Urinary Incontinence Nursing Care Plan Notes

 

Definition

Urinary incontinence (UI) is any involuntary leakage of urine. It can be a common and distressing problem, which may have a profound impact on quality of life. Urinary incontinence almost always results from an underlying treatable medical condition but is under-reported to medical practitioners. There is also a related condition for defecation known as fecal incontinence.

Causes

• Polyuria (excessive urine production) of which, in turn, the most frequent causes are: uncontrolled diabetes mellitus, primary polydipsia (excessive fluid drinking), central diabetes insipidus and nephrogenic diabetes insipidus.Polyuria generally causes urinary urgency and frequency, but doesn’t necessarily lead to incontinence.
• Caffeine or cola beverages also stimulate the bladder.
• Enlarged prostate is the most common cause of incontinence in men after the age of 40; sometimes prostate cancer may also be associated with urinary incontinence. Moreover drugs or radiation used to treat prostate cancer can also cause incontinence.
• Disorders like multiple sclerosis, spina bifida, Parkinson’s disease, strokes and spinal cord injury can all interfere with nerve function of the bladder.

Pathophysiology

Continence and micturition involve a balance between urethral closure and detrusor muscle activity. Urethral pressure normally exceeds bladder pressure, resulting in urine remaining in the bladder. The proximal urethra and bladder are both within the pelvis. Intraabdominal pressure increases (from coughing and sneezing) are transmitted to both urethra and bladder equally, leaving the pressure differential unchanged, resulting in continence. Normal voiding is the result of changes in both of these pressure factors: urethral pressure falls and bladder pressure rises.

Diagnosis

Patients with incontinence should be referred to a medical practitioner specializing in this field. Urologists specialize in the urinary tract, and some urologists further specialize in the female urinary tract. A urogynecologist is a gynecologist who has special training in urological problems in women. Family physicians and internists see patients for all kinds of complaints, and are well trained to diagnose and treat this common problem. These primary care specialists can refer patients to urology specialists if needed.

A careful history taking is essential especially in the pattern of voiding and urine leakage as it suggests the type of incontinence faced. Other important points include straining and discomfort, use of drugs, recent surgery, and illness.

The physical examination will focus on looking for signs of medical conditions causing incontinence, such as tumors that block the urinary tract, stool impaction, and poor reflexes or sensations, which may be evidence of a nerve-related cause.

A test often performed is the measurement of bladder capacity and residual urine for evidence of poorly functioning bladder muscles.

Other tests include:

• Stress test – the patient relaxes, then coughs vigorously as the doctor watches for loss of urine.
• Urinalysis – urine is tested for evidence of infection, urinary stones, or other contributing causes.
• Blood tests – blood is taken, sent to a laboratory, and examined for substances related to causes of incontinence.
• Ultrasound – sound waves are used to visualize the kidneys, ureters, bladder, and urethra.
• Cystoscopy – a thin tube with a tiny camera is inserted in the urethra and used to see the inside of the urethra and bladder.
• Urodynamics – various techniques measure pressure in the bladder and the flow of urine.

Patients are often asked to keep a diary for a day or more, up to a week, to record the pattern of voiding, noting times and the amounts of urine produced.

Types

• Stress incontinence, also known as effort incontinence, is due essentially to insufficient strength of the pelvic floor muscles.
• Urge incontinence is involuntary loss of urine occurring for no apparent reason while suddenly feeling the need or urge to urinate.
• Overflow incontinence: Sometimes people find that they cannot stop their bladders from constantly dribbling or continuing to dribble for some time after they have passed urine. It is as if their bladders were constantly overflowing, hence the general name overflow incontinence.
• Mixed incontinence is not uncommon in the elderly female population and can sometimes be complicated by urinary retention, which makes it a treatment challenge requiring staged multimodal treatment.
• Structural incontinence: Rarely, structural problems can cause incontinence, usually diagnosed in childhood (for example, an ectopic ureter). Fistulas caused by obstetric and gynecologic trauma or injury can lead to incontinence. These types of vaginal fistulas include, most commonly, vesicovaginal fistula and, more rarely, ureterovaginal fistula. These may be difficult to diagnose. The use of standard techniques along with a vaginogram or radiologically viewing the vaginal vault with instillation of contrast media.
• Functional incontinence occurs when a person recognizes the need to urinate but cannot make it to the bathroom. The urine loss may be large. Causes of functional incontinence include confusion, dementia, poor eyesight, poor mobility, poor dexterity, unwillingness to toilet because of depression, anxiety or anger, drunkenness, or being in a situation in which it is impossible to reach a toilet.People with functional incontinence may have problems thinking, moving, or communicating that prevent them from reaching a toilet. A person with Alzheimer’s Disease, for example, may not think well enough to plan a timely trip to a restroom. A person in a wheelchair may be blocked from getting to a toilet in time. Conditions such as these are often associated with age and account for some of the incontinence of elderly women and men in nursing homes.Disease or biology is not necessarily the cause of functional incontinence. For example, someone on a road trip may be between rest stops and on the highway; also, there may be problems with the restrooms in the vicinity.
• Bedwetting is episodic UI while asleep. It is normal in young children.
• Transient incontinence is a temporary version of incontinence. It can be triggered by medications, adrenal insufficiency, mental impairment, restricted mobility, and stool impaction (severe constipation), which can push against the urinary tract and obstruct outflow.
• Giggle incontinence is an involuntary response to laughter. It usually affects children.

