Inverclyde Nurse-Led Enuresis Inverclyde Nurse-Led Enuresis Service Service Inverclyde Nurse-Led Enuresis Service School health department
History •Originally led by cmo’s •2003, at suggestion of Dr. Bryan kelly Paediatrician, the service became nurse-led •The first clinic commenced in Port Glasgow •Second 6 months later commenced in Greenock •Two school nurses were trained to use “The three systems approach” •Further two nurses and two nursing assistants have completed training this year
The Three Systems Approach •Developed using evidence based studies by Dr. Richard Butler, Clinical Psychologist and Dr Philip Holland Consultant Paediatrician both at Leeds Primary Care Trust •Published in 2000 •It sought to provide a clinical tool whereby the problem of enuresis could be better understood and treated • It also sought to take pressure off the child by giving physical explanations of which the child has no control
Founded on the notion that bedwetting results from: •Inability to reduce nocturnal urine volume (through lack of vasopressin release) •Bladder instability •Lack of arousal to full bladder signals
First Visit •Full history taken •Parents asked to measure bladder capacity for 1 day at weekend •Record wet/dry nights • Advice is given re fluids. = Drink at least 6-7 drinks during day •No brown drinks •No fizzy drinks • No lifting •No nappies •Good bedtime routine
Second Visit •Predicted bladder capacity estimated (age + 1 x 30mls.) •Charts analysed •Treatment started • A few children have come back to the clinic, and after the simple advice given, have become dry!!
The Three Systems Checklist Lack of Vasopressin •Wets soon after sleep •Size of wet patch large •Weak urine concentration in the morning Bladder Instability •Frequent daytime voiding •Urgency / need to dash to toilet •Pass small amounts •Small bladder capacity •Size of wet patch variable •Wakes up after wetting Arousability •Will occasionally wake to void •Will wake but avoid going to the toilet •Will wake to external sounds •Will wake when ill or excited
Treatment Lack of vasopressin Desmopressin acetate (desmomelt 120mcg - 240mcg) Unstable bladder Ditropan (oxybutynin 2.5mg up to 10mg in divided doses) Difficulties with arousability Bedtime routine, fluids, reinforcement with charts Sometimes alarm added into treatment for lack of vasopressin and arousability
Follow up •Seen within 2 weeks of starting treatment •Approx. every 6 weeks after a treatment pathway has become successful •Telephone consultations •Closer follow up if using alarm •After 3 successful months on desmomelts treatment is slowly decreased to ensure medication is not being taken unnecessarily •If child F.T.A. X 2 a letter is sent to parents asking to contact within 10 days or will be discharged •G.P. Would be notified if no contact from parent, and child still on medication
•Referrals are taken from G.P’s, School Nurses, Health Visitors and direct referral from parents •Referrals are taken for children with nocturnal enuresis and daytime wetting •Closely work with nurses on L north at I.R.H who run a hospital based clinic and take referrals from clinics •Enuresis is affected by constipation and referrals are made by the clinic to the community childrens nurses on the ward •There is a direct referral pathway from the clinics to Dr. Kelly at the I.R.H
Referrals Email Jean.Burton@renver-pct.scot.nhs.uk Tracey.Doyle@renver-pct.scot.nhs.uk Letter to: Jean Burton at P.G.H.C Tracy Doyle at G.H.C Telephone 01475 506026 (answer machine) Self referral by parent to school health dept via Greenock or Port Glasgow health centre
Further Information E.R.I.C = education and resources for improving childhood continence www.eric.org.uk www.trusteric.org (for teens) www.ericshop.og.Uk (webshop) www.i-c-c-s.org (helpful handouts) www.urinecontrol.co.uk (ferring) www.promocon.co.uk (disabled living) www.emea.europa.eu
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