A Brief Discussion

Not very long ago, when working in an in-patient rehab center, I was shocked to discover patients calling the adult incontinence garments "hospital underwear." We were making good inroads into reducing the use of these products with the hope that if we used less it would be possible to acquire higher-quality products that would function optimally for patients who really needed them. It was of concern that some facilities had become diaper-free because many of our patients benefited from briefs, particularly as a "just in case security blanket" and we felt it was unrealistic for our patient population to be brief-free.

From the patients' perspective, they have a right to maintain their dignity and body-worn absorbent products help to achieve this. From a nurse's point of view, these products can be thought of as time savers and laundry savers but also skin destroyers. Before going further, let's get together and come up with an acceptable term, please. I have only just begun, and we have: hospital underwear, adult diaper, brief and body-worn absorbent product—yes, you have guessed it—BWAP, really! I suggest a brief exchange, "absorbent brief," shortened to "brief" or "adult brief."

Moisture-Associated Skin Damage in the Long-Term Care Setting: Categories of MASD

Brief Rationale

The reason for wearing a brief is to maintain socially acceptable dry clothes with no odor. Remaining continent is important to all except the little people in society under the age of about three. Most of us as children had an episode of wetting ourselves. Mine was during prayers at the end of the school day. I had asked to go to the bathroom but was told we were finishing soon; well, soon was not soon enough. I still cringe at the memory and am surprised the teacher did not apologize, surely he should have. Would it have prevented the fear and embarrassment? Probably not, but it may have stopped the teasing and name calling that followed.

To discover that people live with the fear of an incontinence episode at other times in their lives is surprising to some. Addressing their difficulties in a way that is acceptable to both them and society is something we are getting better at but still need to work on. How this started may not be clear, but the lingering odor in long-term care facilities and nursing homes must have been a major driving force, and the need to reduce catheterizing patients was also a motivator. The recognition of moisture-associated skin damage and ways to choose from the increasing quantities of body-worn absorbent products have become the current banner. The place of patient satisfaction and monitoring outcomes will mean that addressing continence issues will remain paramount in the future. Wound, ostomy, and continence nurses are in an excellent position to lead,¹ but the bedside nurse has a pivotal, prominent role in this arena to accomplish significant, positive change for patients. Clinical nurse specialists do not work alone. We lead and educate, so reaching toward the nurses of the future is a fundamental necessity.

Continence Assessment and Care Planning

Recognizing the patient's continence issue and planning an approach that reduces risk can be simple, but they are complicated by nursing assistant routines and habits, motivation, time constraints, and perceptions of acceptability. The continence assessment help sheet below outlines the types of incontinence, which of course may not manifest as simply. Spending some time looking at this and reflecting on the patients you assess will help mature assessment skills and the ability to devise a plan of care for the patients. Nursing assistants may have become so used to using adult diapers on patients that they may not see a need for scheduled toileting programs.

Using adult diapers without a plan of care is not acceptable if continence is a possibility. A basic continence assessment and "brief" discussion with the patient sets a scene that ensures the most valuable outcome.² Clearly, nurses have to lead with their patients, advocating and clearly defining their plan of care. Doctors' orders and imaginary Q2 hour schedules will not suffice. How will it be possible within the confines of time and nurse-patient ratios, budgeting, and documentation requirements is yet to be discovered by those rising to the challenge. There are more products than ever on the market. Fitting the most effective products to the patient should not be a hit-or-miss affair.² The Internet and social media will play a part, and we need to be careful that big business, memorable logos, and sleek advertising do not influence those in our charge toward the pretty and expensive options.

Lastly, Beyond Briefs to Catheters

Indwelling catheters are not generally recommended as a management strategy for incontinence. Their use should have a rationale that rules out other approaches to containment. No detail here, just a few questions:

• Why, when we know closed drainage systems prevent urinary tract infections, are we still changing over from leg bags to overnight drainage bags and changing drainage bags weekly? Having patients rinse, wash, and re-use drainage bags is unnecessary if all is kept connected. More to the point, why does The Care and Management of Patients With Urinary Catheters: A Clinical Resource Guide³ give detailed instructions on how to wash and clean drainage bags? It is also considered an area for further research! It does not mention adding an overnight bag to the leg bag, nor has anyone developed an environmentally friendly disposable overnight drainage bag system. If a patient has successfully re-used their system and come up with a way that works for them, fine—let them continue. If we are educating staff and patients on best practice, let us present "best practice" while acknowledging that compromise is sometimes required.
• Securing catheters, keeping drainage bags off the floor, and preventing loops where urine rocks back and forth need better observation and comment and correction from nurse specialists, educationalists, and managers.
• Getting staff to replace a leaking catheter with a smaller size to reduce irritation and bladder spasm is still a struggle. The urethra is not a hollow tube that needs to be filled. It naturally closes by the attraction of the mucous membrane, and a catheter separates the membrane, so a larger size just irritates more.

Lastly, why do we use such large catheters? If you needed to have a catheter, would you choose a 12 French or an 18 French? The Care and Management of Patients With Urinary Catheters: A Clinical Resource Guide³ states, under "Catheter Size" (page 6), that the smallest catheter that maintains adequate drainage should be used. Referring then to Appendix B of this guide, it is of note that the parameters are wide, and this allows nurses to continue to place size 14- to 16-French catheters routinely in women and 16- to 18-French catheters in men. Tradition and culture are hard to ignore, but those who lead need to follow best practice and not what they were taught in nursing school, all those years ago.

References

1. Berke C, Conley MJ, Netsch D, et al. Role of the wound, ostomy and continence nurse in continence care: 2018 update. J Wound Ostomy Continence Nurs. 2019;46(3):221-225.

2. Gray M. Kent D. Elmer-Seltun J. McNichol L. Assessment, selection, use and evaluation of body worn absorbent products for adults with incontinence: a WOCN Society consensus conference. J Wound Ostomy Continence Nurs. 2018;45(3):243-264.

3. Wound, Ostomy and Continence Nurses Society. The Care and Management of Patients With Urinary Catheters: A Clinical Resource Guide. Mt Laurel, NJ: Wound, Ostomy and Continence Nurses Society; 2016.

About the Author

Margaret Heale has a clinical consulting service, Heale Wound Care in Southeastern Vermont and draws on her extensive experience as a wound, ostomy and continence nurse in acute and long-term care settings to provide education and holistic care in her practice.