Nursing diagnosis – URGE URINARY INCONTINENCE

URGE  URINARY  INCONTINENCE

DEFINITION

Involuntary passage of urine occurring shortly after a strong sense

of urgency to void

DEFINING CHARACTERISTICS

• Bladder contraction or spasm

• Increased or decreased volume

• Frequency

• Nocturia

• Inability to reach toilet in time

• Urgency

RELATED FACTORS

• Alcohol intake

• Decreased bladder capacity

• Atrophic urethritis

• Detrusor hyperactivity with

• Atrophic vaginitis

impaired bladder contractility

• Bladder infection

• Fecal impaction

• Caffeine intake

• Use of diuretics

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Fluid and electrolytes

• Behavior

• Physical regulation

• Elimination

• Self-care

EXPECTED OUTCOMES

The patient will

• Have fewer episodes of incontinence.

• State increased comfort.

• State understanding of treatment.

• Have minimal, if any, complications.

• Discuss impact of disorder on himself and family members.

• Demonstrate skill in managing incontinence.

SUGGESTED NOC OUTCOMES

Tissue Integrity: Skin & Mucous Membranes; Urinary Continence;

Urinary Elimination

INTERVENTIONS AND RATIONALES

Determine: Observe voiding pattern; document intake and output.

This ensures correct fluid replacement therapy and provides informa-

tion about patient’s ability to void adequately.

Perform: Provide appropriate care for patient’s urologic condition,

monitor progress, and report patient’s responses to treatment.

Patient should receive adequate care and take part in decisions

about care as much as possible.

Assist with specific bladder elimination procedures, such as the

following:

bladder training—place patient on commode every 2 hr while

awake and once during night, provide privacy, and gradually

increase intervals between toileting (these measures aim to restore a

regular voiding pattern). As well as rigid toilet regimen—place

patient on toilet at specific times (to aid adaptation to routine

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physiologic function), and keep baseline micturition record for

3–7 days (to monitor toileting effectiveness).

Administer pain medication; discuss effectiveness with patient to

reinforce that pain can be alleviated, which reduces tension and anxiety.

Place commode next to bed, or assign patient bed next to

bathroom. A bedside commode or convenient bathroom requires less

energy expenditure than bedpan. If using commode, keep bed and

commode at same level to facilitate patient’s movements. If using

bathroom, provide good lighting from bed to bathroom to reduce

sensory misinterpretation; remove all obstacles between bed and bath-

room to reduce chance of falling. Prepare pleasant toilet environment

that is warm, clean, and free from odors to promote continence.

Provide a clock to help patient maintain voiding schedule through

self-monitoring.

Unless contraindicated, maintain fluids to 3,000 ml daily to mois-

ten mucous membranes and ensure hydration; limit patient to 150

ml after dinner to reduce need to void at night.

Have patient wear easily removable clothes (gown instead of paja-

mas and Velcro fasteners instead of buttons or zippers) to reduce

frustration and delay in voiding routine.

If patient loses control on way to bathroom, instruct patient to

stop and take a deep breath. Anxiety and rushing may strengthen

bladder contractions.

Inform: Explain urologic condition to patient and family members;

include instructions on preventive measures and established bladder

schedule. Patient education begins with educational assessment and

depends on establishing a therapeutic relationship with patient and

family. Prepare patient for discharge according to individual needs to

allow patient to practice under supervision.

Instruct patient and family members on continence techniques for

home use. This reduces fear and anxiety resulting from lack of knowl-

edge of patient’s condition and reassures patient of continuing care.

Attend: Encourage patient to express feelings and concerns related to

his or her urologic problem to identify patient’s fears.

Manage: Refer patient and family members to psychiatric liaison

nurse, support group, or other resources, as appropriate.

Community resources typically provide healthcare not available from

other healthcare agencies.

