ANALISIS JURNAL DIAGNOSTIK

SISTEM INTEGUMEN

Young coconut juice can accelerate the healing

process of cutaneous wounds

Disusun Oleh : Kelompok 1

S-15 A

1. Achmad Aditya Rifani A (S15001)

2. Eka Afrida Yunita (S15013)
3. Lilis Artikasari (S15025)

PROGAM STUDI S-1 KEPERAWATAN

STIKes KUSUMA HUSADA
SURAKARTA
2016
A. Proses Mendapat Jurnal

B. IsiJurnal
1. Judul penelitian

2. Penulis jurnal

3. Latar Belakang

4. Tujuan Penelitian

5. Metode Penelitian

6. Hasil Pengamatan

7.Kesimpulan

7. Kekurangan

8. Kelebihan

9. Implikasi
Individually tailored ultrasound-assisted
prompted voiding for institutionalized older
adults with urinary incontinence
Authors

1.

1.

1.

1.
o

First published: 21 July 2014Full publication history

DOI: 10.1111/iju.12569 View/save citation
Cited by (CrossRef): 2 articles Check for updates

Funding Information

Abstract
Objectives

To assess individually tailored ultrasound-assisted prompted voiding as a means of managing

urinary incontinence in hospitalized elderly patients.

Methods

A total of 88 incontinent elderly individuals who were inpatients in general hospitals were
included. Each individual's mean bladder volume before starting to void (voided urine volume
plus residual urine volume) was regarded as the optimal bladder volume. Bladder volume was
regularly monitored with an ultrasound device, and when the urine volume had reached the
individual's optimal bladder volume, the subject was prompted to void. The outcomes were
evaluated on the basis of scores on a four-grade scale for items in six domains: urine volume,
voiding function, urinary control, physical and cognitive function for toileting, and caregivers'
burden in regard to continence care. The score for use of a pad/diaper, an item of urinary control
domain, was used as the primary outcome measure.

Results

A total of 80 participants were included for analysis. After ultrasound-assisted prompted voiding
care for a 4-week period, the score for use of a pad/diaper in 50 out of 80 participants (62.5%)
had decreased, and 21 out of 80 participants (26.3%) no longer required the use of a pad/diaper
at all. The scores of the other 30 out of 80 participants (37.5%) were unchanged. The
improvement was not significantly affected by patients' backgrounds at baseline. The mean
scores in the domains of urinary control, physical function, cognitive function and caregivers'
burden improved significantly.

Conclusion

The present preliminary study suggests that individually tailored ultrasound-assisted prompted
voiding can improved urinary incontinence of institutionalized elderly patients. Further studies
are worth carrying out.

Abbreviations & Acronyms

ADL

activities of daily living

NA

not available

Introduction
The majority of institutionalized elderly persons suffer urinary incontinence.[1-4] Urinary
incontinence entails sanitation problems, affects the dignity of sufferers and increases caregivers'
burden. Urinary incontinence in dependent elderly persons is closely associated with impairment
of ADL and cognitive function.[4] Management of urinary incontinence is an urgent task for the
globally aging society, especially in Japan, which has the longest life expectancy in the world
(http://www.who.int/gho/publications/world_health_statistics/EN_WHS2013_Full.pdf). In
incontinent older adults, bladder volume might exceed the optimal bladder capacity as a result of
impaired sensation, leading to urinary leakage. Urinary incontinence of institutionalized older
adults is usually managed by continence care, which is classified into four categories: bladder
training, habit retraining, timed voiding and prompted voiding.[5] In prompted voiding care, a
commonly used method, the incontinent persons are asked at regular intervals whether they have
a desire to void, and when the response is yes, they are prompted to go to the toilet. Proper
voiding in the toilet is praised and encouraged for the next time. These approaches have been
shown to reduce wet episodes by approximately half, and to increase the number of proper
voidings as a proportion of the total number of voidings;[6-8] however, these approaches or
modified approaches have not been adequately studied to date.[1] Urinary incontinence is a
manifestation of dysfunction of the lower urinary tract, and might not be properly managed by
nursing care alone. Despite such urological common sense, just 3% of incontinent elderly
persons in nursing homes in Japan have been found to have consulted a urologist.[2] Although
personalized care should be the core for patients with urinary incontinence, because of the
shortage of nurses specializing in continence care even a basic urological assessment is
unfeasible.[9]

In the present study, we provided incontinent older adults with individualized continence care
that was directed by ultrasound-estimated bladder volume, and evaluated its effects on urinary
control, physical and cognitive function and caregivers' burden in regard to continence care.

