Urinary incontinence is an underdiagnosed and underreported problem that increases with age, affecting 38-55% of women older than 60 years and 50-84% of the elderly in long-term care facilities. It is estimated that around 423 million people (20 years and older) worldwide experience some form of urinary incontinence. Approximately 13 million Americans experience urinary incontinence. 24% to 45% of women report some degree of urinary incontinence. In general, the prevalence of men is about half that of women.
The International Continence Society defines urinary incontinence as the involuntary loss of urine that represents a hygienic or social problem to the individual. Urinary incontinence can be thought of as a symptom as reported by the client, as a sign that is demonstrable on examination, and as a disorder.
Four types of urinary incontinence are defined in the Clinical Practice Guideline issued by the Agency for Health Care Policy and Research. Some authors include functional incontinence as a fifth type of incontinence.
- Stress urinary incontinence. The involuntary leakage of urine occurs with increases in intraabdominal pressure (e.g., exertion, effort, sneezing, or coughing). Due to urethral sphincter and/or pelvic floor weakness.
- Urge urinary incontinence. The involuntary leakage of urine may be preceded or accompanied by a sense of urinary urgency (but can be asymptomatic as well) due to detrusor overactivity. The contractions may be caused by bladder irritation or loss of neurologic control.
- Mixed urinary incontinence. The involuntary leakage of urine is caused by a combination of stress and urges urinary incontinence as described above.
- Overflow urinary incontinence. The involuntary leakage of urine from an overdistended bladder due to impaired detrusor contractility and/or bladder outlet obstruction. A common cause in men is benign prostatic hyperplasia.
- Functional urinary incontinence. The involuntary leakage of urine due to environmental or physical barriers to toileting. This type of incontinence is sometimes referred to as toileting difficulty.
Urinary incontinence may have multiple etiologies, with varying degrees of contribution.
- Underlying disorders or diseases. Structural and functional disorders involving the bladder, urethra, ureters, and surrounding connective tissue can contribute to the etiology of urinary incontinence. In addition, a disorder of the spinal cord or central nervous system may be a major etiologic factor. Medical comorbidities also can be important.
- Poor anatomic pelvic support. The most common cause of stress incontinence in women is urethral hypermobility secondary to poor anatomic pelvic support. Women may lose this pelvic support with postmenopausal estrogen loss, childbirth, surgery, or certain disease states that affect tissue strength.
- Intrinsic sphincter deficiency. A less common cause of stress incontinence is intrinsic sphincter deficiency, which can result from the aging process, pelvic trauma, surgery, or neurologic dysfunction. The most common cause of intrinsic sphincter deficiency in men is radical prostatectomy for prostate cancer or transurethral resection of the prostate for benign prostatic hyperplasia.
- Pharmacologic causes. Many medications contribute to urinary incontinence, directly or indirectly. Medications must always be considered as the cause of new-onset urinary incontinence- especially in elderly persons, in whom polypharmacy is often encountered. Medications such as drugs with anticholinergic properties, alpha-adrenergic agonists, alpha-antagonists, diuretics, calcium channel blockers, sedative-hypnotics, angiotensin-converting enzyme (ACE) inhibitors, and antiparkinson medications may cause incontinence.
Incontinence occurs when micturition physiology, functional toileting ability, or both have been disrupted. During episodes of stress incontinence, an increase in intra-abdominal pressure raises pressure within the bladder to the point where it exceeds the urethra’s resistance to urinary flow. Leakage ceases when bladder pressure again falls below urethral pressure. In urge incontinence, some researchers believe that detrusor overactivity represents the premature initiation of the normal micturition reflex. Relative cholinergic denervation may also explain some of these findings. Subtle obstruction and the effects of aging on smooth muscle and the autonomic nervous system are two possible contributors.
Nurses need to have different communicative resources to effectively assist the client diagnosed with urinary incontinence in order to successfully implement nursing interventions. The focus of the approaches for nursing interventions for urinary incontinence varies among educational, behavioral, and physical. The following are nursing diagnoses associated with urinary incontinence.
- Impaired Urinary Elimination
- Urinary Retention
- Risk for Impaired Skin Integrity
Urinary Incontinence Nursing Care Plan
Below are sample nursing care plans for the problems identified above.
Impaired Urinary Elimination
Urinary incontinence has been identified as a World Health Organization health priority. It has many physical, mental, and social effects on the client’s life. Age-related changes in the lower urinary tract include decreased bladder capacity and a feeling of fullness, decreased detrusor muscle contraction rate, decreased pelvic floor muscle strength, and increased residual urine volume. Urinary incontinence has a great impact on daily and social activities such as work, travel, physical exercise, and sexual function, and thus reduces the quality of life.