SUGGESTED NIC INTERVENTIONS

Fluid Monitoring; Perineal Care; Self-Care Assistance: Toileting; Uri-

nary Elimination Management; Urinary Habit Training; Urinary

Incontinence Care

Reference

Dingwall, L., & McLafferty, E. (2006, October). Do nurses promote urinary

continence in hospitalized older people?: An exploratory study. Journal of
Clinical Nursing, 15(10), 1276–1286.

Nursing diagnosis – STRESS URINARY INCONTINENCE

STRESS  URINARY  INCONTINENCE

DEFINITION

Sudden leakage of urine with activities that increase intra-abdominal

pressure

DEFINING CHARACTERISTICS

• Dribbling with increased abdominal pressure

• Frequency

• Urgency

RELATED FACTORS

• Degenerative changes in pelvic

• Intrinsic urethral sphincter

muscles

deficiency

• High intra-abdominal pressure

• Weak pelvic muscles

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Fluid and electrolytes

• Behavior

• Physical regulation

• Elimination

• Self-care

EXPECTED OUTCOMES

The patient will

• Maintain continence.

• State increased comfort.

• State understanding of treatment.

• State understanding of surgical procedure.

• Demonstrate skill in managing urinary elimination problems.

• Identify resources to assist with care following discharge.

SUGGESTED NOC OUTCOMES

Tissue Integrity: Skin & Mucous Membranes; Urinary Continence;

Urinary Elimination

INTERVENTIONS AND RATIONALES

Determine: Observe patient’s voiding patterns, time of voiding,

amount voided, and whether voiding is provoked by stimuli. Accu-

rate, thorough assessment forms basis of an effective treatment plan.

Perform: Provide appropriate care for patient’s urologic condition,

monitor progress, and report patient’s responses to treatment.

Patient expects to receive adequate care and to participate in

decisions regarding care.

Help patient to strengthen pelvic floor muscles by Kegel exercises

for sphincter control. Exercises increase muscle tone and restore cor-

tical control.

Promote patient’s awareness of condition through education to

help patient understand illness as well as treatment.

Help patient reduce intra-abdominal pressure by losing weight,

avoiding heavy lifting, and avoiding chairs or beds that are too high

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or too low. These measures reduce intra-abdominal pressure and

bladder pressure.

Provide supportive measures:
– Respond to call bell quickly, assign patient to bed next to bath-

room, put night-light in bathroom, and have patient wear easily

removable clothing (gown rather than pajamas and Velcro fasteners

rather than buttons or zippers). Early recognition of problems pro-

motes continence; easily removed clothing reduces patient frustration

and helps achieve continence.

– Provide privacy during toileting to reduce anxiety and promote

elimination.

– Have patient empty bladder before meals, at bedtime, and

before leaving accessible bathroom area to promote elimination,

avoid accidents, and help relieve intra-abdominal pressure.

– Limit fluids to 150 ml after dinner to reduce need to void at

night.

– Encourage high fluid intake, unless contraindicated, to moisten

mucous membranes and maintain hydration.

– Suggest patient eat increased amount of salty food before going

on a long trip (unless contraindicated). Increased sodium decreases

urine production.

– Make protective pads available for patient’s undergarments, if

needed, to absorb urine, protect skin, and control odors.

If surgery is scheduled, give attentive, appropriate preoperative

and postoperative instructions and care to reduce patient’s anxiety

and build trust in caregivers.

Inform: Alert patient and family members about need for toilet

schedule. Prepare for discharge according to individual needs to

ensure that patient will receive proper care.

Attend: Encourage patient to express feelings and concerns related to

urologic problems. This helps patient focus on specific problem.

Manage: Refer patient and family members to psychiatric liaison

nurse, support group, or other resources, as appropriate.

Community resources typically provide healthcare not available from

other healthcare agencies.

SUGGESTED NIC INTERVENTIONS

Pelvic Muscle Exercise; Teaching: Individual; Urinary Elimination

Management; Urinary Habit Training; Urinary Incontinence Care

Reference

Anders, K. (2006, May). Recent developments in stress urinary incontinence in

women. Nursing Standard, 20(35), 48–54.

