Subjective
Daughter states her mother
is confused.
She has not had a bowel
movement in 6 days
Objective
Patient has no urinary
output documented for the past 10 hours.
Intake includes 1100 ml
of IV fluids and 3 cups of ice chips (~160 ml)
Her NGT is intact to the
left nare. It is currently clamped.
|
Problem
Impaired urinary elimination
|
Long Term:
Client will demonstrate
postvoiding residual volumes less than 150 mL to 200 mL or 25 of total bladder capacity
to be evaluated upon discharge.
|
Routinely screen all adult
women and aging men for urinary incontinence or LUTS including bothersome urgency.
Urinary incontinence and overactive bladder dysfunction
are prevalent problems, particularly among women and aging males in the sixth decade
of life or older (Hunskaar et al, 2005). Routine screening
is justified because urinary incontinence is prevalent, negatively affects physical
health and psychosocial function, and is amenable to treatment (Gray, 2003).
Assess
bladder function using the following techniques:
§
Take a focused history including duration of bothersome LUTS, characteristics of
symptoms, patterns of diurnal and nocturnal urination, frequency and volume of urine
loss, alleviating and aggravating factors, and exploration of possible causative
factors.
In close consultation with a physician or advanced practice nurse, administer a
validated questionnaire querying lower urinary symptoms, associated bowel elimination
symptoms, and symptoms of pelvic organ prolapse in women.
§
Perform a focused physical assessment of perineal skin integrity, evaluation of
the vaginal vault, evaluation of urethral hypermobility, and neurological evaluation
including bulbocavernosus reflex and perineal sensations.
Review results of urinalysis for the presence of urinary infection, polyuria, hematuria,
proteinuria, and other abnormalities, or obtain urine for analysis.
A
focused history and physical examination are essential elements of the initial evaluation
of impaired urine elimination (Staskin et al, 2005). EBN: There
is limited evidence to support the diagnostic value of the physical examination
in the diagnosis of urinary incontinence and differential diagnosis of stress versus
urge incontinence in elderly women (van Gerwen & Largo-Janssen, 2006).
There are 23 validated tools for the evaluation of lower urinary tract symptoms,
bowel elimination symptoms, and symptoms associated with pelvic organ prolapse in
women. These instruments can assist the clinician to differentiate the primary type
of incontinence, distinguish urgency form pelvic pain, and identify associated bowel
elimination disorders and pelvic organ prolapse (Avery et al, 2007).
Teach
the client general guidelines for bladder health:
§
Clients should avoid dehydration and its irritative effects on the bladder; fluid
consumption for the ambulatory, normally active adult should be approximately 30
mL/kg of body weight (0.5 oz per pound per day).
§
Clients with storage LUTS, overactive bladder dysfunction, or urinary incontinence
should reduce or cease caffeine intake (Gray, 2001).
§
Clients with lower urinary tract pain or interstitial cystitis should be encouraged
to eliminate potential bladder irritants: caffeine, alcohol, aspartame, carbonated
beverages, alcohol, citrus juices, chocolate, vinegar, and highly spiced foods such
as those flavored with curries or peppers (Bade, Peeters & Mensink, 1997;
Interstitial Cystitis Association, 1999).
These foods should be reintroduced singly to the diet to determine their effect
(if any) on bothersome LUTS.
§
All clients should be counseled about measures to alleviate or prevent constipation
including adequate consumption of dietary fluids, dietary fiber, exercise, and regular
bowel elimination patterns.
§
All clients should be strongly advised to stop smoking; it is associated with an
increased risk of bladder cancer (Bjerregaard et al, 2006), urinary incontinence
(Danforth et al, 2006), and bothersome lower
urinary tract symptoms in men (Haidenger et al, 2000).
Dehydration
increases irritating voiding symptoms and may enhance the risk of urinary infection.
Constipation predisposes the individual to urinary retention, and it increases the
risk of urinary infection. Smoking may increase the severity and risk of stress
incontinence, and it is clearly linked with an increased risk for bladder cancer
(Tampakoudis et al, 1995).
EBN: Client education, alteration of fluid volume intake, reduction of
caffeine consumption, and bladder training and pelvic floor muscle training administered
by generic and advanced practice nurses reduce the frequency of urinary incontinence,
pad use, and perceived severity of bothersome LUTS (Borrie et al, 2002;
Dougherty et al, 2002;
Dowd, Kolcaba & Steiner, 2000;
Sampselle et al, 2000).
|
|
|
|
R/T
dysfunction of bowel elimination
and acute urinary retention
|
Short Term:
Client will state absence
of pain or excessive urgency during bladder storage or during urination to be evaluated
on [date] at 1300.
|
Teach the client to recognize
symptoms of UTI (dysuria that crescendos as the bladder nears complete evacuation;
urgency to urinate followed by micturition of only a few drops; suprapubic aching
discomfort; malaise; voiding frequency; sudden exacerbation of urinary incontinence
with or without fever, chills, and flank pain).
There are a variety of typical and unexpected symptoms in women with a history of
recurring UTI (Malterud & Baerheim, 1999).
Perform urinalysis in
all elderly persons who experience a sudden change in urine elimination patterns,
lower abdominal discomfort, acute confusion, or a fever of unclear origin. Elderly persons, particularly adults aged 80 years and
older, often experience atypical symptoms with a UTI or pyelonephritis (Bostwick, 2000;
Suchinski et al, 1999).
Encourage elderly women
to drink at least 10 oz of cranberry juice daily, regularly consume one to two servings
of fresh blueberries, or supplement the diet with cranberry concentrate capsules
(usually taken in 500 mg doses with each meal). EBN: Systematic literature review reveals that consumption
of 400 mg of cranberry tablets, 8 to 10 oz of cranberry juice, or an equivocal portion
of foods containing whole cranberries or blueberries exerts a bacteriostatic effect
on Escherichia coli, the most common pathogen associated with urinary
infection among community-dwelling adult women. Mixed evidence tends to support
a reduction in UTI risk among community-dwelling women, although no beneficial effect
has been found in clients with neurogenic bladder dysfunction who are managed by
intermittent or indwelling catheters (Gray, 2002).
|
|
|
|