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Nursing Care Plans: Nursing Diagnosis and Intervention, 5/e
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Urinary Elimination, Altered Patterns of: Incontinence - Stress Incontinence; Urge Incontinence; Reflex Incontinence; Full Incontinence; Total IncontinenceUrinary Retention
Audrey Klopp, RN, PhD, ET, CS, NHA

NANDA: Stress incontinence: The state in which an individual experiences a loss of urine less than 50 ml occurring with increased abdominal pressure

Urge incontinence: The state in which an individual experiences involuntary passage of urine occurring soon after a strong sense of urgency to void

Reflex incontinence: The state in which an individual experiences an involuntary loss of urine occurring at somewhat predictable intervals when a specific bladder volume is reached

Functional incontinence: The state in which an individual experiences an involuntary unpredictable passage of urine

Total incontinence: The state in which an individual experiences a continuous and unpredictable loss of urine

There are several types of urinary incontinence; all are characterized by the involuntary passage of urine. Urinary incontinence is not a disease but rather a symptom. Incontinence occurs more among women, and the incidence increases with age, although urinary incontinence is not a given with aging. An estimated 10 million people are incontinent; billions are spent annually in the management of urinary incontinence. Micturition (urination), is a complex physiologic function that relies on proper function of the bladder muscles and sphincters responding to spinal nerve impulses (S2, S3, and S4). Urinary incontinence occurs whenever the bladder, sphincter, or the nerves involved in micturition are diseased or damaged. Relaxed pelvic musculature following childbirth, postmenopausal urethral atrophy, central nervous system (CNS) diseases (such as Parkinson's and cerebrovascular accident [CVA]), spinal cord lesions or injury, and postoperative injuries can result in urinary incontinence. Careful diagnosis, including urodynamic studies, should precede treatment decisions, although empiric management is common. Urinary incontinence can lead to altered skin integrity, as well as severe psychological disturbances. Incontinent individuals often withdraw from social contact, and urinary incontinence is a major determinant in the institutionalization of the elderly. This care plan addresses five types of urinary incontinence: stress, urge, reflex, functional, and total. Education and continuity of care are addressed for each specific type, as well as for the problem of urinary incontinence as an entity.


I. Stress Incontinence

Related Factors

Defining Characteristics

Expected Outcome

Patient is continent of urine or verbalizes satisfactory management.

Ongoing Assessment

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(i) Ask whether urine is lost involuntarily during coughing, laughing, sneezing, lifting, or exercising.
Whenever intrabdominal pressure increases, a weak sphincter and/or relaxed pelvic floor muscles allow urine to escape involuntarily.
(i) Examine perineal area for evidence of pelvic relaxation:
(i) Determine parity.
Childbirth trauma weakens pelvic muscles.
(i) Explore menstrual history.
Postmenopausal hypoestrogenism causes relaxation of the urethra.
(i) Ask about previous surgical procedures.
In men, transurethral resection of the prostate gland can result in urinary incontinence.
(i) Weigh patient.
Obesity contributes to increased intraabdominal pressure.
(c) Culture urine.
Infection can cause incontinence.

Therapeutic Interventions

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(i) Prepare patient for surgery as indicated.
Many types of procedures are used to control stress incontinence; the most commonly performed are Marshall-Marchetti, Burch's colposuspension, and sling procedures.
(i) Prepare patient for the implantation of an artificial urinary sphincter,
Which uses a subcutaneous pumping device to deflate or inflate a cuff that controls micturition.
(i) Encourage weight loss if obese.

Education/Continuity of Care

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(i) Teach patient to perform Kegel exercises
To strengthen the pelvic floor musculature. Kegel exercises are used to strengthen the muscles of the pelvic floor, and can be practiced with a minimum of exertion. The repetitious tightening and relaxation of these muscles (10 repetitions, four to five times per day) helps some patients regain continence. Kegel exercises may be used in combination with biofeedback to enhance outcome.
(c) Encourage prescribed use of sympathomimetics and estrogens as ordered
To increase sphincter tone and improve muscle tone.
(i) Teach patient to use transcutaneous electrical nerve stimulator (TENS) as indicated.
To improve pelvic floor tone.
(c) Teach female patient use of vaginal pessary (a device reserved for nonsurgical candidates).
Which works by elevating the bladder neck, thereby increasing urethral resistance.

II. Urge Incontinence

Related Factors

Defining Characteristics

Expected Outcome

Patient is continent of urine or verbalizes management.

Ongoing Assessment

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(i) Ask patient to describe episodes of incontinence; note descriptions of "feeling the need suddenly but being unable to get to the bathroom in time."
Urge incontinence occurs when the bladder muscle suddenly contracts.
(i) Consider age.
This type of urinary incontinence is the most frequent type among the elderly.
(c) Culture urine.
Bladder infection can result in strong urge to urinate; successful management of a urinary tract infection may eliminate or improve incontinence.