In women

Bladder symptoms affect women of all ages. However, bladder problems are most prevalent among older women.Up to 35% of the total population over the age of 60 years is estimated to be incontinent, with women twice as likely as men to experience incontinence. One in three women over the age of 60 years are estimated to have bladder control problems.

Bladder control problems have been found to be associated with higher incidence of many other health problems such as obesity and diabetes. Difficulty with bladder control results in higher rates of depression and limited activity levels.

Incontinence is expensive both to individuals in the form of bladder control products and to the health care system and nursing home industry. Injury related to incontinence is a leading cause of admission to assisted living and nursing care facilities. More than 50% of nursing facility admissions are related to incontinence.

Coital incontinence (CI) is urinary leakage that occurs during either penetration or orgasm and can occur with a sexual partner or with masturbation. It has been reported to occur in 10% to 24% of sexually active women with pelvic floor disorders.

In men

Men tend to experience incontinence less often than women, and the structure of the male urinary tract accounts for this difference. It is common with prostate cancer treatments. Both women and men can become incontinent from neurologic injury, congenital defects, strokes, multiple sclerosis, and physical problems associated with aging.

While urinary incontinence affects older men more often than younger men, the onset of incontinence can happen at any age. Recent estimates by the National Institutes of Health (NIH) suggest that 17 percent of men over age 60, an estimated 600,000 men, experience urinary incontinence, with this percentage increasing with age. Incontinence is treatable and often curable at all ages.

Incontinence in men usually occurs because of problems with muscles that help to hold or release urine. The body stores urine—water and wastes removed by the kidneys—in the urinary bladder, a balloon-like organ. The bladder connects to the urethra, the tube through which urine leaves the body.

During urination, Detrusor muscles in the wall of the bladder contract, forcing urine out of the bladder and into the urethra. At the same time, sphincter muscles surrounding the urethra relax, letting urine pass out of the body. Incontinence will occur if the bladder muscles suddenly contract or muscles surrounding the urethra suddenly relax. 

Urinary Incontinence Nursing Care Plan

Assessment	Assessment for urinary incontinence includes the number of times and frequency of micturation, characteristics of urine. For patients who are using diapers or incontinent pads, it should be weigh to measure the amount of urine. For patients with indwelling catheter, hourly measurement is a must to calculate properly. Rogers (2008), specified that history taking, physical examination, voiding diary, urinalysis and culture, post-void residual urine volume (ultrasound or catheterization), urodynamic testing, pelvic musculature examination and cough stress test are the important data to evaluate urinary incontinence. Kessler (2008), emphasized the importance of bladder diary as a useful tool in the diagnosis of this condition. He affirmed that history-taking is the cornerstone of urinary incontinence assessment wherein the patient is instructed to record the times of voiding, voided volumes,incontinence episodes, pad usage, degree of urgency, physical exercise during urinary leakage and the degree of incontinence.
NursingDiagnoses*	Impaired urinary elimination; Altered thought process; Self-care deficit; Potential for impaired skin integrity; Potential for infection; Anxiety and stress; Stress/Functionalurinary incontinence; Alteration in comfort; Altered role performance; Body image disturbance; Potential for fluid volume deficit; Sleep pattern disturbance.
Planning	The major goals for the patient may include control of urinary incontinence, promote regular urinary elimination patterns and prevent complications.
Implementation	Promoting urinary continence: Initiate bladder training by providing schedule with specified time for the patient to void. Bladder training is easy if the patient is under indwelling catheters, wherein the caregiver scheduled the time to close and to open the clamped catheter tube. To optimize the likelihood of voiding as scheduled, measured amounts of fluids may be administered about 30 minutes before voiding attempts. Usually, there is a temporal relationship between drinking, eating, exercising and voiding. Fluid intake restriction to decrease the frequency of urination is not advisable. Sufficient fluid intake (2000 to 3000 mL/day according to patient needs) must be ensured to maintain hydration. Voiding and episodes of incontinence are recorded. As the patient’s bladder capacity and control increase, the interval is lengthened. This theory was supported in the study of Shamliyan et al (2008), proven that bladder training resolved urinary incontinence in women. Other measures can be helpful to promote voluntary urination are, suprapubic tapping or stroking of the inner thigh may produce voiding by stimulating the voiding reflex arc. Listening to running water or perineal wash with lukewarm water will also help. Managing patient with altered thought process: Interventions are difficult if managing patients with altered thought process, catheter as ordered is the last sort for urinary incontinence, strict care is encouraged to prevent occurrence of infection secondary to urinary catheterization. The caregiver must be taught how to provide daily hygiene, including skin inspection and catheter care. Instruction on emptying the urine bag must also be provided. Diapers and incontinent pads can be an option but meticulous perineal hygiene is necessary to prevent complications such as skin problems and bed sores. Promoting hygiene, skin care and preventing infection: Hygiene and skin care is strictly observed for patients with urinary incontinenceproblem to avoid occurrence of complications such as skin problems, bed sore, skin and urinary infection. Skin care and perineal care should be done every after voiding using non-allergenic soap with lukewarm water. Always pat dry the perineal area. Provision of comfort: When providing comfort diapers and incontinence pads are last resort, because they only manage rather than solve the incontinence problem. Also, they have a negative psychological effect on the patient because many people think of them as diapers. Every effort should be made to reduce the incidence of incontinence episodes through the other methods that have been described. Incontinence pads may be useful at times for patients with stress or total incontinence to protect clothing, but they should be avoided whenever possible. When incontinence pads are used, they should wick moisture away from the body to minimize contact of moisture and excreta with the skin. Wet incontinence pads must be changed promptly, the skin cleansed, and a moisture barrier applied to protect the skin. Promoting role performance, promoting body image and relieving anxiety and stress: Privacy should be provided during voiding efforts. Promote positive feedback and optimistic attitude to reinforce patient’s ego and esteem. Periods of continence and successful voidings are positively reinforced. Maintaining hydration: Monitoring intake and output is necessary to assess hydration. Signs and symptoms of good hydration and dehydration should be assessed and monitored every shift. Promoting sleep and rest: Fluid intake should be consumed before evening to minimize the need to void frequently during the night.
Evaluation	Nursing interventions focus on improving the voiding pattern, bladder control, control of urine urgency and to promote the voluntary micturation. Prevention of complications in hydration, sleep pattern, urinary problems like infection, and integumentary complications such as infection, skin problems and bedsores. Maintain privacy and uplifting the morale of the patients, thus promoting self-esteem and body image. Promote comfort for the patient and the caregivers. Lessen the burden of both the patients and caregivers, thus preventing the occurrence anxiety, depression and stress during the treatment.