- Impaired Urinary Elimination
- Increased intra-abdominal pressure
- Urethral hypermobility
- Damage to the nerves, muscle, and connective tissue of the pelvic floor
- Surgical procedures
- Loss of bladder tone
- Frequency, urgency, hesitancy, dysuria, incontinence
- Bladder fullness
- Suprapubic discomfort
- Changes in the amount and character of the urine
After implementation of nursing interventions, the client is expected to:
- Display continuous flow of urine.
- Exhibit adequate urine output for an individual situation.
- Demonstrate behaviors to regain bladder and urinary control.
|Assess and record time, amount of voiding, and size of the stream.||A thorough history is essential to the evaluation of urinary incontinence. Clients may be reluctant to initiate discussions about incontinence; therefore, all clients, especially those older than 65 years, should be asked focused questions about voiding problems.|
|Utilize a questionnaire is assessing the client’s history of incontinence.||Incontinence histories can be very complex and time-consuming. Most centers use some form of incontinence questionnaire as an aid. The 3 incontinence questions (3IQ) is a brief questionnaire that may be useful to distinguish between stress, urge, mixed, and other causes.|
|Assess for the presence of comorbidities and medical conditions.||The client should be asked about medical conditions such as chronic obstructive pulmonary disease and asthma (which can cause cough), heart failure (with related fluid overload and diuresis), neurologic conditions (which may suggest dysregulated bladder innervation), and musculoskeletal conditions (which may contribute to toileting barriers).|
|Assess a female client’s gynecologic history.||For females, a gynecological history should be obtained to assess the number of births, whether births were vaginal or by cesarean birth, and whether or not they are currently pregnant.|
|Review the client’s use of medications and substances.||The client should be asked about medication and substance use, as they can directly or indirectly contribute to incontinence. Potential adverse effects include impairment of cognition, alteration of bladder tone or sphincter function, inducement of cough, and promotion of diuresis.|
|Perform maneuvers and tests to assess for urinary incontinence.||The cough stress test is a test wherein the client is asked to cough to demonstrate involuntary leakage of urine. The test is more sensitive when done in a standing position. The cotton swab test is performed by asking the client to bear down after insertion of a swab placed into the bladder through the urethra to demonstrate urethral hypermobility.|
|Assist the client in assuming a normal position to void; for example, stand and walk to the bathroom at frequent intervals.||This encourages the passage of urine and promotes a sense of normality|
|Encourage the client to void when the urge is noted but not more than every 2 to 4 hours per protocol.||Voiding with urge prevents urinary retention. Limiting voids to every 4 hours, if tolerated, increase bladder tone and aids in bladder retraining.|
|Limit fluid intake in the evening, but encourage intake of 2,000 to 2,500 as tolerated. Instruct to avoid caffeine-containing products.||This helps the client maintain adequate hydration and promotes urinary flow. “Scheduling” fluid intake reduces the need to void during the night. Caffeine-containing products include coffee, tea, hot chocolate, and colas. Caffeine is a natural diuretic and has a direct excitatory effect on bladder smooth muscle.|
|Instruct the client in pelvic floor training, such as tightening the buttocks and stopping and starting the urine stream.||A level A guideline from the American Congress of Obstetricians and Gynecologists (ACOG) recommends pelvic floor training as an apparently effective noninvasive treatment for adult women diagnosed with stress and mixed incontinence. Kegel exercises have been shown to improve the strength and tone of the muscles of the pelvic floor.|
|Instruct the client to keep a voiding diary.||A voiding diary is a daily record of the client’s bladder activity and is a useful supplement to the medical history of the client. Voiding diaries should record the volume and type of fluid intake and the frequency and volume of voids. Episodes of incontinence should be recorded, including an estimate of the volume; associated activities; and associated symptoms such as urgency.|
|Encourage the obese client to consider weight loss as a first-line treatment.||Given that obesity has been identified as a risk factor for the development of urinary incontinence, it is not surprising that interventions to address obesity can result in improved continence.|
|Provider and instruct in the use of continence pads when indicated.||Absorbent pads and internal and external collecting devices have an important role in the management of chronic incontinence. Absorbent products are helpful during the initial assessment and work-up of urinary incontinence.|
|Perform catheterization, as indicated.||Urinary diversion, using various catheters, has been one of the mainstays of severe anti-incontinence therapy. Bladder catheterization may be a temporary measure or a permanent solution for overflow incontinence. Self-catheterization is the preferred approach if the client is able to perform it. Indwelling Foley catheters or a suprapubic tube are considered if the client is unable to perform self-catheterization.|
|Administer medications as prescribed.||Medication may have some benefits in stress and urge urinary incontinence. These agents are not uniformly effective, and adverse effects may limit their long-term use.