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.

Nursing diagnosis – OVERFLOW URINARY INCONTINENCE

OVERFLOW  URINARY  INCONTINENCE

DEFINITION

Involuntary loss of urine associated with overdistention of the bladder

DEFINING CHARACTERISTICS

• Bladder distention

• High postvoid residual volume

• Nocturia

• Reported and observed involuntary leakage of small volumes of

urine

RELATED FACTORS

• Bladder outlet obstruction

• Severe pelvic prolapse

• Detrusor external sphincter

• Side effects of anticholinergic,

dyssynergia

calcium channel blocker, or

• Detrusor hypocontractility

decongestant medications

• Fecal impaction

• Urethral obstruction

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Fluid and electrolytes

• Behavior

• Physical regulation

• Elimination

• Self-care

EXPECTED OUTCOMES

The patient will

• Void 200–300 mL of clear, yellow urine every 3–4 hr while

awake.

• Have postvoid residual of less than 50 ml.

• Have reduction in urinary incontinence episodes or complete

absence of urinary incontinence.

• Experience relief of most bothersome aspect of urinary

incontinence.

• Remain clean and dry without urine odor.

• Express understanding of condition and activities to prevent/reduce

overflow incontinence.

• Express improvement in quality of life.

SUGGESTED NOC OUTCOMES

Knowledge: Treatment Regimen; Urinary Continence

INTERVENTIONS AND RATIONALES

Determine: Monitor and record patient’s voiding patterns to

determine existence and extent of overflow incontinence.

Monitor and record patient’s intake and output to determine fluid

balance.

Perform: Ask patient to keep a bladder diary of continent and incon-

tinent voids to promote understanding of the extent of the problem

of overflow incontinence. Discuss voiding and fluid intake patterns.

Accurate understanding of patient’s pattern provides a baseline for

introducing new activities.

185
Provide privacy and adequate time to void to decrease anxiety

and promote relaxation of sphincter.

Assist patient to assume usual position for voiding. Some patients

are unable to void while lying in bed and may develop urinary

retention and overflow incontinence.

Massage (credé) the bladder area during urination to increase

pressure in the pelvic area to encourage drainage of urine from the

bladder.

Institute indwelling or intermittent catheterization, as ordered.

Catheterization is used as a last resort to empty the bladder prevent-

ing overflow incontinence.

Assist with application of pads and protective garments (used only

as a last resort) to prevent skin breakdown and odor and to

promote social acceptance.

Inform: Teach patient and/or family to catheterize patient with

chronic overflow incontinence related to urinary retention using

clean technique to manage long-term overflow incontinence.

Teach stress management and relaxation techniques. Stress and

anxiety interfere with sphincter relaxation, causing urinary retention

and overflow incontinence.

Attend: Encourage patient to share feelings related to incontinence to

reduce anxiety.

Encourage patient to drink six to eight glasses of noncaffeinated,

nonalcoholic, and noncarbonated liquid, preferably water, per day

(unless contraindicated). 1,500–2000 mL/day promotes optimal renal

function and flushes bacteria and solutes from the urinary tract.

Caffeine and alcohol promote diuresis and may contribute to excess

fluid loss and irritation of the bladder wall.

Encourage patient to respond to the urge to void in a timely man-

ner. Ignoring the urge to urinate may cause incontinence.

Encourage patient to participate in regular exercise, including

walking and modified sit-ups (unless contraindicated). Weak abdomi-

nal and perineal muscles weaken bladder and sphincter control.

Encourage patient to avoid anticholinergics, opioids, psychotrop-

ics,    -adrenergic agonists,    -adrenergic agonists, and calcium-

channel blockers (unless contraindicated), which inhibit relaxation of

the urinary sphincter and cause urinary retention.

Manage: Provide referrals for physical therapy or psychological

counseling as necessary to enhance success.

