence equipment recommended for the individual from the continence nurse who will visit the individual or the local specialist continence advisor. They will explain to you how to support the individual and how the equipment should be used correctly. You should attend any available training sessions regarding the various types of equipment. You can also access information from the individuals care plan and colleagues and senior members of staff. New equipment and treatments are constantly being developed so you need to keep your knowledge up to date. You can also obtain information via the internet, attending exhibitions and obtaining relevant literature.
2. agree with the individual their preferred times and places for using continence equipment

There are various pieces of equipment which can support the individual to manage their continence. The type of equipment can dictate where they can be used as can the individuals urgency and mobility. In order to agree the individuals preferred time and place for using the continence equipment it should be discussed with them. By providing the correct atmosphere in which the individual is able to talk freely and openly with you, without embarrassment, they will be more willing to discuss the options available.

The types of equipment includes

* Hand held urinals ??“ for individual with restricted mobility
* Specialist adapted clothing ??“ eg split crotch knickers, wrap around skirts (to aid use of hand held urinal)
* Sheaths and body urinals ??“ Commonly used by men, fits over the penis and urine collects in a bag attached to leg
* Catheters ??“ only to be used on medical advice, there are two types.
1. Intermittent which is inserted into the bladder several times a day in order to empty the bladder contents into a jug/toilet
2. Indwelling catheter which is left in place for a maximum of three months
* Protection for beds and chairs ??“ Various covers to protect which can be washable or disposable. They range from basic PVC covers to quilted absorbent types.
* Protection for clothing ??“ Pads are the most popular product which people use to protect themselves.

3. agree the level and type of support required for use of equipment

Be aware that continence is a sensitive issue to most people even though you may deal with it on a daily basis. It is important that you focus on the individual with the problem and respect their right to choose the support they would like whilst using the equipment. You should ask the individual if they need help, what sort of help, the equipment they would like help with or which part of using the equipment. For example they may be quite able to clean themselves after using a bed pan but need support to get on and off of it. Alternatively they may be able to get on and off the toilet but unable to wipe themselves because of muscular or joint problems in their shoulders. Any support needs to be agreed prior to help being given.

The level of support the individual needs may also depend on their urgency to use the toilet. If it is urgent the support they require may differ from the not so urgent. In an urgent case they may require you to wheel them to the toilet and let them walk back or if not so urgent they may prefer to walk there and back. This can easily be established by asking the individual how urgently they wish to go. If the individual requires help to use the toilet, they may only require help with their clothing and sitting on the toilet and then you should offer to wait outside ensuring the call bell is to hand. Bedpans can be uncomfortable to sit on and individuals may feel they will soil the bed when using them. It is important to find out if they would prefer help and support to use the commode instead.

4. support the individual to use continence equipment in ways that respect dignity and privacy and promote active participation.

Using the toilet is a private activity and individuals should be able to feel that staff or others will not burst in on them whilst they are doing so. Individuals should be encouraged to lock doors but know you are on hand and can be called and respond immediately if they need assistance. When offering support, do so quietly, without a public announcement. If an individual has to use a commode, ensure they are able to do this in private, ensure bedroom curtains and doors are closed to preserve their dignity and privacy. An individual may only need assistance to get to a private area and be quite able to use the continence equipment for themselves, once there. With the correct mobility aid to hand they may be able to reach the toilet without support so it may be necessary to ensure that equipment is available for the individual to use. You should encourage the individual to participate and find the most appropriate methods of using equipment to maintain their independence as much as possible. It is important to encourage individuals to dispose of their own waste where possible as this will allow them to maintain their privacy and dignity and also actively participate.

