Short Term Therapy Needs for Long Term Residents: Incontinence/Independent Toileting Management

Working in a Skilled Nursing Facility (SNF) with both short-term rehabilitation residents and long-term care residents, I have learned that it is especially important to not overlook the therapeutic needs that the residents living in the facility may have, which are often over-shadowed by the acute, fast-track therapy programs that provided to the short-term patients. Despite how long they have resided at the facility, there is typically always something that they could improve on or be more independent with after the time and attention of a therapist. Not to mention, from a program development and business stand point, building and maintaining a caseload with long-term residents is a productive and financial must.

One area that many long-term residents struggle with is incontinence, especially bladder/urinary incontinence. How this incontinence is managed is often a quality of care indicator for a facility: is the patient assisted with their toileting as much or as frequently as needed, is their skin integrity at risk in regards to their incontinence?, and how does this affect the patient’s dignity and over-all quality of life? Through skilled therapy services, options and treatments they may not have been considered or addressed can make quite a difference to a patient’s independence within a SNF.

Identifying Incontinence/Independent Toileting Needs:

A simple chart review or discussion with any nursing staff can immediately identify residents with incontinence issues. The therapeutic need is tougher to identify. Completing an observation screen to view and assesses the patient’s current bowel/bladder management programs can clarify areas that a therapist may be able to improve or correct a situation to increase a patient’s performance with their toileting needs. Make sure to consider the patient’s cognitive status. If you are going to setup a specific program and ensure safe, proper carry-over with lasting effects, the patient needs to be able to comprehend the new program or at least consistently perform with training.

Treatment Considerations for Incontinence/Independent Toileting Needs:

The focus of the plan of care should ultimately be decrease the amount of times a patient is incontinent and/or decrease the amount of caregiver assistance they require for their toileting needs. It is not enough to simply drill a patient on completing toileting tasks on the commode. A therapeutic approach should be applied that overcomes the barriers that limit a patient’s independent completion of their toileting needs and establishes a consistent program with good follow through:

• First focus on the performance components that are involved in toileting such as leg strength, core/trunk stability, and weight shifts in standing and sitting. From a biomechanical frame of reference, sometimes simply increasing a patient’s strengths in the right areas can improve their overall performance.
• Repetition, repetition, repetition. Toileting is something a person has to complete several times a day, every day. Hammering out safe transfer techniques to the point that they are nearly automatic can support a successful independent toileting program. For patients with cognitive deficits, making sure that they consistently lock their wheelchair brakes and use the grab bars with toilet transfers can make or break their program.
• Consider adapting the environment. The standard American commode is only 15-16 inches high. The addition of grab bars, raised toilet seats, and versa-frames over commodes can completely change a patient’s approach and need for assistance with toilet transfers.
• Focus on independent completion, no matter where. Particularly in a SNF, a resident does not have to go to bathroom in the bathroom. It is perfectly acceptable for a patient to use a bedside commode, urinal, or other adaptive toileting setting if the benefit is that they can then complete the task with minimal or no assistance.

Goals and Outcomes for Incontinence/Independent Toileting Needs:

Once the treatment course has reached a point that nursing or the patient themselves can manage their toileting needs consistently and at the highest level of independence, consider discharge. It is best practice to complete a follow-up screen and communicate with nursing and caregivers over the next few weeks to ensure the patient is maintaining their discharged level of performance. If successful:

• The patient is less incontinent; decreasing the amount of disposable clothing items and laundry services used.
• The caregivers do not need to assist the patient as often; decreasing their overall work load and increasing their availability for other care needs.
• The patient regains some dignity; able to complete an essentially private task more privately.
• Most importantly, the patient has become more independent.

Long-term benefits from short-term therapy to long-term residents.