CARE PLAN #2 NURSING DIAGNOSIS

APPENDIX III CARE PLAN #

CARE PLAN #2 NURSING DIAGNOSIS –

Overflow Incontinence Related to Incomplete Bladder Emptying or Urinary Retention from Neurogenic Bladder or Urethral Blockage Nursing Goal:

To reduce the PVR urine volume and promote adequate voiding.

To prevent the development of urine reflux to the kidneys and subsequent renal impairment.

Signs & Symptoms:

Abdominal discomfort and possible distended bladder Dribbling incontinence/post void dribbling (overflow UI)

Impaired sensation of bladder fullness and/or feeling of incomplete bladder emptying Post-void residual urine > 200 mLs on two separate occasions

Intervention Rationale

Evaluate residents past medical history for conditions that may cause or contribute to incomplete bladder emptying. Medical conditions that can affect bladder emptying include:

Prostate or urethral abnormalities (e.g. BPH, prostate cancer, urethral stricture) Medications which cause urinary retention Pelvic organ prolapse

Neurologic conditions (See Care Plan #1)

Chronic prostatitis, benign prostatic

hypertrophy (BPH), and urethral strictures are often the cause of urethral obstruction in men. Attempts should be made to relieve the

obstruction by surgery or release of stricture. Medications with anticholinergic properties can cause urinary retention.

Pelvic organ prolaspe in women can partially obstruct the urethra preventing complete bladder emptying.

Neurologic conditions that affect the brain, spinal cord or peripheral nerves can cause urinary retention.

If medical history indicated that resident is at risk for urinary retention determine PVR volume as outlined in Care Plan #1.

Normal PVR is < 50 mL and findings of between 50 mL and 200 mLs bear repeat measurement. PVR volume must be measured no longer than 20 minutes after the patient voids. Abnormal PVR is > 200 mLs and those residents should be referred to the urologist. Assess resident for presence of bowel

impaction by performing a digital rectal exam.

Stool in the recto-sigmoid colon may compress (push down) on the bladder and obstruct the urethra producing incomplete bladder emptying and/or overflow UI.

Evaluate residents‘ medication regimen for drugs known to cause urinary retention.

Medications should be discontinued if side effect is causing urinary retention.

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If volume does not warrant catheterization, consider teaching techniques to facilitate voiding and complete emptying of bladder such as:

A. Crede‘s maneuver:

Place the hands, just below the navel, one hand on top of the other

Firmly press down and in toward the pelvic bone.

Wait several minutes, then repeat again several times to ensure complete emptying B. Valsalva‘s maneuver (bearing down):

Lean forward on thighs and contract abdominal muscles.

Strain or bear down and void.

Repeat until no more urine is expelled. C. Double voiding:

Teach the resident to void twice during each trip to the bathroom by having the resident void, remain on the toilet, and to void a second time after a rest period of several minutes.

D. Suprapubic tapping

Drumming the abdomen overlying the bladder

E. Identify the trigger mechanism: Triggers include pulling pubic hairs,

stroking the abdomen or inner thigh, digital anal stimulation, pouring warm water over perineum or placing hands in warm water.

In many residents, Crede‘s maneuver can help to empty the bladder. Because bladder pressure is markedly increased, the bladder neck opens and emptying continues, as long as the bladder is being compressed.

Valsalva‘s maneuver contracts the abdominal muscles which manually compresses the bladder.

Double voiding increases voided volume and may be effective in cases of mild to moderate urethral obstruction.

The application of rhythmic tapping is thought to produce a summation effect on the tension receptors in the bladder wall and activation of the reflex arc via afferent nerve charges produced which will trigger voiding. Trigger mechanisms may initiate bladder contractions.

If resident persists with incomplete bladder emptying, consider intermittent (in and out) catheterization since residents with transient urinary retention (usually seen following recent indwelling catheterization) may benefit from intermittent catheterization until the bladder muscle tone returns (e.g., up to approximately 10 days). Perform intermittent catheterization on a daily, 4 to 6 hour schedule or more often if catheterization volumes excess 400 mLs. Always have patient void prior to

Regular, complete bladder drainage reduces the risk of infection as bacteria multiply rapidly in stagnant urine retained in the bladder.

Moreover, overdistention hinders blood flow to the bladder wall, increasing the susceptibility to infection from bacterial growth. Intermittent catheterization has been proven to be a safe and effective long-term treatment for residents with bladder-emptying dysfunction. It is preferable to the long-term use of an indwelling (Foley) catheter.

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catheterization. A voiding trial can aid in determining when bladder tone has returned (see Monograph II).

Outcomes:

Resident will:

Have learned a method of bladder decompression within 2 weeks. Not develop a UTI related to incomplete bladder emptying.

Be free from acute causes of urinary retention (i.e., bowel impaction, medications). Staff will:

Ensure complete bladder emptying.

Institute UTI prevention strategies if intermittent catheterization is instituted. Monitor resident for incomplete bladder emptying.

Bladder and Bowel Master Series

CARE PLAN #5

NURSING DIAGNOSIS – Functional (urinary or bowel) Incontinence Related to Decreased Mobility or Cognition

Nursing Goal:

To promote normal bladder/bowel function through nursing interventions and the use of toileting devices.

Signs & Symptoms:

Memory deficits

Anger and frustration with urination and/or defecation Decreased mobility

Recent illness and hospitalization

Development of a major illness affecting lifestyle and mobility Significant functional disability

Inaccessible toilet and/or staff

Intervention Rationale

Perform an environmental assessment of the resident‘s living environment to include adequacy and availability of bathroom facilities.