Outcome 4 Be able to support continence safely

The learner can:
1. identify risks that may arise while supporting continence

You should be appropriately trained and fully competent when supporting an individual with their continence. This is especially important in relation to infection control and the correct disposal of waste, which can increase the risk of cross infections if carried out incorrectly. It is important that you are able to recognise pressure area problems and report this immediately as this could lead to a pressure sore if left unchecked. Always follow the individuals plan of care in regards their continence support and use only equipment and moving and handling techniques as advised in their risk assessment. Ensure you discuss any equipment to be used with the individual and that they fully understand so they are able to cooperate. Also ensure the following

* Ensure floors are dry before/after use to avoid slips
* Ensure any grab rails in toilets are secure to avoid falls. Advise individuals to use the rails.
* Call bell works to call for help in emergency
* Wear PPE ??“ avoid cross infection
* Encourage good hand hygiene after using toilet to avoid the spread of infection
* Correct disposal of waste

2. encourage the individual to maintain personal hygiene whilst managing continence

Any support you offer individuals must be both appropriate and acceptable to the individual. You should establish how much help the individual needs by asking if they are able to clean themselves or do they need help. It is important to encourage and maintain the individual??™s personal hygiene to avoid soreness and skin irritations which can accompany incontinence. The area around the urethra should be kept clean and the skin should not be allowed to dry out. The individual should be encouraged to use wipes impregnated with specialist incontinence cleansers. After bath or shower, encourage the use moisturiser and barrier cream. The moisturiser will stop the skin drying out and becoming prone to soreness and irritation. A barrier cream eg zinc oxide, lanolin will protect the skin from the effects of urine. Always encourage and where necessary assist the individual to wash their hands after using the toilet, to avoid cross infection.

3. dispose of used equipment and soiled materials safely

* Stoma bag ??“ Comes with a small bag for disposal. This should be tied up and placed in yellow bag. In some homes the faeces are disposed of into bedpan washer and the empty stoma bag is disposed of in yellow bag
* Used catheter bags ??“ yellow bag
* Soiled bed linen ??“ Follow your workplace procedures eg. Place in red plastic bag and laundered separate to other laundry
* Used pads ??“ disposed of as per workplace procedures (Yellow bag)
* Used PPE – disposed of as per workplace procedures (Yellow bag)
* etc

4.ensure the environment is clean, tidy and accessible before and after use

It is important to find and leave a clean tidy environment when using toilet facilities and the toilet or commode is clean after use so that they will be pleasant for the next person. You should check that all the waste has been flushed away and there is no residue in the pan. Wipe the seat if there has been a spillage, and ensure the individual washes their hands. It is important to leave the facilities clean for the dignity of the individual. You should deal with any smell created, discreetly, by using ventilation or air fresheners where appropriate.

5. use protective equipment, protective clothing and hygiene techniques to minimise risks

Keys to good practice are:
* Wash your hands, wear gloves and apron
* If the waste is in a bed pan, commode or urine bottle for disposal, it should be covered and taken to the sluice or toilet where it should be flushed away in accordance with your workplace procedures. You should then remove gloves and apron, dispose of them correctly and wash your hands.
* If the waste is required for examination it should be covered and left in an appropriate place, such as the sluice, until the examination is carried out and then it can be disposed of. Ensure disposal of body waste complies with procedures for your workplace

Many individuals who use a commode or urinal bottle will want to be able to dispose of their own waste, if they are able. Ensure hygiene procedures are followed.

Outcome 5 Be able to monitor and report on support for managing
The learner can:
1. use agreed processes to monitor continence and support for managing continence

The individual will go through an assessment process where their care needs and wishes will be established and agreed in order to form a care plan. This Care Plan may be planned in stages as information is gathered. Each stage should be documented, dated and when completed review dates set. All staff must be aware of the planned care and have easy access to the documentation. As the individuals carer you will have your agreed role in their support. The carer will follow the care plan and monitor any changes to the individual??™s needs, choices and preferences and then report on any changes so that the care plan can be updated. The care plan is a living document.

2. record and report on support for managing continence in agreed ways.
You may need to keep various records regarding an individual??™s continence. This could include the following:
Bowel chart – here you will record;
* Urgency ??“ did individual have to rush to the toilet
* Straining ??“ Did individual have to push excessively to open bowels
* Consistency of stool ??“ refer to??™ Bristol stool chart??™
* Faecal leakage
* Other information ??“ pain, bleeding
Intake and output chart ??“ here you will record
* Time of input/output
* Other information ??“ pad changes, wet clothing/bedding, changes in behaviour
You may also need to complete the individuals care plan notes detailing any support you have given to the individual in line with your workplace procedures

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