Are your incontinent patients truely incontinent?

Specialties Geriatric

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I am asking this question because there seems to be so much concern in LTC settings about under-staffing of CNAs. Say you have a dependent pt (who requires help in transfer) in bed or in a wheelchair who can be toileted on a commode but can normally only hold it for 5-10 minutes. If the facility is under-staffed, that pt is likely to wet or soil him or herself before the CNA can attend to them. That pt will then likely be considered incontinent.

If a patient requires a two-person assist transfer to a commode (or toilet) and only one caregiver is normally available, the same thing can happen. If a patient requires a one-person assist transfer but the caregiver is often not available, again the patient may be considered incontinent.

These patients (who may not actually be incontinent by common standards for older patients) will likely be put in briefs and have to be changed in bed periodically. However this activity can be scheduled whereas giving them toileting assistance as needed cannot be as easily scheduled. So the incentive is to diagnose them as incontinent and the indignity of being in briefs and being changed may be more common than it needs to be. Changing briefs is a labor-intensive and difficult activity and being in briefs can contribute to skin breakdown.

I am wondering how common this questionable incontinence diagnosis is in LTC settings.

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Specializes in Transitional Nursing.

J've always said ALL "incontinent" patients are only incontinent because they can't access the toilet. Fix that part and they'll be continent.

Obviously, this isn't always possible, but whenever it is - offer the bathroom. Even if a confused patient says they don't have to go, often times they will do just that if they are brought to the restroom and they get a visual on the commode.

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Most of the LTC facilities I have worked at do not allow briefs in bed. I was told this is because it increases the risk of pressure ulcers.

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Yes!!!!! I argue this point all the time. If I was unable to transfer myself for what ever reason and I had to wait forever for someone to answer my call bell and help me to the bathroom, I would be incontinent. So when the CNAs are doing their charting and marking incontinent because they were....look at how it skews the #s!

Sometimes it is a fact. 2 CNAs, one nurse and 10 residents that need max assist at once....do the math.

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Thanks for your comment CoffeeRTC. What concerns me is the negative psychological effect on these patients who are treated like infants (whose dirty briefs must be changed) when they are normal older people who need toileting help in a limited time frame (10 -15 minutes). Imagine how depressing and demoralizing it is for these pts.

The sad thing is that changing multiple patient's briefs may actually take longer and be less efficient than attending to their toileting needs one at a time. However following a set schedule often does not permit such "as needed" toileting requests.

But even if it takes a little longer to keep patients out of briefs, the positive psychological effect on the patient, his or her family, less stress on the CNAs (who often dread changing multiple patient's briefs), and fewer problems with skin breakdown would seem to justify some additional staff.

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Specializes in Assisted Living nursing, LTC/SNF nursing.

Give me 10 fairly heavy care residents WITHOUT major physical issues (eg. tube feeding aspiration precautions; unhealable open fractures that will get infected and the resident will eventually pass from it) and Less impaired cognition with 2 hardworking, caring CNA's, the staffing could be adequate, but certainly not the usual. Instead, it's no time to do anything with great care and without accidental neglect or nurses and CNA's not helping each other from shift to shift.

I feel for the most part that staffing is not adequate in most SNF and LTC homes, more and more rules and regulations coming into play than ever before. It's a terrible responsibility for the Director of Nursing and being able to leave the job at work and for nurses to not question staffing limitations and getting everyone toileted and basically cared for like they are SUPPOSE to be without everyone looking like chickens with their heads just cut off. Patient directed care can be so unorganized even if you know your Ressies like family and with the day to day operations and then the disaster drills, mandatory meetings, everyday Dr. and family issues/crisis's (those everyday things that don't allow for a routine d/t another new rule or regulation becoming enacted on, etc.). I guess I am becoming a bite jaded these days with the nonstop stress from the moment you punch in until the moment you punch out in LTC/SNF because it's really got me down on how it's going in healthcare these days and really never gets better. I find myself trying to figure out how I can retire sooner than later. And please don't flame me for what I've said. I just feel every single person in healthcare has felt the same way as I do, especially as you get older and have seen these drastic changes.

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J've always said ALL "incontinent" patients are only incontinent because they can't access the toilet. Fix that part and they'll be continent.

I would challenge this statement. It depends on what type of incontinence you are talking about. Many people have physical issues that cause incontinence (for example, men who have had prostate surgeries and women with weak pelvic floor muscles).

I've also had residents with advanced dementia who were incontinent r/t advanced dementia (I will never forget taking a lady to the bathroom when I was a nurse aide and having her look up at me and ask "How do I make the pee come?").

The last two facilities I worked in did a Bladder Assessment at admission and quarterly addressed any incontinence in the care plan as needed. We (the writer's of said care plan) had to specify the TYPE of incontinence and I never saw a resident who was consistently incontinent r/t not being toileted in a timely manner at that facility (I did, however, regularly hear complaints of call lights not being answered timely at certain times of day...so I imagine if one needed to toilet during those times of day it might happen). I am not saying it never happened...I'm saying it didn't happen regularly.

It has not been the norm for any LTC facility I've worked at...occasional accident MAYBE...consistent pattern? Absolutely not!

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Specializes in LTC and Pediatrics.

While staffing is often short in LTC, I can tell you that people are not put in briefs and then only changed in bed. Residents are taken to the toilet throughout the day, whether or not they experience incontinence.

I tend to agree with what HyzenthalyLPN said.

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At my former LTC job, residents were told by some of the CNA's to just go ahead and pee in their briefs. Those CNA's were very busy on their own personal cell phones and were very busy socializing with the other CNA's. They didn't want to be bothered by the residents PERIOD. Yes, management was made aware of this problem and nothing happened to those CNA's.

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Specializes in Transitional Nursing.
I would challenge this statement. It depends on what type of incontinence you are talking about. Many people have physical issues that cause incontinence (for example, men who have had prostate surgeries and women with weak pelvic floor muscles).

I've also had residents with advanced dementia who were incontinent r/t advanced dementia (I will never forget taking a lady to the bathroom when I was a nurse aide and having her look up at me and ask "How do I make the pee come?").

The last two facilities I worked in did a Bladder Assessment at admission and quarterly addressed any incontinence in the care plan as needed. We (the writer's of said care plan) had to specify the TYPE of incontinence and I never saw a resident who was consistently incontinent r/t not being toileted in a timely manner at that facility (I did, however, regularly hear complaints of call lights not being answered timely at certain times of day...so I imagine if one needed to toilet during those times of day it might happen). I am not saying it never happened...I'm saying it didn't happen regularly.

It has not been the norm for any LTC facility I've worked at...occasional accident MAYBE...consistent pattern? Absolutely not!

There are many reasons pts can't access the toilet, and sometimes it's because they don't know they need the toilet, and all kinds of other reasons. Bottom line is offer the toilet as often as possible and I promise you'll see improvement.

Aside from physiological issues, the vast majority of incontinent patients will use the toilet if they need to go, they just have to have access to it.

As I said before, sometimes It's possible, sometimes it's not, but simply having dementia doesn't mean the person should never be offered to use the bathroom.

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simply having dementia doesn't mean the person should never be offered to use the bathroom.

I think there is a misunderstanding here. At no point have I suggested a person should not be toileted.

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