Nursing Care Plan for Impaired urinary elimination, dysfunction of bowel elimination and acute urinary retention

Nursing Care Plan

Medical Diagnoses: Impaired urinary elimination, dysfunction of bowel elimination and acute urinary retention

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

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).







AEB

No ouput over ten hours and a supple amount of liquids charted on intake.















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*I = Implementation. Check those interventions/actions/orders that were implemented.

References:

Avery KN, Bosch JL, Gotoh M et al: Questionnaires to assess urinary and anal incontinence: review and recommendations, J Urol 177(1):3949, 2007.

Bjerregaard BK, Raaschou-Nielsen O, Sorensen M et al: Tobacco smoke and bladder cancer-in the European Prospective Investigation into Cancer and Nutrition, Int J Cancer 119(10):24122416, 2006.

Borrie MJ, Bawden M, Speechley M et al: Interventions led by nurse continence advisers in the management of urinary incontinence: a randomized controlled trial, Can Med Assoc J 166(10):12671273, 2002.

Bostwick JM: The many faces of confusion. Timing and collateral history often hold the key to diagnosis, Postgrad Med 108(6):6062, 6566, 7172, 2000.

Danforth KN, Townsend MK, Lifford K et al: Risk factors for urinary incontinence among middle-aged women, Am J Obst Gynecol 194(2):339345, 2006.

Dowd T, Kolcaba K, Steiner R: Using cognitive strategies to enhance bladder control and comfort, Holist Nurs Pract 14(2):91103, 2000.

Gray M, Hufstuttler S, Albo M: Interstitial cystitis: a guide to recognition, evaluation and management for the nurse practitioner, J Wound Ostomy Continence Nurs 29:93102, 2002.

Hunskaar S et al: Epidemiology of urinary (UI) and fecal incontinence (FI) and pelvic organ prolapse (POP). In Abrams P, Cardozo L, Khoury S et al, editors: 3rd International consultation on incontinence, ed 3, Plymouth, UK, 2005, Plymbridge, Health Publications.

Malterud K, Baerheim A: Peeing barbed wire. Symptom experiences in women with lower urinary tract infection, Scand J Prim Health Care 17(1):4953, 1999.

Suchinski GA, Piano MR, Rosenberg N et al: Treating urinary tract infections in the elderly, Dimens Crit Care Nurs

Tampakoudis P, Tantanassis T, Grimbizis G et al: Cigarette smoking and urinary incontinence in womena new calculative method of estimating the exposure to smoke, Eur J Obstet Gynecol Reprod Biol 63(1):2730, 1995.

Return to Table of Contents

Assessment	Nursing DX/Clinical Problem	Client Goals/Desired Outcomes/Objectives	Nursing Interventions/Actions/Orders and Rationale	*I	Evaluation
					Goals	Interventions
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).
	AEB No ouput over ten hours and a supple amount of liquids charted on intake.