Urge Urinary Incontinence NANDA Definition State in which the individual experiences involuntary passage of urine occurring with

precipitous desire to urinate; urge incontinence is defined within the context of overactive bladder syndrome; the overactive bladder is characterized by bothersome urgency (a sudden and strong desire to urinate that is not easily deferred); overactive bladder is typically associated with frequent daytime voiding and nocturia, and approximately 37% will experience urge incontinence. Defining characteristics Diurnal urinary frequency (voiding more than once every 2 hours while awake); nocturia (awakening 3 or more times per night to urinate; voiding more than 8 times within a 24-hour period as recorded on a voiding diary (bladder log); bothersome urgency (a sudden and strong desire to urinate that is not easily deferred); symptom of urge in incontinence (urine loss associated with desire to urinate); enuresis (invonluntary passage of urine while asleep) Related factors Neuro;ogical disorders (brain disorder, including cerebrovascular accident, brain timor, normal pressure hydrocephalus, traumatic brain injury ) Inflammation of bladder ( calculi; tumor, including transitional cell carcinoma and carcinoma in situ, inflammatory lesions of the bladder; urinary tract infection) Bladder outlet obstruction (see Urinary retention) Stress urinary incontinence (mixed urinary incontinence; these conditions often coexist but relationship between them remains unclear) Idiopathic cause (implicated factors include depression, sleep apnea/hypoxia)

Client outcomes Client will (specify time frame) Report relief from urge urinary incontinence or a decrease in the incidence or severity of incontinent episodes Identify containment devices that assist in the management of urge urinary incontinence.

Nursing interventions Take a nursing history focusing on duration of urinary incontinence, diurnal frequency, nocturia, severity of symptoms, and alleviating and aggravating factors. Perform a focused physical assessment, beginning with perineal skin assessment. Perform a focused pelvic examination including visual in spection of the vaginal mucosa, observation of urethral hypermobility and related pelvic floor descent (prolapse) and digital assessment of pelvic floor muscle strength. Assist the woman moderately severe to severe vaginal wall prolapse (descent to or beyond the introitus) to a female urologist or urogynecologist. Complete a urinalysis, examining for the presence of nitrites, leukocytes, glucose,or hemoglobin (red blood cells). Teach the client to complete a voiding diary (bladder log) by recording voiding frequency, the frequency of urinary incontinent episodes, and their association with urgency ( a sudden and strong desire to urinate that is difficult to defer) over a 3- to-7-day period. An electronic voiding diary may be kept whenever feasible. In addition to these parameters, the client may be asked to record voided volume and fluid intake. Review all medications the client is receiving, paying particular attention to sedatives, narcotics, diuretics, antidepressants, psychotropic drugs, and cholinergics. Consult the physician or nurse practitioner about altering or eliminating these medications if they are suspected of affecting incontinence. Assess the client for urinary retention (see the care plan for Urinary Retention. Assess the client for functional limitations (environmental barriers, limited mobility or dexterity, impaired cognitive function ( see the car plan for functional urinary incontinence). Consult the physician concerning diabetic management and pharmacotherapy for urinary tract infection when indicated. Assess for signs and symptoms of atrophic vaginal changes in the perimenopausal or postmenopausal woman, including vaginal dryness, tenderness to touch, mucosal dryness, friability, and discomfort with gentle palpation. Specifically query the woman with atrophic vaginitis concerning associated lower urinary tract. Symptoms (usually voiding frequency, urgency, and dysuria). Refer the woman with atrophic vaginal changes and bothersome lower urinary tract symptoms to a gynecologist, urologist, or womens health nurse practitioner for further evaluation and management. Teach the principles of bladder training to women with urge urinary incontinence. 1. Assist the client in completing a voiding diary over a period of a minimum of 3 days or up to 7 days.

2. Review the results with the client, determined typical voiding frequency and establishing goals for voiding frequency. 3. Using baseline voiding frequency, as determined by the diary, teach the client to urinate by the clock when awake, typically every 30 to 120 minutes. 4. Encourage adherence to the program with timing devices and verbal encouragement and support, and address individual reasons for schedule interruption. = independent = collaborative Gradually increase the trine between urinations to the negotiated goal. Time intervals between voiding are typically increased in increments of 15 to 30 minutes for clients with a baseline frequency of less than every 60 minutes and increments of 25 to 30 minutes for clients with a baseline frequency of more than every 60 minutes. Review with the client the types of beverages consumed, focusing on the intake of bladder irritants, including caffeine and alcohol. Review with the client the volume of fluids consumed and gradually adjust the fluid intake to meet the Adequate Intake recommendation of 3 liters for the 19 to 30-year-old male and 2,2 liters for the 19-to 30-year old female. Water balance studies suggest that adult men require 2,5 liters per day. Instruct in techniques of urge suppression. Teach the client to identify, isolate, contract, and relax the pelvic floor muscles. When a strong or precipitous urge to urinate is perceived, teach the client to avoid running to the toilet. Instead, she or he should perform repeated, rapid pelvic muscles contractions until the urge is relieved. Relief is followed by micturition within 5 to 15 minutes, using nonhurried movements when locating a toilet and voiding. Begin transvaginal or transrectal electrical stimulation using a low-frequency current (5 to 20 Hz) in consultation with the physician. Teach the client to self-administer antimuscarinic (anticholinergic) drug as directed. Teach dosage and administration of the medication and the importance of combining pharmacotherapy with scheduled voiding, adequate fluid intake, restriction of bladder irritants, and urge suppression techniques. Assist the client in selecting. Obtaining, and applying a containment device for urine loss as indicated (see the care plan for Total urinary Incontinence) Provide the client with information about incontinence support groups such as the National Association for Continence and the Simon Foundation for Continence. Geriatric