Consider instituting strategies to aid cognitively impaired resident in toileting.

Certain environmental barriers, such as location of the toilet, may be contributing to functional UI.

Consider covering the bathroom mirror for cognitively impaired residents who become confused and agitated when looking in the mirror. Resident may have an inability to recognize the toilet (visual agnosia). Visual cues such as a picture of a toilet on the bathroom door or of a man standing and voiding into a commode might aid residents in identifying the proper location and use of the toilet. Also, painting the bathroom door a bright eye-catching color that is different from the color of other doors may be helpful for residents with dementia. The bathroom should be well lit.

In collaboration with physical therapy staff, evaluate functional ability.

Observe resident while toileting (e.g. ability to

Physical disabilities, such as a recent stroke or severe arthritis, may necessitate changes in the environment to facilitate toileting.

Bladder and Bowel Master Series

ambulate, transfer on and off toilet, disrobe) and determine resident‘s ability or toilet using the following grading scale:

Level 1 – supervision Level 2 – limited assistance Level 3 – extensive assistance Level 4 – total dependence

information that can direct interventions. Difficulty ambulating increases the time required to reach the toilet, contributing to the severity of functional incontinence. Slow ambulation has the potential to affect

interventions such as toileting programs and bladder/bowel retraining.

Increase functional status by the use of less restrictive clothing (i.e., use of Velcro closures on clothing instead of zippers or buttons, dresses, skirts for women) and increasing ambulation (refer to physical therapy if necessary).

With decreased mobility and/or manual dexterity, the time needed to respond to the urge to urinate is increased.

Encourage nursing staff to answer calls for assistance promptly.

Resident may try to climb over bed rails or attempt to independently ambulate which may lead to a fall, injury, or an incontinent episode. Leave night light on and place bedside

commode next to the bed to facilitate nighttime self-toileting. Leave side rail down when possible.

Keeping commodes easily available and providing light at night facilitates toileting. More falls are caused by restricting the

resident‘s access to the bathroom by using side rails and restraints.

Institute a toileting program (scheduled voiding) that establishes a voiding routine, usually every 2 hours, whether or not a sensation to void is perceived. The schedule can be adjusted to the needs of the resident. The voiding interval is shortened when UI persists and lengthened when the resident is consistently dry at a certain interval. Encourage defecation during toileting after breakfast. Sit resident on the toilet or bedside commode within 30 minutes after eating breakfast.

Scheduled voiding can be used with the

resident who is unable to comprehend the need to void in appropriate places, who is unable to communicate the sense of urgency or the imminence of voiding. Habit training consists of timed, scheduled voiding.

Breakfast is the best meal for triggering a bowel movement. Peristalsis occurs, which forces stool to the descending colon and rectum.

Suggest the use of toileting devices such as male and female urinals, bedside commodes, bed pans and more easily accessible

bathrooms.

These devices may promote self-toileting and alleviate or eliminate functional incontinence.

For men, recommend the use of an external urine collection device for use at night or when leaving the house. External devices consist of

External urinary collection devices can be used for short-term therapy. There is an increased incidence of urinary tract infections (secondary

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an external condom catheter for men. Care consists of changing catheter daily, washing the penis between changes and avoiding the use of Betadine and adhesives. In women, consider the use of female pouches.

to constriction of the penis) and mechanical irritation with long-term use. Complications occur from improper and prolonged use of these devices.

Incontinence products should only be used after all other specific treatment modalities have been tried.

Absorbent products can be a useful, rational way to contain urine or fecal leakage, but in certain residents they can also encourage dependency and promote more incontinence. The type of product should be based on the degree and severity of incontinence.

Outcomes:

Resident will:

Have decreased incontinent episodes related to functional capability within two weeks. Have functional and environmental impediments to self-toileting removed.

Have learned to use toileting devices as necessary to decrease incontinence. Staff will:

Be able to anticipate and remove functional impediments to a resident being able to independently toilet.

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Appendix IV

CONTINUING EDUCATION ACTIVITY POST TEST

Date: Name: _____________________________________________ After reading this Independent Study Monograph, participants should select and circle the single most appropriate answer to each of the following questions.

1. One of the most common bladder disorders seen in the nursing home setting is: a) Bladder stones

b) Urinary incontinence c) Urethral obstruction d) Bladder cancer

2. Important functions of the bladder includes: a) Ability to expand and store urine b) Filter wastes from the blood c) Support the urinary sphincters

d) Act as a passageway through which urine exits the body 3. An age related change seen in the lower urinary tract is:

a) The largest urine production occurs during the day b) A decrease in bladder spasms or bladder overactivity c) Improved renal function

d) The bladder may not empty completely

4. One of the leading causes for a person to be admitted to a nursing home is: a) Heart disease

b) Hypertension c) Urinary incontinence d) Diabetes

5. Causes of acute or transient urinary incontinence include: a) Atrophic vagintitis

b) Incomplete bladder emptying c) Urinary tract infection d) All of the above

6. Mixed UI among nursing home residents is a combination of overflow and urgency incontinence. a) True

b) False

7. The following medications can impair bladder function: a) Hypnotic/sedative

b) Calcium channel blocker c) Anticholinergic

d) All of the above

In document Independent Study Monograph I. Assessment of Bladder and Bowel (Page 67-73)