Therapeutic Interventions

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(i) Prepare patient for sphincterotomy (surgical correction) as indicated.
Denervation, resulting in complete incontinence, may be undertaken (rhizotomy). Urinary diversion (ileal conduit) may be performed as a last resort.
(i) Facilitate access to toilet and teach patient to make scheduled trips to bathroom.

Education/Continuity of Care

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(i) Teach use of medications that reduce or block detrusor contractions (anticholinergics).
These inhibit smooth muscle contractions and may reduce episodes of incontinence.
(i) Educate patient in the use of biofeedback techniques.
For control of pelvic floor musculature.

III. Reflex Incontinence

Related Factors

Defining Characteristics

Expected Outcome

Patient verbalizes or demonstrates management techniques.

Ongoing Assessment

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(i) Ask whether patient feels urgency or sensation of voiding.
Spinal cord-injured patients may have damaged sensory fibers, and may not have the sensation of the need to void.
(i) Document history of spinal cord injury, including level.

Therapeutic Interventions

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(i) Consider use of external catheter.
(c) Use indwelling catheter as last resort.
Although risk of infection is considerable with both external and indwelling catheters, indwelling catheters interfere with clothing, movement, and sexual activity and may result in odor or other embarrassing sensory phenomena.

Education/Continuity of Care

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(c) Teach patient or caregiver (or perform for patient) intermittent (self-) catheterization.
To empty bladder at specified intervals.

IV. Functional Incontinence

Related Factors

Defining Characteristics

Expected Outcome

Patient experiences fewer episodes (or no episodes) of incontinence.

Ongoing Assessment

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(i) Assess patient's recognition of need to urinate.
Patients with functional incontinence are incontinent because they cannot get to an appropriate place to void. Institutionalized patients are often labeled "incontinent" because their requests for toileting are unmet. Elderly patients with cognitive impairment may recognize need to void, but may be unable to express the need.
(i) Assess availability of functional toileting facilities (working toilet, bedside commode).
(i) Assess patient's ability to reach toileting facility, both independently and with help.
(i) Assess frequency of patient's need to toilet.
This is the basis for an individualized toileting program.

Therapeutic Interventions

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(i) Establish a toileting schedule.
A toileting schedule assures the patient of a specified time for voiding, and reduces episodes of functional incontinence.
(i) Explore the benefit of placing a bedside commode near the patient's bed.
(i) Encourage use of clothing that can be easily and quickly removed. Prophylactically care for perineal skin.
Moisture-barrier ointments are useful in protecting perineal skin from urine scalds.
(i) Treat any existing perineal skin excoriation with a vitamin-enriched cream, followed by a moisture barrier.

Education/Continuity of Care

Actions/Interventions
Key:
(i) independent
(c) collaborative
(i) Teach patient or caregiver the rationale behind and implementation of a toileting program.

V. Total Incontinence

Related Factors

Defining Characteristics

Expected Outcomes

Ongoing Assessment

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(i) Assess amount of urine loss.
(i) Assess perineal skin condition.
The urea in urine converts to ammonia in a short period of time and is caustic to skin.

Therapeutic Interventions

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(i) Encourage use of diapers or external collection devices.
Most of these patients are women with fistulas; indwelling catheters are useless in the presence of vesicovaginal or urethrovaginal fistulas, because there is a communication between the bladder or urethra and the vagina.
(i) Prepare patient for surgical correction as indicated.

VI. All Types of Incontinence

Education/Continuity of Care

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(i) Teach patient or caregiver normal anatomy of genitourinary tract and factors that normally control micturition and maintain continence.
(i) Assist patient in recognizing that any episode(s) of incontinence that pose(s) a social or hygienic problem deserve(s) investigation so that appropriate therapy can be implemented.
Many people accept urinary incontinence as an inevitable consequence of aging and may be unaware that therapeutic measures can improve incontinence.
(i) Inform patient of the high incidence of urinary incontinence.
This information may decrease feelings of hopelessness and isolation that often accompany urinary incontinence.
(i) Assist patients, through careful interview to identify possible causes for urinary incontinence.
(i) Teach patients the necessity, purpose, and expected results of urodynamic diagnostic evaluation.
Urodynamic studies evaluate bladder filling and sphincter activity and are particularly useful in differentiating stress and urge incontinence.
(i) Provide information regarding all available methods of managing urinary incontinence.
So that patient can make an informed decision.
Methods include the following:
(i) Provide information on odor control.
Vinegar and commercially prepared solutions are useful in neutralizing urinary odor.
(i) Familiarize patient with potential risk of skin breakdown.
Urea contained in urine metabolizes to ammonia within minutes and is responsible for "urine burns" or "scalding." Spray or wipe preparations, such as Skin Prep and Bard Barrier Film, protect skin from urine.
(i) Refer to Help for Incontinent People (HIP), PO Box 544, Union, SC 29379.

NIC

Urinary Catheterization; Urinary Catheterization: Intermittent; Urinary Habit Training; Urinary Incontinence Care

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