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There may be an underlying condition that causes this resistance, or they may not understand that care is required.

Think

• Does they understand the care required?
• Do they recognise the toilet and remember how to use it?
• How might they interpret the assistance being offered?
• Is there an underlying condition causing this (e.g. pain, embarrassment, etc.)?
• What can you do to avoid the distress this causes?
• Can you implement a plan that takes a positive approach to communicating with and supporting this individual?

Do

• Try to find ways to promote independence in using the toilet, e.g. environment, signage, toileting programmes, prompting etc.
• Don’t talk to other’s on route
• Use mobility aid if needed
• Good visual aids – no clutter
• Good lighting, clean, warm toilet/bathroom
• Mirror may need covered/removed or any reflective stimuli
• Try not to cause embarrassment and ensure privacy
• Try distraction techniques
• Never force things, go away and come back later trying a different method of explaining, or ask a colleague to take over.

This could indicate a prostate problem (in a man) or a neurological condition that results in incomplete bladder emptying.
This symptom should be considered in relation to other symptoms (i.e. a sensation of incomplete bladder emptying,
etc). It could also be related to inadequate oral fluid intake.

Start a timed toileting regime (see SPHERE information leaflet: Voiding Programmes).

Encourage them to practice double voiding (see SPHERE information leaflet Successful Bladder Emptying).

Keep a bowel chart and resolve constipation if present (see SPHERE information leaflet: Constipation and Laxatives).

Discuss with the medical staff for potential further investigation of prostate.

A post-void bladder scan should be carried out.

Record fluid intake and output over a 24-hour period using a bladder diary and do this for 3 days in a row if possible.

This symptom may indicate an underlying health problem that requires attention and should be considered in relation to other
symptoms, e.g. urgency, urge incontinence, symptoms of UTI etc. Medical intervention may be required.

Could they be drinking an excessive amount of fluids, i.e. more than 2,500mls (see SPHERE information leaflet: Impact of Fluids on Bladder).

They may be reacting to a high intake of caffeine (caffeine should be reduced gradually to avoid caffeine withdrawal headaches). Caffeine is found in coffee, tea, some fizzy drinks such as Cola and Irn Bru and high energy drinks. (See SPHERE information leaflet: Impact of Fluids on the Bladder).

Are they constipated? Encourage the individual to practice double voiding (see SPHERE information leaflet: Successful
Bladder Emptying).

Do they have any pain or discomfort passing urine. If so, routine checking of urine sample
should be done to rule out urinary tract infections.

This symptom may indicate an underlying health problem that requires medical attention.

See SPHERE information leaflet Types of Incontinence: Nocturia.

Find out when they take their last drink of fluids before sleeping and what type of fluids they are taking.

Do they have any problems with lower limb oedema during the day?

This symptom may indicate an underlying health problem that requires medical attention.

Could they be constipated? Constipated faeces can put pressure on the bladder and cause symptoms of frequency and urgency, but it can also cause low urine output during the day, followed by passing large volumes of urine at night, when the pressure on the bladder is released by lying down.

Do they have lower limb oedema? Large amounts of urine passed during the night might be in response to fluid being reabsorbed from the skin when lying down.

Are they drinking large volumes of fluid (especially caffeine-containing drinks) later in the day?

Individuals vary widely in the frequency with which they empty their bowels and any change to the normal routine and/or eating patterns will have an impact. However, most people have their move their bowels at least 3 times per week.

Healthy bowel elimination is characterised by regular bowel movements (every 1-2 days), a soft, formed stool that is easy to pass (no straining). If their bowels move less than 3 times per week and have difficulty passing a hard stool, this is likely to be due to constipation. An increase in fibre, fluid, activity or laxatives may be required to achieve healthy bowel elimination. (see SPHERE Information leaflets: Constipation and Laxatives; Gastro-Colic Reflex; Medication Impact on the Bowel)

Pain and discomfort is not normal and should be investigated. It may indicate an underlying pathology, such as haemorrhoids or constipation (or both) or other underlying bowel disease.

Establish a regular bowel pattern, which might improve symptoms. Aim for a daily bowel movement, type 4 or 5 on the Bristol Stool Scale. See SPHERE Information leaflets: Gastro-Colic Reflex; Constipation and Laxatives
See NICE Guideline on Colorectal Cancer

Indicates constipation and/or an underlying problem. Keep in mind that people with acute or chronic health conditions may have difficulty in achieving abdominal pressure that facilitates full bowel emptying.

