Hygiene is something many elderly people need help with, and good lower hygiene can help prevent urinary tract infections. Urinary tract infections are often due to e-coli bacteria, which are found in the feces, entering the urethra due to lack of hygiene. The Care Manual www.vardhandboken.se describes in a good way how hygiene should be managed in care.

Incontinence

Incontinence is common in nursing homes. Many people use incontinence protection. The right incontinence protection is of great importance for how they function and are perceived. There are many types of aids. Needs and aids vary somewhat between women and men.

Regular toilet visits can help many people stay dry, but it requires staff to help those who do not signal themselves that they need help going to the toilet. Staff should never deny anyone the opportunity to use the toilet when someone requests it. The need may come inconveniently, but staff must still be helpful. Sometimes it can also be urgent and for some it can be difficult to hold if it does not go fast enough to get to the toilet.

Temporary incontinence can have several causes. Urinary tract infection/cystitis is common among the elderly. Men who get urinary tract infections must be treated as enlarged prostate is often involved, which can lead to serious upper urinary tract infection. The prostate is a gland around the urethra, between the penis and the bladder, whose function is to help the sperm get through. In connection with aging, the prostate can grow and press against the urethra making it harder to urinate. The enlargement itself does not increase the risk of prostate cancer.

Another problem can be an overfilled bladder. Men with prostate problems can sometimes not empty the bladder, which can lead to serious urinary tract infection that must be treated. A catheter may also be needed to empty the bladder. Women can also be affected, for example in injuries after childbirth or with blockages in the catheter.

Having to wait for help is extremely painful. There is also a risk that the natural ability to empty the bladder is damaged. This is a relatively common but entirely avoidable care injury that causes permanent harm to the individual. For many, catheter placement is painful. Therefore, anesthesia is given before the catheter is inserted. There is reason to wait a good while after the anesthesia has been given before the catheter is inserted.

Symptoms of a urinary tract infection can be that you feel the need to urinate even though you have just urinated and that it stings when you urinate. Contact a nurse if someone seems to have trouble.

Toilet visits need to be made at regular intervals. It happens that elderly people with incontinence problems have incontinence protection without the symptoms being properly investigated. Likewise, estrogen treatment is missed in women who need this or other preventive measures to prevent recurring urinary tract infections. Most people need to sit alone in the toilet to be able to take care of their needs.

Before incontinence protection is introduced, an investigation of the underlying causes of incontinence should be made. It is also important to clarify whether the resident is incontinent only when it comes to urine or both urine and feces. Incontinence protection should be specially tested and adapted for the individual.

Nikola www.nikola.nu is a network for bladder and bowel dysfunction that provides information, tips and advice as support in the work of investigating and shaping good incontinence care. Their quality program is a tool for good care. All nursing homes should also have at least one nurse with prescribing training for incontinence aids.

With the help of Nicola, the degree of incontinence problems can be determined. It can be urge incontinence with leakage, stress incontinence, functional incontinence which can be both physical and psychological. Others may suffer from overflow incontinence as a result of an overfull bladder, while others may have some form of mixed incontinence.

Urinary Tract Infections

Women get urinary tract infections more easily because the urethra is shorter in women than in men. Incomplete bladder emptying, urinary and anal incontinence, constipation and intercourse can be reasons for repeated urinary tract infections. Those with urinary tract infections often urinate, complain of stinging when they urinate.
They may have pain over the bladder and feel chilly. Sometimes there may be a little blood in the urine. Elderly people can become confused by infections. Bad-smelling urine does not always depend on urinary tract infection. Dehydration and vaginal discharge, for example, can also contribute to it smelling bad.
In addition to the symptoms of lower urinary tract infection, the person often has a fever and may feel nauseous. Pain in the side of the stomach or lower back is also common. Elderly people sometimes only get a high fever without other symptoms. This must always be treated.

Often it is confusion and that the urine smells bad that makes staff at the nursing home suspect UTI. If there is suspicion of cystitis or urinary tract infection, a nurse should always be contacted. Urine culture should always be taken if possible before treatment is started.