Methods
The present study was designed as a non-randomized single-arm interventional preliminary
study. A total of 88 incontinent elderly individuals (50 women and 38 men) who were inpatients
in one of 12 general hospitals were recruited to participate in the study between December 2009
and February 2010. Older adults who were incapable of verbal communication, in a critical
condition, bedridden or expected to be discharged within 4weeks were not included. The present
study was approved by the institutional review board of each hospital. Written informed consent
was obtained from each participant or a family member.

All participants underwent a 24-h basic voiding function assessment by checking the pad/diaper
for urine every hour. When urine was detected in the pad/diaper, the volume of the voided urine
was measured with a scale, and residual urine volume was measured with a portable ultrasound
device (BladderScan BVI 6100; Verathon, Bothell, WA, USA or Yuririn; YuriCare, Sagamihara,
Japan). These devices were used because they have been specifically developed for simple
measuring of urinary volume in the bladder. Once the probe is placed on the lower abdomen, the
estimated volume is shown on the monitor in less than 1min. It should be kept in mind, however,
that the devices cannot distinguish urine from ascites or cystic lesions in the pelvis.[10] The
mean bladder volume of each individual before the start of voiding (voided urine volume plus
residual urine volume) was regarded as the optimal bladder volume for that individual to void.
Bladder volume was regularly measured with an ultrasound device, and when the ultrasound-
estimated bladder volume had reached the individual's optimal volume, the patient was prompted
to void. Regular monitoring and/or prompted voiding were optional during the night, depending
on the patients' wishes and conditions. Physical inability to transfer to the toilet was managed by
providing physical assistance, by providing a toilet substitute and/or by rehabilitating walking.
To standardize the intervention and assessment, the investigators' meeting was held before the
study initiation. The members of the care team at each institution were unchanged during the
study.

The efficacy of ultrasound-assisted prompted voiding was evaluated in six domains: (i) urine
volume (total urine volume, nocturnal urine volume and nocturia polyuria index); (ii) voiding
function (urinary frequency, urine volume per voiding, and residual urine ratio); (iii) urinary
control; (iv) physical function; (v) cognitive function; and (vi) caregivers' burden in regard to
urinary incontinence care (Table1). The nocturia polyuria index is calculated by dividing
nocturnal urine volume by 24-h urine volume. The residual urine ratio was calculated by
dividing residual urine volume by the optimal bladder volume. Each domain consisted of one or
three items, and the items were scored as shown in Table1. The assessment data were collected
every week as the evidence of adherence to the protocol, and the data at the end of the fourth
week were used for analysis. The score for use of a pad/diaper, one of the items in the urinary
control domain, was designated as the primary outcome measure. Under a hypothesis that
baseline bladder function might affect the outcomes, the efficacy of ultrasound-assisted
prompted voiding was compared according to arbitrary grouping of bladder function at baseline;
a fair bladder function group (mean voided volume 100mL and mean residual urine ratio
<0.5) and a poor bladder function group (the mean voided volume <100mL and/or the mean
residual urine ratio 0.5). The assessment and ultrasound-assisted prompted voiding were mostly
carried out by the nursing staff. Attending physicians supervised the nursing care.

Table 1. Scoring system for assessment items

Score
Domain/item
0 1 2 3

1. The nocturia polyuria index is calculated by dividing nocturnal urine volume by 24-h urine
volume. Residual volume/(voided volume plus residual volume). Primary outcome measure.