SUGGESTED NIC INTERVENTIONS

Urinary Incontinence Care; Urinary Retention Care

Reference

DuBeau, C. (2006). Clinical presentation and diagnosis of urinary

incontinence. Retrieved December 12, 2006, from http://www.uptodate.com

Nursing diagnosis – FUNCTIONAL URINARY INCONTINENCE

FUNCTIONAL  URINARY  INCONTINENCE

DEFINITION

Inability of usually continent person to reach toilet in time to avoid

unintentional loss of urine

DEFINING CHARACTERISTICS

• Amount of time needed to reach toilet exceeding length of time

between sensing urge to void and uncontrolled voiding

• Loss of urine before reaching toilet

• May be incontinent only in the morning

• Able to empty bladder completely

RELATED FACTORS

• Altered environmental factors

• Psychological factors

• Impaired cognition

• Weakened supporting pelvic

• Impaired vision

structures

• Neuromuscular limitations

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Fluid and electrolytes

• Behavior

• Physical regulation

• Elimination

• Self-care

EXPECTED OUTCOMES

The patient will

• Void at appropriate intervals.

• Have minimal, if any, complications.

• Demonstrate skill in managing incontinence.

• Discuss impact of incontinence on him and family members.

• Identify resources to assist with care following discharge.

SUGGESTED NOC OUTCOMES

Coordinated Movement; Self-Care: Toileting; Symptom Control;

Urinary Continence; Urinary Elimination

INTERVENTIONS AND RATIONALES

Determine: Monitor and record patient’s voiding patterns to ensure

correct fluid replacement therapy.

Perform: Stimulate patient’s voiding reflexes (give patient drink of

water while on toilet, stroke area over bladder, or pour water over

perineum) to trigger bladder’s spastic reflex. Provide hyperactive

patient with distraction, such as a magazine, to occupy attention

while on toilet, reduce anxiety, and ease voiding.

Maintain adequate hydration up to 3,000 ml daily, unless

contraindicated. Scheduling fluid intake promotes regular bladder

distention and optimal time intervals between voidings. Limit fluid

intake to 150 ml after dinner to reduce need to void at night.

Assist with specific bladder elimination procedures, such as the

following: bladder training—this involves muscle-strengthening

183

exercises, adequate fluid intake, and carefully scheduled voiding

times (encourage voiding every 2 hr while awake and once during

night); rigid toilet regimen—place patient on toilet at specific inter-

vals (every 2 hr or after meals) and note whether voiding occurred

at each interval (this helps patient adapt to routine physiologic func-

tion); behavior modification—refrain from punishing unwanted

behavior (e.g., voiding in wrong place), and reinforce positive behav-

ior using social or material rewards (this helps patient learn alterna-

tives to maladaptive behaviors); use of external catheter—apply

according to established procedure and maintain patency, observe

condition of perineal skin and clean with soap and water at least

twice daily (this ensures effective therapy and prevents infection and

skin breakdown); application of protective pads and garments—use

only when interventions have failed to prevent infection and skin

breakdown and allow at least 4–6 weeks for trial period (establish-

ing continence requires prolonged effort).

Maintain continence based on patient’s voiding patterns and limita-

tions. Respond to call light promptly to avoid delays in voiding routine.

Orient patient to toileting environment: time, place, and activity

to offer security. Provide privacy and adequate time to void to allow

patient to void easily without anxiety.

Replace wet clothes immediately. Select clothing that promotes

easy dressing and undressing (e.g., Velcro fasteners and gowns) to

reduce patient’s frustration with voiding routine.

Inform: Teach family members and support personnel to reduce anxi-

ety that results from noninvolvement. Instruct patient and family

members on continence techniques to use at home to increase

chances of successful bladder retraining.

Attend: Encourage patient and family members to share feelings

related to incontinence. This allows specific problems to be identified

and resolved. Attentive listening conveys recognition and respect.

Manage: Refer patient/family to home healthcare agency, or support

group to provide access to additional community resources.