For women, it is good to drink a lot with cystitis. Paracetamol can relieve the symptoms. People with catheters are often diagnosed with UTI too easily. Burning, urges and urinary leakage due to mechanical irritation are common side effects of the catheter. To suspect UTI, the person should have a fever or there is an acute stop in the catheter. It is important to be careful with hygiene in both changing the catheter and the catheter bag to counteract infection.

If you are going to take a urine sample, the lower toilet is first washed. Then it is good if the person who is going to give the sample first gets to pee a little before you start collecting the urine sample. Ideally, the person giving the sample should not have urinated for four hours before the sampling. If the person has a catheter, the safest way to take a sample is to put a new catheter and take the first urine that comes out of the hose for the sample. Sometimes a temporary catheter is used to take a urine sample, for example when the person cannot participate.

Urine stick can point out that there is an infection, but a blank stick does not rule out urinary tract infection. It also applies that it is not "nice" bacteria that are treated. Then the treatment itself can give room for worse bacterial strains. In many regions, urine sticks are not used in nursing homes, as they are considered to pose a risk of incorrect treatment and do not comply with Strama's guidelines for treatment.

Please see the video - Urinary tract infection in the elderly - an (all too) easy diagnosis?
https://www.youtube.com/watch?v=lScaDEumleE

Bleeding

Sometimes older women start bleeding from the genital area. It could be uterine cancer, but also other disorders such as myomas. It is a benign muscle nodule that can be removed if it causes discomfort. Myomas can cause discomfort in the form of pains and frequent urges.

Uterine cancer is a common cancer disease that can often be detected in an early stage and thus successfully removed by surgery. It is rare with pain as an early symptom of uterine cancer. However, irregular bleeding or bloody discharge or heavy discharge is common.

Cervical cancer is often caused by a virus called HPV, human papillomavirus. HPV is spread from person to person by skin or mucous membranes coming into contact with each other, for example through various forms of sex.HPV virus is common and most infections heal by themselves. But sometimes they can cause cell changes that can lead to cancer. Here too, the symptoms are often bleeding, bloody or heavy discharge.

If a resident has discharge or bleeding from the genital area, it should be reported to a nurse.

Diarrhea

In severe diarrhea, a person can lose more than five liters of fluid. For an elderly person with small margins, this can have serious consequences. The cause may be a virus or bacteria, but also symptoms of sepsis or consequences of treatment with medication or radiation. Diarrhea can also be antibiotic-induced when the gut flora is out of balance.

When someone gets diarrhea or vomiting in a nursing home, for safety reasons, it is assumed that it can be contagious. Infection spread in a nursing home can have devastating consequences. The most common cause of stomach flu in Sweden is Calicivirus, which is very contagious. Less than a hundred virus particles are enough to infect. In a drop of vomit or feces, there are millions of virus particles. The onset of the disease occurs within two days with severe vomiting, diarrhea, abdominal pain, moderate fever, headache and muscle pain. Since most people get sick during the winter, the virus is also called winter vomiting disease.

Always inform a nurse if someone has diarrhea. This is more acute with severe general effect such as confusion and lethargy as well as with bloody diarrhea. Likewise, if abdominal pain persists for more than six hours or if the symptoms increase over time. In the case of fluid deficiency, there is reason to introduce a fluid list or take other measures to restore the fluid balance. Care operations should have as a routine to inform and consult hygiene experts in the event of infection spread. Register when someone got sick and recovered, so that it is possible to follow the course and assess what measures need to be taken. Diarrhea in connection with palpitations, anxiety and tremors may also be symptoms of hyperthyroidism (thyroid disease).

Feeling the need to go to the toilet and not being able to empty the intestine is a sign of constipation. Being constipated is often related to eating too little fiber and drinking too little. Being bedridden and sedentary affects the gastrointestinal function negatively by making the passage slower. With increasing age, the intestinal movements that move the stool through the intestinal canal (peristalsis) often deteriorate.