Straining must always be discouraged. If an individual is unable to have a bowel movement without straining this should be investigated (even if it is normal for them). Establish a regular bowel pattern, which might improve symptoms. Aim for a daily bowel movement, type 4 or 5 on the Bristol Stool Scale. See SPHERE Information leaflets: Gastro-Colic Reflex; Constipation and Laxatives; Bowel Incontinence and NICE Guideline on Colorectal Cancer.

Bleeding during a bowel movement is not normal.

This may indicate haemorrhoids or another underlying medical condition and should be discussed with GP/medical staff. See information leaflets and guidelines above.

Bowel movements should be soft and formed -refer to the Bristol Stool Scale for assistance in differentiating between a healthy and unhealthy stool.

See SPHERE Information leaflets: Gastro-Colic Reflex; Constipation and Laxatives; Medication Impact on the Bowel, Types of Incontinence: Bowel Incontinence

Can impact on bladder emptying and can cause symptoms of frequency and urgency and can contribute to nocturnal urinary
frequency and/or incontinence and urinary retention. Keep in mind what the person’s normal bowel pattern is and try to encourage a regular daily bowel movement utilising what you know about the gastro-colic reflex. Aim for a daily type 4 on the Bristol Stool Scale. Remember that a change of routine, different food etc. can adversely impact on the regularity of bowel movements. Check that they are taking adequate fluid intake and passing urine regularly during the day and if not a post void bladder scan should be carried out.

To prevent further risk to the skin they will require a care plan that addresses this issue. Urine and faeces can be very damaging to the skin, so it is essential that a toileting regime is put into place to minimise contact with the skin by urine and/or faeces. See Voiding Programmes and Gastro-colic Reflex.

Can cause symptoms of urgency and frequency. Make sure the urine is dipstick tested and if the patient shows signs of UTI initiate treatment: antibiotics if prescribed; encourage fluids; avoid faecal incontinence and make sure if faecal incontinence occurs, that the perineal and anal area is washed from front to back to avoid contamination of the urethral orifice with faecal matter

Is caused by a lack of oestrogen and occurs in women after the menopause. It can lead to symptoms of frequency and urgency and stress incontinence. This condition can be treated with topical oestrogen in the form of a cream or small pessaries which are inserted into the vaginal area. This treatment it can settle the symptoms of urinary frequency and urgency when other treatment options have not helped.

Can lead to urinary frequency, urgency and urge incontinence because of the presence of glucose in the urine, which can irritate the bladder wall. Longstanding diabetes can also lead to damage of the nerves supplying the bladder and/or bowel
and affect ability to pass urine/open bowels. If a patient has symptoms of urinary frequency and urgency, dipstick urinalysis will highlight any abnormalities that can be reported to the GP/medical staff for a review of their condition by Diabetes Specialist Nurse. Keep in mind that there are medications used to treat diabetes that will excrete glucose in the urine, please check with GP/medical staff.

As men age their prostate can increase in size and in some cases lead to voiding problems. Symptoms include urinary frequency, hesitancy (difficulty in passing urine), nocturia and a sense of incomplete emptying. Some men also experience post-void dribbling incontinence. Constipation will add to the discomfort

Make sure you ask about all symptoms and report to medical staff if you suspect a male patient has symptoms of enlarged prostate, complete an IPSS score sheet (see Hints and Tips section of SPHERE website). There are medical treatments available, but some useful tips to pass on can be found in the following SPHERE Information leaflets: – Impact of Fluids on the Bladder, Medications for Bladder Dysfunction, Successful Bladder Emptying, Urge Control Techniques. Double voiding and penile milking – see SPHERE Self Management Booklet for Men.

Having an operation and the recovery afterwards have been compared to exercise because they place a strain on the heart, lungs and muscles. Physical activity and training help prepare your body for exercise and the same is true before an operation. Improved fitness levels allow your body to cope better with the physical stress of surgery and will reduce your chances of complications.

The benefits of improved fitness before surgery include:

• A better recovery
• Leaving hospital sooner
• Returning to a normal quality of life more quickly
• Reducing your risk of heart disease, stroke and diabetes
• Improving blood pressure control and cholesterol levels
• Helping with weight control
• Reducing anxiety and stress

What to do

If you are normally an active person, we would encourage you to continue doing the activities

that you enjoy before your operation. If you are normally less active, the good news is that it’s never too late to start seeing benefits from regular exercise. The even better news is that you don’t need to do much and every little helps. You should increase what you do gradually, but as little as 30 minutes, 5 days per week is enough to improve your fitness.

