Nursing diagnosis – REFLEX URINARY INCONTINENCE

REFLEX  URINARY  INCONTINENCE

DEFINITION

Involuntary loss of urine at somewhat predictable intervals when a

specific bladder volume is reached

DEFINING CHARACTERISTICS

• Complete emptying (with lesion above pontine micturition center)

or incomplete emptying (with lesion above sacral micturition
center) of bladder

• Either inability to sense full bladder, urge to void, or voiding, or

ability to sense urge to void without ability to voluntarily inhibit
bladder contraction

• Inability to voluntarily inhibit or initiate voiding

• Predictable pattern of voiding

• Sensations associated with full bladder (sweating, restlessness, and

abdominal discomfort)

RELATED FACTORS

• Tissue damage (e.g., radiation therapy)

• Neurological impairment above level of pontine or sacral micturi-

tion center

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Fluid and electrolytes

• Behavior

• Physical regulation

• Elimination

• Self-care

EXPECTED OUTCOMES

The patient will

• Maintain fluid balance, with intake approximately equaling output.

• Have minimal, if any, complications.

• Achieve urinary continence.

• Demonstrate skill in managing urinary incontinence.

• Discuss impact of incontinence on himself and family.

• Identify resources to assist with care following discharge.

SUGGESTED NOC OUTCOMES

Knowledge: Treatment Regimen; Nutritional Status: Food & Fluid

Intake; Tissue Integrity: Skin & Mucous Membranes; Urinary Conti-

nence; Urinary Elimination

INTERVENTIONS AND RATIONALES

Determine: Monitor intake and output to ensure correct fluid

replacement therapy. Report output greater than intake.

Perform: Implement and monitor effectiveness of specific bladder

elimination procedure, such as the following:

– Stimulate reflex arc. Patient who voids at somewhat predictable

intervals may be able to regulate voiding by reflex arc stimulation. Trig-

ger voiding at regular intervals (e.g., every 2 hr) by stimulating skin of

abdomen, thighs, or genitals to initiate bladder contractions. Avoid

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stimulation at nonvoiding times. Stimulate primitive voiding reflexes by

giving patient water to drink while he sits on toilet or pouring water

over perineum. External stimulation triggers bladder’s spastic reflex.

– Apply external catheter according to established procedure and

maintaining patency. Observe condition of perineal skin and clean

with soap and water at least twice daily. Cleanliness prevents skin

breakdown and infection. External catheter protects surrounding

skin, promotes accurate output measurement, and keeps patient dry.

Applying foam strip in spiral fashion increases adhesive surface and

cuts risk of impaired circulation.

– Insert indwelling catheter. Monitor patency and keep tubing free

from kinks to avoid drainage pooling and ensure accurate therapy. Keep

drainage bag below level of bladder to avoid urine reflux into bladder.

Perform catheter care according to established procedure. Maintain

closed drainage system to prevent bacteriuria. Secure catheter to leg

(female) or abdomen (male) to avoid tension on bladder and sphincter.

– Apply suprapubic catheter. Change dressing according to estab-

lished procedure to avoid skin breakdown. Monitor patency and

keep tubing free from kinks to avoid drainage pooling in loops of

catheter. Keep drainage bag below bladder level to avoid urine reflux

into bladder. Maintain closed drainage system to prevent bacteriuria.

– Change wet clothes to prevent patient from becoming

accustomed to wet clothes.

Inform: Instruct patient and family members on continence

techniques to use at home. Have patient and family members return

demonstrations until they can perform procedure well. Patient edu-

cation begins with assessment and depends on nurse’s therapeutic

relationship with patient and family.

Attend: Encourage high fluid intake (3,000 ml daily, unless

contraindicated) to stimulate micturition reflex. Limit fluid intake

after 7 p.m. to prevent nocturia.

Encourage patient and family members to share feelings and con-

cerns regarding incontinence. A trusting environment allows nurse to

make specific recommendations to resolve patient’s problems.

Manage: Refer patient and family members to psychiatric liaison

nurse, home healthcare agency, support group, or other resources, as

appropriate. Community resources typically provide healthcare not

available from other healthcare agencies.

SUGGESTED NIC INTERVENTIONS

Pelvic Muscle Exercise; Urinary Bladder Training; Urinary Elimina-

tion Management; Urinary Incontinence Care

Reference

Zarowitz, B. J., & Ouslander, J. G. (2006, September–October). Management

of urinary incontinence in older persons. Geriatric Nursing, 27(5), 265–270.

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