REFLEX URINARY INCONTINENCE
Involuntary loss of urine at somewhat predictable intervals when a
speciﬁc bladder volume is reached
• 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
• Inability to voluntarily inhibit or initiate voiding
• Predictable pattern of voiding
• Sensations associated with full bladder (sweating, restlessness, and
• Tissue damage (e.g., radiation therapy)
• Neurological impairment above level of pontine or sacral micturi-
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Fluid and electrolytes
• Physical regulation
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
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
Zarowitz, B. J., & Ouslander, J. G. (2006, September–October). Management
of urinary incontinence in older persons. Geriatric Nursing, 27(5), 265–270.