Daughter states her mother is confused.
She has not had a bowel movement in 6 days
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.
Impaired urinary elimination
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
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).
dysfunction of bowel elimination and acute urinary retention
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
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).