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Urinary IncontinenceUrinary incontinence is an uncontrolled leakage of urine. Pathology speaking, the inability to hold urine in the bladder is either caused by the weakened, or the lost of voluntary control over the urinary sphincter. This involuntary micturation commonly occurs as a distressing problem for the patient and its caregivers—which may considerably affect the quality of life. Urinary incontinence is a treatable condition that needs medical attention to prevent the occurrence of underlying complications.

Mayo Clinic categorized urinary incontinence with the following types and definitions:

  1. Stress incontinence  –  occurs while lifting, exercising, laughing, sneezing and coughing which commonly occurs in women, and presumptively the effect of pregnancy and childbirth; and/or hormonal imbalance during menopausal stage.
  2.  Urge incontinence – defined as an oversensitive bladder causing the urge to urinate when sleeping, drinking or listening to running water. Also termed as reflex incontinence, spastic bladder and overactive bladder. This condition is usually nocturnal and common in older adults. It also may be a symptom of a urinary infection in the bladder or kidneys, or may result from injury, illness or surgery.
  3.  Overflow incontinence – happen when the bladder is not completely emptied causing frequent dribbling urination. It can be an indication of nerve damage from diabetic disease or urethral blockage caused by stones, tumors, prostate enlargement (men) or birth defect (women).
  4.  Functional incontinence – this condition is brought about by limitations in movement, thinking and communicating—thus the patient often unable to control bladder before they reach the bathroom. Commonly observe in older patients with Parkinson’s disease, Alzheimer’s disease and arthritis.
  5.  Mixed incontinence – two types of incontinence that occurs concurrently, usually stress incontinence and urge incontinence which is commonly found in women.
  6. Anatomic or developmental abnormalities – incontinence that is caused by anatomic and/or neurologic abnormalities.
  7. Temporary incontinence – usually occur from an underlying specific condition (constipation, UTI) or side-effect of treatment or medications.
  8. Bed-wettingnocturnal enuresis is common in children and normal until 5 years old. This condition is the result of delayed neurological control of the bladder, an inherited disorder.

Urinary Incontinence Nursing Care Plan

AssessmentAssessment for urinary incontinence includes the number of times and frequency of micturation, characteristics of urine. For patients who are using diapers or incontinent pads, it should be weigh to measure the amount of urine. For patients with indwelling catheter, hourly measurement is a must to calculate properly. Rogers (2008), specified that history taking, physical examination, voiding diary, urinalysis and culture, post-void residual urine volume (ultrasound or catheterization), urodynamic testing, pelvic musculature examination and cough stress test are the important data to evaluate urinary incontinence. Kessler (2008), emphasized the importance of bladder diary as a useful tool in the diagnosis of this condition. He affirmed that history-taking is the cornerstone of urinary incontinence assessment wherein the patient is instructed to record the times of voiding, voided volumes, incontinence episodes, pad usage, degree of urgency, physical exercise during urinary leakage and the degree of incontinence.
Nursing Diagnoses*Impaired urinary elimination; Altered thought process; Self-care deficit; Potential for impaired skin integrity; Potential for infection; Anxiety and stress; Stress/Functional urinary incontinence; Alteration in comfort; Altered role performance; Body image disturbance; Potential for fluid volume deficit; Sleep pattern disturbance.
PlanningThe major goals for the patient may include control of urinary incontinence, promote regular urinary elimination patterns and prevent complications.
Implementation*Promoting urinary continence:Initiate bladder training by providing schedule with specified time for the patient to void. Bladder training is easy if the patient is under indwelling catheters, wherein the caregiver scheduled the time to close and to open the clamped catheter tube.

To optimize the likelihood of voiding as scheduled, measured amounts of fluids may be administered about 30 minutes before voiding attempts. Usually, there is a temporal relationship between drinking, eating, exercising and voiding. Fluid intake restriction to decrease the frequency of urination is not advisable. Sufficient fluid intake (2000 to 3000 mL/day according to patient needs) must be ensured to maintain hydration.

Voiding and episodes of incontinence are recorded. As the patient’s bladder capacity and control increase, the interval is lengthened. This theory was supported in the study of Shamliyan et al (2008), proven that bladder training resolved urinary incontinence in women.

Other measures can be helpful to promote voluntary urination are, suprapubic tapping or stroking of the inner thigh may produce voiding by stimulating the voiding reflex arc. Listening to running water or perineal wash with lukewarm water will also help.

Managing patient with altered thought process:

Interventions are difficult if managing patients with altered thought process, catheter as ordered is the last sort for urinary incontinence, strict care is encouraged to prevent occurrence of infection secondary to urinary catheterization. The caregiver must be taught how to provide daily hygiene, including skin inspection and catheter care. Instruction on emptying the urine bag must also be provided. Diapers and incontinent pads can be an option but meticulous perineal hygiene is necessary to prevent complications such as skin problems and bed sores.