SUGGESTED NIC INTERVENTIONS

Pelvic Muscle Exercise; Prompted Voiding; Self-Care Assistance; Uri-

nary Elimination Management; Urinary Habit Training

References

Dowd, T., & Dowd, E. T. (2006, January–February). A cognitive therapy

approach to promote continence. Journal of Wound, Ostomy and
Continence Nursing, 33(1), 63–68.

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

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

Nursing diagnosis – bowel incontinence

Bowel Incontinence
DEFINITION
Change in normal bowel habits characterized by involuntary passage
of stool
DEFINING CHARACTERISTICS
• Constant dribbling of soft stool
• Fecal odor
• Fecal staining of clothing or bedding
• Inability to delay defecation
• Inability to recognize urge to defecate
• Recognizes rectal fullness but reports inability to expel formed stool
• Inattention to urge to defecate
• Self-report of inability to recognize rectal fullness
• Red perianal skin
• Urgency
RELATED FACTORS
• BOWEL INCONTINENCE
• Abnormally high abdominal
pressure
• Abnormally high intestinal
pressure
• Chronic diarrhea
• Colorectal lesions
• Dietary habits
• Environmental factors (e.g.,
inaccessible bathroom)
• General decline in muscle tone
• Immobility
• Impaired cognition
• Impaired reservoir capacity
• Incomplete emptying of bowel
• Laxative abuse
• Loss of rectal sphincter
control
• Lower motor nerve damage
• Medications
• Rectal sphinter abnormality
• Impaction
• Stress
• Toileting self-care deficit
• Upper motor nerve damage
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Fluid and electrolytes
• Elimination
• Neurocognition
EXPECTED OUTCOMES
The patient will
• Experience a bowel movement every ___ day(s) when placed on
commode or toilet at ___ AM/PM.
• Maintain clean and intact skin.
• Have improved control of incontinent episodes.
• State understanding of bowel routine.
• Demonstrate skill in using commode.
• Demonstrate skill in the use of suppository if indicated.
• Express an understanding of the relationship between food and
fluid regulation and the promotion of continence.
• Maintain self-respect and dignity through participation and acceptance
within group.
SUGGESTED NOC OUTCOMES
Bowel Continence; Bowel Elimination; Self-Care: Toileting
INTERVENTIONS AND RATIONALES
Determine: Establish a regular pattern for bowel care; for example,
after breakfast every other day, place patient on the commode chair
1 hr after inserting suppository, allow patient to remain upright for
30 min for maximum response, and then clean the anal area. Procedure
encourages adaptation and routine physiologic function.
Monitor and record incontinent episodes; keep baseline record for
3–7 days to track effectiveness of toileting routine.
Perform: Clean and dry perianal area after each incontinent episode
to prevent infection and promote comfort.
Inform: Demonstrate bowel care routine to family or caregiver to
reduce anxiety from lack of knowledge or involvement in care.
Arrange for return demonstration of bowel care routine to help
establish therapeutic relationship with patient and family or
caregiver.
Establish a date when family or caregiver will carry out bowel
care routine with supportive assistance; this will ensure that patient
receives dependable care.
Discuss bowel care routine with family or caregiver to foster compliance.
Instruct family or caregiver on need to regulate foods and fluids
that cause diarrhea or constipation to encourage helpful nutritional
habits.
Attend: Maintain patient’s dignity by using protective padding under
clothing, by removing patient from group activity after incontinent
episode, and by cleaning and returning patient to the group without
undue attention. These measures prevent odor, skin breakdown, and
embarrassment and promote patient’s positive self-image.
Manage: Maintain diet log to identify irritating foods, and then
eliminate them from patient’s diet.
SUGGESTED NIC INTERVENTIONS
Bowel Incontinence Care; Bowel Management; Perineal Care; Skin
Surveillance
Reference
Dowd, T., & Dowd, E. T. (2006, January–February). A cognitive therapy
approach to promote continence. Journal of Wound, Ostomy and
Continence Nursing, 33(1), 63–68.