|Assist in surgical procedures indicated for urinary incontinence.||Clients diagnosed with urinary incontinence that is refractory to medical therapy may be offered surgical treatment. The procedures used vary, depending on whether the client has stress or urge incontinence. Recommended procedures for stress incontinence in women include midurethral sling, autologous fascia pubovaginal sling, bladder neck suspension, or periurethral bulking therapy. In male stress incontinence, the transobturator male sling may be of particular benefit. Urge incontinence procedures include sacral nerve modulation, injection of botulinum toxin, and bladder augmentation.|
Acute Urinary Retention
The major contributing factor to overflow incontinence is incomplete bladder emptying secondary to impaired detrusor contractility or bladder outlet obstruction. Impaired detrusor contractility is typically neurogenic in nature. The maximal storage capacity of the bladder is reached, oftentimes without the client realizing that this has occurred. Incontinence occurs off the top of a chronically over-filled bladder. Effective emptying is not possible because of an acontractile detrusor muscle.
- Acute Urinary Retention
- Enlarged prostate
- Decompensation of detrusor musculature
- Inability of the bladder to contract adequately
- Urinary frequency
- Urinary hesitancy
- Inability to empty the bladder completely
- Incontinence and dribbling
- Bladder distention
- Residual urine
After implementation of nursing interventions, the client is expected to:
- Void in sufficient amounts with no palpable bladder distention.
- Demonstrate postvoid residuals of less than 50 ml.
- Demonstrate the absence of dribbling or overflow.
|Assess the urinary stream, noting size and force.||This is useful in evaluating the degree of obstruction and choice of intervention. The normal caliber and force of the urinary stream vary among individuals and the nurse should attempt to elicit the history of changes in the urinary stream rather than the specific size and force.|
|Assess for the occurrence of stress incontinence when moving, sneezing, coughing, laughing, or lifting objects.||High urethral pressure inhibits the bladder from emptying or can inhibit voiding until abdominal pressure increases enough for urine to be involuntarily lost.|
|Percuss and palpate the suprapubic area.||A client experiencing urinary retention may have a distended bladder that can be felt in the suprapubic area.|
|Monitor vital signs closely. Observe for hypertension, peripheral or dependent edema, and changes in mentation.||Loss of kidney function results in decreased fluid elimination and accumulation of toxic wastes. It may progress to complete renal shutdown.|
|Weigh the client daily and maintain an accurate intake and output.||Obesity is an important contributor to stress incontinence and the presence of obesity may influence management decisions. The quantity and types of fluids consumed influence urinary voiding symptoms.|
|Encourage the client to void every 2 to 4 hours and when the urge is noted.||This may minimize urinary retention and overdistention of the bladder. Bladder training involves relearning how to urinate. It generally consists of self-education, scheduled voiding with a conscious delay of voiding, and positive reinforcement.|
|Instruct the client to document the time and amount of each voiding.||Urinary retention increases pressure within the ureters and kidneys, which may cause renal insufficiency. Any deficit in blood flow to the kidney impairs its ability to filter and concentrate substances.|
|Encourage oral fluids up to 3,000 ml daily, within cardiac tolerance, if indicated.||Increased circulating fluid maintains renal perfusion an
d flushes kidneys, bladder, and ureters of sediment and bacteria. However, fluids may be restricted to prevent bladder distention if a severe obstruction is present or until an adequate urinary flow is reestablished.
|Provide and encourage meticulous catheter and perineal care.||This reduces the risk of ascending infection. After more than 2 weeks in the urinary bladder, all indwelling catheters become colonized with bacteria. Routine irrigation is not required, however, some authors favor the use of 0.25% acetic acid irrigation because it is bacteriostatic, minimizes catheter encrustation, and reduces odor.|
|Encourage the client to have a sitz bath, as recommended.||Thirty healthy volunteers and 21 clients diagnosed with urinary retention und
erwent a warm sitz bath at 40℃, 45℃, and 50℃ where the number of spontaneous micturitions increased with higher-temperature baths and it seems to be initiated by reflex (thermo-sphincter reflex) internal urethral sphincter relaxation.