Doenges, Moorhouse & Curr (2008); Smeltzer & Bare (2004)*

Treatment

The treatment options range from conservative treatment, behavior management, medications and surgery.The success of treatment depends on the correct diagnoses in the first place.

Physical Therapy

Physical therapy is commonly used as a conservative, early-stage treatment for urinary incontinence. Pelvic floor muscle training, otherwise known as Kegel exercises, has been shown to significantly increase pelvic muscle strength and decrease severity of urinary incontinence in adults and in children, regardless of gender.

Medications

A number of medications exist to treat incontinence including: fesoterodine, tolterodine and oxybutynin.While a number appear to have a small benefit, the risk of side effects are a concern.

Devices

Absorbent pads and various types of urinary catheters may help those individuals who continue to experience incontinence.Some absorbent pads are not bulky like many older types were, but are close fitting underwear with liners.

Absorbent products include shields, undergarments, protective underwear, briefs, diapers, adult diapers and underpads. Absorbent products are associated with leaks, odors, skin breaksown and UTI.

Men also can use an external urine collection device that is worn around the penis. There are two principal types. The traditional type is referred to as a condom or Texas catheter. These are not appropriate for men who are uncircumcised, have large or small anatomy or those who are have retracted anatomy. Condom catheter users frequently experience complications including urinary tract infections and skin breakdown. A recent innovation is the Men’s Liberty that attaches only to the tip of the penis with safe hydrocolloid adhesive and works with all types and sizes of male anatomy. There has not been a confirmed UTI or serious skin injury caused by Men’s Liberty.

Hospitals often use some type of incontinence pad, a small but highly absorbent sheet placed beneath the patient, to deal with incontinence or other unexpected discharges of bodily fluid. These pads are especially useful when it is not practical for the patient to wear a diaper.

The most common form of urine management in hospitals is indwelling or Foley catheters. These catheters may cause infection and other associated secondary complications.

In children

Urination, or voiding, is a complex activity. The bladder is a balloonlike muscle that lies in the lowest part of the abdomen. The bladder stores urine, then releases it through the urethra, the canal that carries urine to the outside of the body. Controlling this activity involves nerves, muscles, the spinal cord and the brain.

The bladder is made of two types of muscles: the detrusor, a muscular sac that stores urine and squeezes to empty, and the sphincter, a circular group of muscles at the bottom or neck of the bladder that automatically stay contracted to hold the urine in and automatically relax when the detrusor contracts to let the urine into the urethra. A third group of muscles below the bladder (pelvic floor muscles) can contract to keep urine back.

A baby’s bladder fills to a set point, then automatically contracts and empties. As the child gets older, the nervous system develops. The child’s brain begins to get messages from the filling bladder and begins to send messages to the bladder to keep it from automatically emptying until the child decides it is the time and place to void.

Failures in this control mechanism result in incontinence. Reasons for this failure range from the simple to the complex.

Incontinence happens less often after age 5: About 10 percent of 5-year-olds, 5 percent of 10-year-olds, and 1 percent of 18-year-olds experience episodes of incontinence. It is twice as common in girls as in boys.