Urine volume

Total urine volume <1000mL 1000mL 1500mL 2500mL

Nocturnal urine volume <500mL 500mL 700mL 1000mL

Nocturia polyuria index <35% 35% 50% 75%

Voiding function

Urinary frequency 7 times 8 to 14 times 15 to 19 times 20 times

Mean urine volume per

150mL 100 to 149mL 50 to 99mL <50mL
voiding

Mean residual urine ratio <25% 25 to 49% 50 to 74% 75%

Urinary control

Expression of desire to void Capable Able, if asked Able, non-verbally Unable

Assistance Physical support

Physical ability to void Independent Unable
needed needed

Use of pad/diaper None Pad only Diaper at night Diaper all day

Physical function Independent House-bound Chair-bound Bed-bound

 Score
Domain/item
0 1 2 3

Occasional assistance All day

Cognitive function Independent Supervision
required assistance

Caregivers' burden in regard to

urinary care

Mental stress None Slight Moderate Great

The statistical analysis was carried out using jmp software, version 9.0.0 (SAS, Cary, NC, USA).
Fisher's exact test was used to compare the changes in pad/diaper use between groups. The
McNemar test was used to compare changes in categorical data. The Wilcoxon rank-sum test
was used to evaluate differences between post-hoc constructed subgroups. Univariate regression
analysis and stepwise regression modeling were carried out to identify significant factors for
reduction of pad/diaper use. P-values less than 0.05 were regarded as statistically significant.

Results
After excluding eight participants (four women and four men) with insufficient data, the data
from the remaining 80 incontinent older adults (46 women and 34 men) were used in the
analysis. The median age of participants was 83years (range 5896years) in women and
77years (range 5295years) in men, respectively (P=0.010). The diseases for admission were
cerebrovascular disease (n=52), skeletal bone fracture (n=8), spinal cord disorder (n=4),
cardiovascular disease (n=4) and miscellaneous (n=12). No patients had abdominal mass or
ascites that might interfere with bladder volume measurement.

At the end of the 4-week intervention, there were no significant changes in score in the urine
volume domain (total urine volume, nocturnal urine volume and nocturia polyuria index) or
voiding function domain (urinary frequency, mean urine volume per voiding and mean residual
urine ratio; data not shown). By contrast, after the 4-week intervention, there was a significant
improvement in three items in the urinary control domain: expression of desire to void, physical
ability to void and use of a pad/diaper (P=0.006, P=0.020 and P<0.001, respectively; Fig.1).
There were also significant improvements in physical function, cognitive function and
caregivers' mental stress (P<0.001, P<0.001 and P <0.001, respectively). The score for the
primary outcome measure; that is, the use of a pad/diaper, of 50 participants (62.5%) had
decreased, and the score of 30 participants (37.5%) was unchanged. There were 21 participants
(26.3%) who no longer required a pad/diaper (score 0). No interinstitutional difference of
reduction of pad/diaper use was observed (P=0.177).
Figure 1.

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Changes in assessment item scores of incontinent older adults (n=80). Items were scored on a
four-grade scale from 0 (fair, shown in white) to 3 (severe, shown in black). Score: , 0; , 1; ,
2; , 3.

The participants were classified into a fair bladder function group (n=54; 67.5%) and a poor
bladder function group (n =26; 32.5%). The reduction in continence aids was rather
pronounced in the poor function group; score reduction was feasible in 57.4% in the fair bladder
function group and in 73.1% in the poor bladder function group, respectively (P=0.221).
Complete freedom from the need to use continence aids was achieved in 20.4% of the
participants in the fair bladder function group and in 38.5% in the poor bladder function group
(P=0.107). Improvement of other assessment items including urine volume, voiding function,
physical function, cognitive function and caregivers' mental stress showed no significant
differences depending on bladder function (data not shown). Univariate regression analysis
including age, sex, reason for admission, assessment items listed on Table1, and baseline
bladder function identified no significant factors for reduction of pad/diaper use (Table2).
Stepwise regression analysis identified no significant factors either.