|Administer medications, as indicated.||Alpha-adrenergic antagonists block the effects of postganglionic synapses that affect smooth muscle and exocrine glands. This action can decrease adverse urinary tract symptoms and increase urinary flow.|
|Catheterize for residual urine and leave indwelling catheter, as indicated.||Some clients diagnosed with overflow incontinence responds well to temporary continuous catheter drainage; their bladder capacity returns to normal, and voluntary detrusor pressure improves. Return of spontaneous voiding is more likely for clients without neurologic injury.|
Risk for Impaired Skin Integrity
Incontinence and skin breakdown related to incontinence have a considerable effect on clients’ physical and psychological well-being. When the skin is exposed to moisture (urine, feces, double incontinence, or frequent cleansing), its permeability increases and the barrier function reduces. The skin is not only exposed to chemical irritation but also to physical irritation (friction). Friction increases when perineal skin rubs over containment materials, clothing, and bed or chair surfaces. The combination of chemical and physical irritation results in a weakened skin status. If these mechanisms affect the integrity of the skin recurrently, further skin breakdown will develop.
- Risk for Impaired Skin Integrity
- Character and flow of urine from catheter
- Reaction to product or chemicals
- Improper removal of the catheter and adhesive
- Not applicable; the presence of signs and symptoms establishes an actual diagnosis
After implementation of nursing interventions, the client is expected to:
- Maintain skin integrity.
- Demonstrate behaviors and techniques to promote healing and prevent skin breakdown.
- Identify individual risk factors.
|Inspect the perineal skin routinely.||This provides an opportunity for early intervention in the potential high-risk populations, who may have thin, less elastic, and more fragile skin and tissues. Up to 50% of nursing home residents and 10-35% of community-dwelling adults are affected by urinary incontinence.|
|Assess nutritional status and initiate corrective measures, as indicated.||A positive nitrogen balance and an improved nutritional state can help prevent skin breakdown and promote skin healing.|
|Encourage adequate fluid intake.||The prevention of dehydration is necessary to maintain circulating volume and tissue perfusion, and good skin turgor to reduce the risk of ulcer formation.|
|Promote good perineal skin care.||The implementation of a structured skin care protocol combined with a pressure ulcer prevention protocol caused statistically significantly lower incontinence-associated dermatitis and fewer grade 1 pressure ulcers (Beeckman et al., 2009).|
|Encourage the use of polymer diapers or underpads for clients diagnosed with chronic incontinence.||More clients in a non-polymer diaper and underpads group experienced alterations than those in a polymer group. Therefore, polymer products, whether diapers or underpads, appeared to be more effective in preventing skin breakdown than non-polymer products.|
|Change position frequently in bed and chair. Encourage 10 minutes of exercise each hour and/or perform passive ROM.||Exercise improves circulation, muscle tone, and joint motion and promotes client participation.|
|Cleanse and moisturize the perineal skin with the appropriate skin products.||Researchers tend to recommend a routine perineal skin care program that includes cleansing with a product with a pH as near as possible to that of normal skin. In a second step, a moisturizer, incorporated into a specially designed cleanser or cleaning system, can be applied. The use of soap and water is not the most appropriate method for skin care for clients diagnosed with incontinence.|
|Promote the use of skin protectants.||The use of skin protectants is recommended for clients considered at risk of incontinence-associated dermatitis, including those experiencing high volume or frequent incontinence or double urinary and fecal incontinence. Combined products, including moisturizing cleansers, moisturizer skin protectant creams, and disposable washcloths that incorporate cleansers, can be used to optimize time efficiency and encourage adherence to the skin care regime.|
|Keep sheets and bedclothes clean, dry, and free from wrinkles, crumbs, and other irritating materials.||This avoids friction or abrasion injury of the skin. If the skin is highly vulnerable as it occurs during severe illness or immobility, additional measures include safe client-handling techniques, special support surfaces, or low-friction textiles to reduce pressure, shear, and friction.|
|Continue regimen for redness and irritation when a break in the skin occurs.||Aggressive measures are important because pressure ulcers can develop in a matter of a few hours. Timely intervention may prevent extensive damage.|
|Monitor the client’s hemoglobin, hematocrit, and blood glucose levels.||Anemia, dehydration, and elevated glucose levels are factors in skin breakdown and can impair healing.|
|Apply skin protectant products to affected areas as prescribed.||Zinc oxide-based products were evaluated in six studies. A topical zinc oxide preparation with antiseptic properties was found to be superior to traditional zinc cream for the treatment of incontinence-associated dermatitis. In eight studies, the use of a no-sting barrier film was evaluated and it was observed that there was a reduction of erythema, skin maceration, and skin stripping.|
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