Promoting hygiene, skin care and preventing infection:

Hygiene and skin care is strictly observed for patients with urinary incontinence problem to avoid occurrence of complications such as skin problems, bed sore, skin and urinary infection. Skin care and perineal care should be done every after voiding using non-allergenic soap with lukewarm water. Always pat dry the perineal area.

Provision of comfort:

When providing comfort diapers and incontinence pads are last resort, because they only manage rather than solve the incontinence problem. Also, they have a negative psychological effect on the patient because many people think of them as diapers. Every effort should be made to reduce the incidence of incontinence episodes through the other methods that have been described. Incontinence pads may be useful at times for patients with stress or total incontinence to protect clothing, but they should be avoided whenever possible. When incontinence pads are used, they should wick moisture away from the body to minimize contact of moisture and excreta with the skin. Wet incontinence pads must be changed promptly, the skin cleansed, and a moisture barrier applied to protect the skin.

Promoting role performance, promoting body image and relieving anxiety and stress:

Privacy should be provided during voiding efforts. Promote positive feedback and optimistic attitude to reinforce patient’s ego and esteem. Periods of continence and successful voidings are positively reinforced.

Maintaining hydration:

Monitoring intake and output is necessary to assess hydration. Signs and symptoms of good hydration and dehydration should be assessed and monitored every shift.

Promoting sleep and rest:

Fluid intake should be consumed before evening to minimize the need to void frequently during the night.

EvaluationNursing interventions focus on improving the voiding pattern, bladder control, control of urine urgency and to promote the voluntary micturation.Prevention of complications in hydration, sleep pattern, urinary problems like infection, and integumentary complications such as infection, skin problems and bedsores.

Maintain privacy and uplifting the morale of the patients, thus promoting self-esteem and body image.

Promote comfort for the patient and the caregivers.

Lessen the burden of both the patients and caregivers, thus preventing the occurrence anxiety, depression and stress during the treatment.

 Doenges, Moorhouse & Curr (2008); Smeltzer & Bare (2004)*

Urinary incontinence is a medical condition with implication that extends beyond physical manifestations. This condition often has serious effects on the lives of many individuals who suffer from embarrassment, stigma, physical discomfort and social isolation—that façade barriers to seek medical attention. Studies have shown that it is difficult to identify high risk or affected individuals because most cases are not reported and not diagnosed (Landefeld et al, 2008).

Tannenbaum et al (2010), reported that interactive continence workshops promote self-management and consultation seeking among older women with incontinence. Through the joint effort and cooperation from the victims of urinary incontinence, their caregivers and medical practitioners (nurses and doctors), we can improve symptoms and prognosis—thus, improving the quality of life. Awareness and health promotion is a must in creating a wider public acceptance—to unlock a new perspective in the nursing management of urinary incontinence.

References:

  • Doenges, M.E., Moorhouse, M.F. & Curr, A.C. (2008). Nurses Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales, 11th ed.Philadelphia: F.A. Davis Company. Kessler, T.M. (2008).
  • Diagnosis of Urinary Incontinence. Journal of the American Medical Association, 300(3), 283. Landefeld, C.S. et al. (2008).
  • National Institutes of Health State-of-the-Science Statement: Prevention of Fecal and Urinary Incontinence in Adults. Annals of Internal Medicine, 148(6). Mayo Clinic.
  • http://www.mayoclinic.org/urinary-incontinence/types.html Rogers, R.G. (2008). Urinary Stress Incontinence in Women. The New England Journal of Medicine, 358, 1029–1036.
  • Shamliyan, T.A. et al. (2008). Systematic Review: Randomized, Controlled Trials of Nonsurgical Treatments for Urinary Incontinence in Women. Annals of Internal Medicine, 148, 459–473. Smeltzer, S.C. & Bare, B.G. (2004).
  • Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, 10th Ed. PA: Lippincott Williams & Wilkins. Tannenbaum, C. et al. (2010).
  • Lessons Learned: Impact of a Continence Promotion Activity for Older Community-Dwelling Women. Neurology and Urodynamics, 29, 540–544.
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She is currently working as a medical-surgical nurse at Ministry of Health, Sultanate of Oman. A writer, blogger, researcher, correspondent and publication consultant for nursing journal and health-related educational websites. Her field of specialization focused on Intensive Care and Emergency Management. She is now taking up MAN major in Adult Health Nursing at the University of the Philippines Open University. A nursing professor for 8 years in the Philippines and served as a staff nurse at UST hospital. A caring and devoted nurse who introduced a “Pinay Nightingale” in the land of the pharaohs. A nurse by profession, an educator by devotion and a writer / researcher by passion.