I. Preventing Incontinent Episodes and Keeping Your Hands CLEAN! by Catherine D'Ambrosio, RN, PhD

Modifying Prompted Voiding to Meet Your Elder's Needs and Your Capabilities

by Catherine D'Ambrosio, RN, PhD     dambrosi@uw.edu 

This to-do list is most effective in preventing incontinence when performed every hour (while your elder is awake).  Because the process (of assisting a frail elder to maintain their toileting continence) can be very labor-intensive and family caregivers do not always have enough time, the steps below can be performed every other hour and still be effective in reducing how often a frail elder has incontinent episodes.

1. Set a timer for an hourly (or every two-hour) reminder to yourself.
2. At the top of each hour, ask your elderly family member if she is wet (with urine), soiled (with feces), or clean and dry.
3. Physically check for wetness or soiling and:
4. 1. Give feedback (to your elder) about what you have found, -for example, "You are wet.", "You are soiled.", or "You are dry."
   2. If your elder is dry, add a positive verbal feedback to your findings.  -for example:  "You are dry.  Good job!" or "Excellent!  You are dry."
5. Ask your elder if she needs to use the toilet.  You may repeat this question up to three times if she initially refuses.
6. If your elder responds "Yes.", then assist her to the toilet.  {Figuring-out how much physical and cognitive assistance your elder needs -and how much assistance you are (physically and emotionally) capable of providing  -can be a bit complicated.  (How much assistance is the right amount and type of assistance?)}
7. If your elder makes it to the toilet and successfully uses it (urinates and / or defecates into the toilet), then:
8. 1. make a positive comment -such as: "Excellent!" or "Good job.", then
   2. assist her (as needed) to wipe, pull her pants up, and return to her bed, chair or sofa
   3. inform your elder you will check with her again at the top of the next hour about whether or not she needs to use the toilet at that time. 
9. If your elder is dry and responds "No." to your question about whether she needs to use the toilet, do not prompt any further.  After telling her "You are dry.", inform her you will be checking with her again in an hour regarding whether she needs to use the toilet.
10. If your elder is wet or soiled and responds "No" to your question (prompt) about whether she needs to use the toilet,
11. 1. tell her she is wet and / or soiled.
    2. change her clothing and linens, and
    3. cleanse skin as per usual routine.
    4. try not to say anything negative regarding the incontinence to your elder.  (Your elder is most likely already humiliated and quite frustrated with herself.)
    5. tell her you will check with her again at the top of the next hour about whether she needs to use the toilet.
12. If your elder has an incontinent episode on her way to the toilet,
13. 1. assist her to the toilet to finish urinating and / or defecating
    2. assist your elder to clean herself up, and clean any soiled areas
    3. try not to say anything negative regarding the incontinence to your elder.
        
14. Keep a log (link to page here) of what happens each hour. 

This to-do list is based on decades of nursing care research on maintaining and improving continence among frail, cognitively impaired elders in nursing homes.  The seminal studies were initially conducted by researchers named Schnelle, Ouslander and Hu beginning in the late 1980's.  This to-do list -or some variation on this to-do list is commonly called "prompted voiding". 

If you -as a family caregiver are able to provide prompted voiding and support your elder's continence, you are providing a higher level of continence care than what can be provided in all but the most expensive nursing homes.

Most nursing homes cannot provide even "every two hour prompted voiding" (much less hourly prompted voiding) to support every elder's continence.  Prompted voiding is simply too time-consuming -and therefore too expensive.  It takes (on average) 60 minutes of specially-trained nursing assistants' time to provide prompted voiding and support an elder's continence each day.  It takes only 20 minutes out of each day of nursing assistants' time to diaper an incontinent elder.  

Because prompted voiding is more labor-intensive and requires special training of the nurses and nursing assistants, it is more expensive than what most nursing homes can afford to provide.  Only very expensive nursing homes with very high nursing staff to patient ratios can perform prompted voiding on every eligible elder.