 Assess the functional and cognitive status of the elderly client with urge incontinence. Plan care in long-term or acute care facilities based on knowledge of the elderly clients established voiding patterns, paying particular attention to patterns of nocturia Carefully monitor the elderly client for potential adverse effects of antispasmodic medications, including a severely dry mount interfering with the use of dentures, eating, or speaking, or confusion, nightmares, constipation, mydriasis, or heat intolerance.

Home care The interventions described previously may be adapted for home care use. Teach the importance of avoiding dehydration or excessive fluid consumption and the paradoxical relation ship between dehydration and symptoms of urgency. Teach the family and client to identify and correct environmental barriers to toileting within the home. Encourage a mind-set and program of self-care management. Implement a bladder training program as appropriate, inclunding self -monitoring activities (reducing caffeine intake, adjusting amount and timing of fluid intake, decreasing long voiding intervals while awake, making dietary changes to promote bowel regularity), bladder training, and pelvic muscle exercise. Help the client and family to identify and correct environmental barriers to toileting within the home.

Client/family Teaching Teach the client and family to recognize foods and beverages that are likely to irritate the beverages that are likely to irritate the bladder. Teach the family and client to recognize and manage side nary incontinence is not a normal part of aging and that incontinence can be corrected or managed with proper evaluation and care. Provide information to health care providers and the community about the signs, symptoms, and management of urinary tract infections and interstitial cystitis. Teach all person the signs and symptoms of urinary tract infection and management. Teach all persons to recognize hematuria and to promptly seek care if this symptom occurs.

Urinary retention NANDA Definition Incomplete emptying of the bladder

Defining characteristics Measured urinary residual greater than 150 to 200 mL or 25% of total bladder capacity; obstructive lower urinary tract symptoms (poor force of stream, intermittency of stream, hesitancy of urination, postvoid dribbling, feelings of incomplete bladder, feellings of incomplete bladder emptying); often accompanied by storage lower urinary tract symptoms ( urgency, day and nighttime voiding frequency); occasionally accompanied by overflow incontinence (dribbling urine loss caused when intravesical pressure overwhelms the sphincter mechanism)

Related factors (r/t) Bladder outlet obstruction (benign prostatic hyperplasia, prostate cancer, prostatitis, acute prostatic congestion and inflammation following implantation of irradiated seeds, urethral stricture, bladder neck dyssynergia, bladder neck contracture, detrusor striated sphincter dyssynergia, pseudo-dyssynergia or high tone pelvic floor muscle dysfunction, obstructing cystocele or urethral distortion, urethral tumor, urethral polyp, posterior urethral valves, postoperative complication); deficient detrusor contraction strength (sacral level spinal lesions, caunda equine syndrome, peripheral polyneuropathies, herpes zoster or simplex affecting sacral nerve roots, injury or extensive surgery causing denervation of pelvic plexus, medication side effect, complication of illicit drug use, impaction of stool)

Client outcomes Client will (specify time frame): Demonstrate a consistent ability to urinate when desire to void is perceived or via a timed schedule; have a measured urinary residual volume less than 150 to 200 mL or 25% of total bladder capacity (voided volume plus urinary residual volume). Experience correction or relief from obstructive symptoms. Experience correction or alleviation of irritative symptoms. Be free of upper urinary tract distress (renal function remains sufficient; febrile urinary infections are absent) Nursing interventions

Obtain a focused urinary history emphasizing the character and duration of lower urinary symptoms. Query the client about episodes of acute urinary retention ( complete inability to void) or chronic retention ( documented elevated postvoid residual volumes)

Question the client concerning specific risk factors for urinary retention including:

 Disorders affecting the sacral spinal cord such as spinal cord injuries of vertebral levels T12 to L2, disk problem, cauda equine syndrome, tabes dorsalis Acute neurological injury causing sudden loss of mobility such as spinal shock or ischemic strocke Metabolic disorders such as diabetes mellitus, chronic alcoholism, and related conditions associated with polyuria and peripheral polyneuropathies Herpetic infection involving the sacral skin and underlying spinal dermatomes. Heavy-metal poisoning (lead, mercury) causing peripheral polyneuropathies Advanced stage HIV Medications including antispasmodics/parasympatholytics, alpha-adrenergic agonists, antidepressants, sedatives, narcotics, psychotropic medications, illicit drugs Recent surgery requiring general or spinal anesthesia Bowel elimination patterns, history of fecal impaction, encopresis. current or recent surgical procedures perform a focused physical assessment or review results of a recent physical including perineal skin integrity; inspection, percussion, and palpation of the lower abdomen for obvious perineal skin sensation and the bulbocavernosus reflex; and vaginal vault examination in women and digital rectal examination in men. Determine the urinary residual volume by catheterizing the client immediately after urination or by obtaining a bladder ultrasound after micturition. Complete a bladder log including patterns of urine elimination, urine loss (if present), nocturia, and volume and type of fluids consumed for a period of 3 to 7 days. Consult with the physician concerning eliminating or altering medications suspected of producing or exacerbating urinary retention Teach the client with mild to moderate obstructive symptoms to double void by urinating, resting in the bathroom for 3 to 5 minutes, and then trying again to urinate. Teach the client with urinary retention and infrequent voiding to urinate by the clock Advise the male client with urinary retention related to benign prostatic hyperplasia (BPH) to avoid risk factors associated with acute urinary retention as follows: Avoid over-the-counter coldremedies containing a decongestant ( alpha-adrenergic agonists) Avoid taking over-the-counter dietary medications (frequently contain alpha-adrenergic agonists)

 Discuss voiding problem with a health care provider before beginning new prescription medications After prolonged exposure to cool weather, warm the body before attempting to urinate. Avoid overfilling the bladder by adopting regular urination patterns and refraining from excessive intake of alcohol. Teach the elderly male client with BPH to self-administer a 5 alpha reductase inhibitor such as finasteride or dutasteride or an alpha-adrenergic;blocking agent such as tamsulosin, alfuzosin, doxazosin, or terazosin as directed. Provide careful instructions concerning the dosage, administration schedule, and side effects of these drugs including possible adverse side effects ( postural hypotension) when multiple doses are inadvertently missed. Teach the client who is unable to void specific strategies to manage this potential medical emergency as follows: Attempt urination in complete privacy. Place the feet solidly on the floor. If unable to void using these strategies, take a warm sitz bath or shower and void (if possible) while still in the tub or shower. Drink a warm cup of coffee or tea to slimulate the bladder, which may promote voiding. If unable to void within 6 hours or if bladder distention is producing significant pain, seek urgent or emergency care. Remove the indwelling urethral catheter at midnight in the hospitalized client to reduce the risk of acute urinary retention. Consult the physician about bladder stimulation in the client with urinary retention caused by deficient detrusor contraction strength. Teach the client with significant urinary retention to perform self-intermittent catherization as directed. Advise clients who undergo intermittent catheterization that bacteria are likely to colonize the urine but that this condition does not indicate a clinically significant urinary tract infection. For the individual with urinary retention who is not a suitable candidate for intermittent catheterization, insert an indwelling catheter. Advise client with indwelling catheters that the presence of bacteria in the urine is an almost universal finding after the catheter has remained in place for a period of 30 days or longer and that only symptomatic infections warrant treatment.

Employ the following strategies to reduce the risk for catheter-associated urinary tract infection whenever feasible: Insert a silver-impregnated catheter for short-term in dwelling catheterization (less than 30 days). Maintain a closed drainage system whenever feasible. Change the catheter every 4 to 6 weeks whenever possible; more frequent catheter changes should be reserved for patients who experience catheter encrustation and blockage. Patients with a catheter-associated urinary tract infection who are managed in a acute care or long-term care facility should be placed in a separate room from patients who have an indwelling catheter to reduce the risk of spreading the offending pathogen. Educate staff about the risk of catheter-associated urinary tract infection and specific strategies to reduce this risk.

Geriatric

Aggressively assess elderly clients, particularly those with dribbling urinary incontinence, urinary tract infections, and related conditions for urinary retention. Assess elderly client for impaction when urinary retention is documented or suspected. Assess elderly male clients for retention related to BPH or prostate cancer/

Home care

The interventions listed previously may be adapted for home care use. Encourage the client to report any inability to void. Maintain an up-to-date medication list; evaluate sideeffect profiles for risk of urinary

retention Refer the client for physician evaluation if there is a new occurrence of urinary retention.

Client/family teaching Teach techniques for intermittent catheterization including use of a clean rather than a sterile technique, use of soap and water or a microwave technique to wash the catheter, and reuse of the catheter.

Teach the client with an indwelling catheter to assess the tube for patency, maintain the drainage system below the level of the symphysis pubis, and routinely cleanse the bedside bag. Teach the client with an indwelling catheter or undergoing intermittent catherization the symptoms of a significant urinary infection including hematuria, acute-onset incontienence, dysuria, flank pain, or fever.

Impaired spontaneous ventilation Nanda definication Decreased energy reserves resulting in an individuals inability to maintain breathing adequate for supporting life. Defining characteristics Dyspnea; increased metabolic rate; increased heart rate, decreased Po2, incrased Pco2, decreased Sa02; increased restlessness; apprehension; increased use of accessory muscles; decreased tidal volume; decreased cooperation. Related factors Metabolic factors; respiratory fatigue