Table 2. Results of logistic regression analysis for reduction of pad/diaper use

Univariate analysis
Factors
Odds ratio 95% confidence interval

Age 0.976 0.9331.020

Sex
 Univariate analysis
Factors
Odds ratio 95% confidence interval

Female 1.0 Reference

Male 1.471 0.5873.797

Reason for admission

Cerebrovascular disease 1.0 Reference

Skeletal bone fracture 1.222 0.2706.466

Spinal cord disorder 2.200 0.26246.115

Cardiovascular disease NA NA

Miscellaneous 1.467 0.4076.064

Total urine volume

0 1.0 Reference

1 0.494 0.1491.504

2 0.485 0.1271.767

3 0.353 0.0139.860

Nocturnal urine volume

0 1.0 Reference

1 1.114 0.3683.539

2 0.585 0.1801.894

3 0.260 0.0112.958

Nocturia polyuria index

0 1.0 Reference

1 0.719 0.3683.539

2 1.083 0.1801.894

3 NA NA

Urinary frequency

0 1.0 Reference
 Univariate analysis
Factors
Odds ratio 95% confidence interval

1 1.435 0.5214.003

2 0.421 0.0911.777

3 1.263 0.10928.917

Mean urine volume per voiding

0 1.0 Reference

1 0.900 0.3032.610

2 1.607 0.4595.924

3 NA NA

Mean residual urine ratio

0 1.0 Reference

1 1.400 0.4654.568

2 2.100 0.43415.290

3 1.400 0.12631.254

Expression of desire to void

0 1.0 Reference

1 0.429 0.0991.610

2 0.800 0.1563.913

3 1.040 0.2094.965

Physical ability to void

0 1.0 Reference

1 NA NA

2 NA NA

3 NA NA

Use of pad/diaper

0 NA NA
 Univariate analysis
Factors
Odds ratio 95% confidence interval

1 1.0 Reference

2 0.600 0.1043.018

3 1.320 0.2456.120

Physical function

0 1.0 Reference

1 1.667 0.05254.431

2 2.200 0.08259.504

3 1.375 0.05236.521

Cognitive function

0 1.0 Reference

1 0.389 0.0452.481

2 0.741 0.0823.990

3 0.436 0.0522.260

Mental stress

0 1.0 Reference

1 1.432 0.2467.666

2 1.313 0.2276.960

3 0.750 0.0905.862

Baseline bladder function

Fair 1.0 Reference

Poor 2.014 0.7485.888

Discussion
In the present study, we first carried out a simple urological assessment by measuring voided
volume and residual urine volume with an ultrasound device. This simple urological assessment
enabled calculation of the optimal bladder volume for voiding for each individual. The bladder
volume of each participant was then measured regularly with an ultrasound device, and the
participant was prompted to go to the toilet if bladder volume had reached the optimal bladder
volume. As a result of this intervention, consumption of continence aids by 50 participants
(62.5%) decreased, and 21 participants (26.3%) no longer needed to use aids. Consumption of
continence aids by the other 30 participants (37.5%) was unchanged, and there was no increase
in consumption of continence aids. The ultrasound-assisted prompted voiding improved
expression of desire to void, physical ability for voiding, physical function, cognitive function
and caregivers' mental stress. Previous studies on prompted voiding as a means of continence
care for incontinent older adults have shown it to be effective in reducing wet episodes or
incontinence frequency. Schnelle etal. reported that prompted voiding decreased wet episodes as
a proportion of total micturitions from 30% to 18%.[6] Hu etal. found that prompted voiding
reduced wet episodes by 60%, as opposed to a reduction of just 20% by usual care.[7] Colling
etal. reported data showing that urinary incontinence frequency decreased from 70% at baseline
to 57% in the treatment phase, but that it returned to the baseline level after treatment stopped.
They identified greater bladder capacity and less impaired mental capacity as predictors of good
outcomes.[8] Ouslander etal. suggested that prompted voiding was effective in reducing wetness
and increasing the toileting rate in the daytime, but not the night-time.[11] However, because of
the differences in efficacy assessment parameters, and cultural and/or medical backgrounds, it
seems difficult to simply compare these previous studies with the present study. In Japan, Tanaka
etal. carried out individualized comprehensive care that included prompted voiding to improve
the ADL and urinary incontinence of nursing home residents.[12] Their primary outcome
measure was pad/diaper use, the same as in the present study. The results showed improvement
in 34 participants (27.9%), no change in 68 participants (55.7%) and deterioration in 20
participants (16.4%). Our intervention achieved a high level of improvement, although
differences between the target populations, types of institution, and labor volume and skill of
nursing staff are possible confounders.

In a post-hoc analysis that was designed to assess the effects of baseline bladder function on
outcomes, bladder function was arbitrarily classified as fair or poor function, and the outcomes
were compared. The majority (67.5%) of the participants in the present study had fair bladder
function at baseline, and those with fair bladder function were expected to have a better outcome.
To the contrary, although non-significant, the outcomes were better in the group with poor
bladder function, with no need for pad/diaper having been achieved in 38.5% of the poor bladder
function group versus 20.4% of the fair bladder function group. There were no significant
differences between the groups in improvements in any of the other assessment items including
urine volume, voiding function, physical function, cognitive function and caregivers' mental
stress.