For people who are dependent on support during toilet visits, it can be difficult to get help just when it presses (the gastrocolic reflex). Being forced to wait to empty the bowel reinforces constipation. In severe constipation, a person can get constipation diarrhea. To try to prevent constipation, care staff should plan regular toilet visits even for people with incontinence protection.

If you as an employee have diarrhea, you should stay home from work. If you have been abroad, diarrhea can be due to, for example, salmonella. This means that you must submit stool samples to limit the spread of infection in an effective way.

Stress can sometimes give symptoms such as increased gas formation, increased bowel sounds, constipation, diarrhea. Nausea, vomiting and pain can be part of the picture. The symptoms can occur even if the diet is good. Stomach ulcers can sometimes be traced back to stress. It also happens that the elderly have constipation diarrhea. For those suffering from IBS, it can help to avoid certain types of food.

Slow Stomach

A slow stomach can mean suffering for the elderly with, among other things, confusion and pain in the abdomen. Diet, fluid and activity affect. Likewise, to regularly offer toilet visits to those who do not come forward themselves.

Many elderly people get a slow stomach. Not infrequently, they receive various drugs to keep the stomach going. However, there is a lot to do that helps to keep the stomach going. The intestines absorb water and nutrients from the stool on the way through the body. Over time, the stool becomes more concentrated. People have different toilet habits. There are those who need to go three times a day, but also three times a week is perfectly normal. Some people have a tendency to have a slow stomach while others often have diarrhea. Sometimes constipation can be a side effect of drugs.

Both relaxation and exercise can help normalize bowel emptying. Drinking plenty is important as well as eating a fiber-rich diet. Vegetables, fruits, whole grain products, coarse bread, porridge on coarse grains like oats and wheat bran are fiber-rich. Fiber-rich "Pajala porridge" is offered at many nursing homes for breakfast.
Regular toilet visits reduce the risk of constipation. For those who start to become forgetful, it may be good to remind them to go to the toilet. This can reduce the risk of both constipation and incontinence. Some people find themselves helped by stomach massage. Others find it too intimate.

If the stool is hard and difficult to get out, it can also cause pain in the anal opening. Not infrequently, constipation leads to abdominal pain. In really severe constipation, the stool may need to be softened with an enema. In severe constipation, the resident may need to go to the hospital to get help with relieving constipation.

Those who have pain as a result of cracks in the anal opening may need to be lubricated. There are both softening and pain-relieving ointments available. When it comes to drugs, there are several different types with different functions. Bulking agents contain fiber and help to retain water in the stool and increase volume. Osmotic laxatives draw water to the stool and thus soften it. They give effect within three days. Micro enemas and bowel irritating drugs are often more fast-acting but should not be used regularly.

Reflection questions about functional changes in the stomach and intestine
Care Staff:
• Does the prescription of incontinence protection work well?
• How do you usually notice that one of your residents has UTI?
• Do you have routines for how to take clean urine samples?
• Can all colleagues perform genital hygiene correctly?
• Do you have good routines for stomach flu?
• Do you have a working method that helps to avoid unnecessary constipation?
• Do you have routines that remind the residents to go to the toilet regularly?

Manager, nurse, occupational therapist and physiotherapist:
• Are there functioning routines for investigating residents with incipient incontinence problems?
• Do you use diet and movements to help residents keep their stomach going?
• Do you use support from Nikola?
• Do you have a nurse with prescriber training?
• How do you deal with UTI with mild discomfort?
• Do you have secure routines when it comes to urine sampling?
• Do you have good routines for cohort care in the event of infection spread?
• Are they known even by emergency care?
• Do the nursing assistants contact the nurse in all situations when there is a risk of dehydration?

Resident and relatives:
• Do you find that the routines for toilet visits work on the unit?
• Does your relative have recurring urinary tract infections?
• Did you as relatives receive good information when something happens at the unit, for example, the spread of winter vomiting disease?

Erland Olsson
Specialist nurse
Sofrosyne - Better care every day