You should be exerting yourself hard enough so that your heart rate goes up and your body feels warm. So why not find something that you enjoy and make a start today? Get your friends and family involved, or join a group, to make it even more enjoyable and help you stay motivated. It is important to increase the amount of exercise you do gradually. If you have a heart or lung condition, or have any concerns, speak to your GP, surgeon or pre-assessment nurse before starting an exercise program. For more information see the NHS Inform Keeping Active webpage.

In order for your body to recover from surgery, it needs the right energy and nutrients. A healthy balanced diet is important to help prepare your body for surgery.

You should aim to eat three regular meals with a good balance of the food groups – protein, carbohydrates and healthy fats. Try to avoid adding any extra sugar or salt to your diet. For more information see the NHS Inform Eatwell Guide: How to eat a healthy balanced diet page.

Vitamins and minerals are crucial to recovery after surgery, for example iron, folate, zinc and vitamins A, C and K. Try to get as many different types as possible by eating a healthy balanced diet with a good intake of fruit and vegetables. Aim to eat 5 different portions each day.

Depending on why you’re having surgery, some people may actually lose weight without trying before their operation. It is important your body has good energy stores to recover after surgery. If you have lost weight without trying to, or have a reduced appetite, try these simple changes to stop any more weight loss:

• Eat little and often – try 5-6 small snacks or meals per day
• Take drinks after meals and not before
• Use full fat milk and full fat dairy products
• Add margarine or butter to mashed potatoes
• Add grated cheese and/or cream to soups and sauces

More information

If you want more information about a healthy balanced diet, and would like some delicious meal suggestions, then you can find more information on the NHS Eat Well website and British Dietetic Association website.

If you are a smoker, stopping, or even cutting down, before your surgery is one of the best changes you can make to improve your health. Smoking puts an additional strain on your heart and lungs and increases the risk of complications during and after surgery. Smoking increases the risk of problems during or after your operation.

Heart

• reduced oxygen supply to heart and body
• heart attack

Lungs

• difficulty breathing during or after surgery
• chest infection or pneumonia
• collapsed lung

Blood clots

• blood clots in your veins or lungs

Bones, skin and wounds

impaired healing and scaring

wound infection

Immune system

• increased risk of infection

Vaping

Vaping, or using an e-cigarette, is not as harmful as smoking cigarettes. However, we don’t yet know the long-term health consequences. Vape liquid still contains nicotine, which increases your heart rate and blood pressure and puts a strain on your heart. We would also advise avoiding vaping before your operation.

What you can do… The important thing is that stopping smoking before surgery reduces your risk of these complications. The longer before your operation you can stop, the better. However, even avoiding cigarettes in the last few days can help. An operation provides a great opportunity to improve your long-term health by stopping smoking. Perhaps it could be an opportunity to quit smoking for good?

Support to stop

Quitting smoking is not easy, but we are here to support you. Maybe you could also get your friends and family to help by stopping at the same time?

If stopping is something you are motivated to do, speak to your surgeon or pre-assessment nurse who can refer you to our smoking cessation service. They offer individual and group support, as well as a range of nicotine replacement options. For more information see the NHS Inform stopping smoking website.

Alcohol, like all things, should be enjoyed in moderation. You don’t need to totally avoid alcohol before your operation, but we would advise that you stay below the recommended maximum amounts.

For both men and women this is less than 14 units per week, with no more than 3-4 units on any single day.

This would be around one and a half pints of beer, or two small glasses of wine.

You should avoid alcohol in the 24 hours before your operation.

Medical conditions can affect your recovery from surgery. It is important to make sure any conditions you have are controlled as well as possible before your surgery.

Diabetes

Good blood sugar control is really important to reduce your risk of infections. Talk to your diabetes nurse early to see if they need to make any changes to your treatment.

Blood Pressure

Blood pressure should be controlled to reduce your risk of stroke. Have your blood pressure checked at your GP surgery in good time before your operation. Your GP can then change your medication if needed.

Heart, lung, and other medical problems

If you have any other long-term medical problems, consider asking your GP or nurse for a review, especially if you think your health is not as good as it could be.

Most people feel some anxiety about having surgery. If you are very anxious or upset, it may be helpful to talk about your concerns with your GP. Techniques including mindfulness, relaxation and breathing exercises or yoga could help you relax before and after your surgery.

If you have loose teeth or crowns, a visit to the dentist may reduce the risk of damage to your teeth during an operation.

Are you going to prepare your body as best as possible and get fit for surgery? Although it may seem daunting, it is possible to make a few small changes that will make a big difference.

We are here to support you through this challenging time. If you have any questions about what you’ve just read then ask your pre-assessment nurse, surgeon or anaesthetist who will be able to guide you further.