It is well known that cognitive impairment is a strong risk factor for urinary incontinence.[13-18]
Cognitive impairment precedes urinary incontinence by approximately 6years in Alzheimer's
disease and by approximately 3years in diffuse Lewy body disease.[19] Our strategy for urinary
incontinence care favorably influenced the participants' physical and cognitive functions. The
present study is the first to show a possible beneficial impact on cognitive function by continence
care, although only simple questionnaires were used for assessment, and the favorable changes
were partially attributable to spontaneous regression of basal conditions during the study period.
The limitations of the present study included its non-randomized single-arm design, hospital-
based study, the use of simple questionnaires to assess outcome measures, arbitrary grouping of
bladder function and the lack of long-term outcome data. The study population was mostly in-
patients of the subacute phase who might undergo spontaneous recovery from dysfunctions. A
large-scale comparative study with a long follow-up time based on validated measures, such as
the Mini-Mental Scale Examination[20] for cognitive function, Barthel Index[21] for ADL and
Zarit Burden Scale[22] for caregivers' burden, is required to validate the present study results.
Optimization of bladder function assessment and intervention, the net burden of caregivers
including job satisfaction or quality of life and the cost-effectiveness of the intervention should
also be explored. In conclusion, individually tailored ultrasound-assisted prompted voiding based
on ultrasound-estimated bladder volume improved continence status of institutionalized
incontinent older adults. Further studies including comparative arms with more elaborated
assessments are warranted to confirm our preliminary study.

Acknowledgments
Financial support for this study was provided by the Japanese Society of Geriatric Urology in
2009. The sponsor of this study had no role in the design, methods, subject recruitment, data
collections, analysis or preparation of the paper. We thank the following care staff and doctors
for their cooperation in the performance of this study: Toyoko Yamato, Einosuke Nakashita,
Kimitoshi Nakahara, Tetsu Kousaka, Katsuki Tsuchiyama, Ken-ichi Kameda, Yoshitaka Aoki,
Hiromi Sanematsu, Emi Ozawa, Akinori Horii, Yoshiko Takasaki, Kayoko Aoki, Satomi
Kubota, Kyoko Ito and Hiromi Monden.

Individual disesuaikan USG dibantu diminta membatalkan untuk orang dewasa yang lebih tua
dilembagakan dengan inkontinensia urin.
Iwatsubo E1, Suzuki M, Igawa Y, Homma Y.
Informasi penulis
Abstrak
TUJUAN:

Untuk menilai secara individual disesuaikan USG-dibantu diminta membatalkan sebagai sarana
pengelolaan inkontinensia urin pada pasien usia lanjut di rumah sakit.
METODE:

Sebanyak 88 orang lanjut usia mengompol yang pasien rawat inap di rumah sakit umum dimasukkan.
Volume kandung kemih berarti masing-masing individu sebelum mulai membatalkan (volume urin
voided ditambah volume urine sisa) dianggap sebagai volume kandung kemih optimal. Volume kandung
kemih secara teratur dipantau dengan alat USG, dan ketika volume urine telah mencapai volume yang
kandung kemih yang optimal individu, subjek diminta untuk membatalkan. Hasil dievaluasi atas dasar
skor pada skala empat kelas untuk item dalam enam domain: volume urin, membatalkan fungsi, kontrol
kemih, fungsi fisik dan kognitif untuk ke toilet, dan beban pengasuh dalam hal perawatan kontinensia.
Skor untuk penggunaan pad / popok, item domain kontrol kemih, digunakan sebagai ukuran hasil
utama.
HASIL:

Sebanyak 80 peserta termasuk untuk analisis. Setelah USG-dibantu diminta membatalkan perawatan
untuk jangka waktu 4 minggu, skor untuk penggunaan pad / popok di 50 dari 80 peserta (62,5%)
mengalami penurunan, dan 21 dari 80 peserta (26,3%) tidak lagi diperlukan menggunakan pad / popok
sekali. Skor dari 30 keluar lain dari 80 peserta (37,5%) tidak berubah. Peningkatan ini tidak signifikan
dipengaruhi oleh latar belakang pasien pada awal. Nilai rata-rata dalam domain kontrol kemih, fungsi
fisik, fungsi kognitif dan beban pengasuh meningkat secara signifikan.
KESIMPULAN:

Penelitian pendahuluan ini menunjukkan bahwa disesuaikan secara individual USG-dibantu diminta
berkemih dapat ditingkatkan inkontinensia urin dari pasien usia lanjut dilembagakan. Penelitian lebih
lanjut yang layak melaksanakan.