Nursing Diagnosis: Total urinary Incontinence Application of NANDA, NOC, NIC

Nursing Diagnosis: Total urinary Incontinence
Mikel Gray

NANDA Definition: Continuous and unpredictable loss of urine.
NOTE: In this book, the diagnosis total urinary incontinence will be used to refer to continuous urine loss from an extraurethral loss, and stress urinary incontinence will be used to refer to leakage from sphincter incompetence, regardless of severity.

Defining Characteristics: Continuous urine flow varying from dribbling incontinence superimposed upon an otherwise identifiable pattern of voiding to severe urine loss without identifiable micturition episodes

Related Factors: Ectopia (ectopic ureter opens into the vaginal vault or cutaneously; bladder ectopia with exstrophy/epispadias complex); fistula (opening from bladder or urethra to vagina or skin that bypasses urethral sphincter mechanism, allowing continuous urine loss)

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
·         Tissue Integrity: Skin and Mucous Membranes
·         Urinary Continence
·         Urinary Elimination
Client Outcomes
·         Urine loss is adequately contained, clothing remains unsoiled, and odor is controlled
·         Maintains intact perineal skin
·         Maintains dignity, hides urine containment device in clothing, and minimizes bulk and noise related to the device
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
·         Urinary Incontinence Care
Nursing Interventions and Rationales
·         Obtain a history of duration and severity of urine loss, previous method of management, and aggravating or alleviating features. The symptom of continuous incontinence may be caused by extraurethral leakage or other types of incontinence that have been inadequately evaluated and/or managed. The patient history will provide clues to the etiology of the urinary leakage (Gray, Haas, 2000).
·         Perform a focused physical assessment, including inspection of the perineal skin, examination of the vaginal vault, reproduction of the sign of stress urinary incontinence (refer to care plan for Stress urinary Incontinence), and testing of bulbocavernosus reflex and perineal sensations. The physical examination will provide evidence supporting the diagnosis of extraurethral or another type of incontinence (stress, urge, or reflex), providing the basis for further evaluation and/or treatment (Gray, Haas, 2000).
·         Complete a bladder log of urine elimination patterns and frequency and severity of urine loss. The bladder log provides further information, allowing the nurse to differentiate extraurethral from other forms of urine loss and providing the basis for further evaluation and treatment (Gray, Haas, 2000).
·         Assist the patient to select and apply a urine containment devices or devices. Review types of containment products with the patient, including advantages and potential complications associated with each type of product. Urine containment products include a variety of absorptive pads, incontinent briefs, underpads for bedding, absorptive inserts that fit into specially designed undergarments, and condom catheters. Careful selection of a containment product and education concerning its use maximizes its effectiveness in controlling urine loss for a particular individual (Shirran, Brazelli, 2000; McKibben, 1995).
·         Evaluate disposable vs. reusable products for urine containment, considering factors of setting (home care vs. acute care vs. long-term care), preferences of the patient and caregiver(s), and immediate vs. long-term costs. The impact of routine use of urine containment devices is significant, regardless of the setting. Economic factors, as well as patient and caregiver preferences, have an impact on the success and ultimate cost of a reusable vs. disposable urine containment device (Shirran, Brazelli, 2000; Hu, Kaltreider, Igou, 1990; Cummings et al, 1995).
·         Cleanse the skin with an incontinence cleansing product system or plain water when changing urinary containment devices or pads. Use soap and water on the perineum no more than once daily or every other day as necessary. Excessive cleansing of the perineal skin may exacerbate alterations in skin integrity, particularly among the elderly (Byers et al, 1995; Lindell, Olsson, 1990).
·         Apply a skin moisturizer following cleansing. Moisturizers promote comfort and may reduce the risk of skin breakdown (Kemp, 1994).
·         Apply a protective barrier or ointment to the perineal skin when incontinence is severe, when double fecal and urinary incontinence exist, or when the risk of a pressure ulcer is considered significant. A moisture barrier is indicated when the risk of altered skin integrity is complicated by coexisting factors of shear, fecal incontinence, or exposure to prolonged pressure (Fiers, Thayer, 2000; Kemp, 1994).
·         Consult the physician concerning use of an antifungal powder or ointment when perineal dermatitis is complicated by monilial infection. Teach the patient to use the product sparingly when applying to affected areas. Antifungal powders or ointments provide effective relief from monilial rash; however, application of excessive amounts of the product retain moisture and diminish its effectiveness (Fiers, Thayer, 2000).
·         Consult the physician concerning placement of an indwelling catheter when severe urine loss is complicated by urinary retention, when careful fluid monitoring is indicated, when perineal dryness is required to promote the healing of a stage 3 or 4 pressure ulcer, during periods of critical illness, or in the terminally ill client when use of absorbent products produces pain or distress. Although not routinely indicated, the indwelling catheter provides an effective, transient management technique for carefully selected patients (Urinary Incontinence Guideline Panel, 1996; Treatment of Pressure Ulcers Guideline Panel, 1994).
·         Refer the client with "intractable" or extraurethral incontinence to a continence service or specialist for further evaluation and management of urine loss. The successful management of complex, severe urinary incontinence requires specialized evaluation and treatment from a health care provider with special expertise (Doughty, 1991; Gray; 1992).
·         Provide privacy and support when changing incontinent device of elderly client. Elderly, hospitalized clients frequently express feelings of shame, guilt, and dependency when undergoing urinary containment device changes (Biggerson et al, 1993).
·         Employ meticulous infection control procedures when using an indwelling catheter.

Home Care Interventions
·         NOTE: The interventions identified are all applicable to the home care setting. Review the interventions for appropriateness to individual clients.
Client/Family Teaching
·         Teach the family to obtain, apply, and dispose of or clean and reuse urine containment devices.
·         Teach the family a routine perineal skin care regimen, including daily or every other day hygiene and cleansing with containment product changes.
·         Teach the client and family to recognize and manage perineal dermatitis, ammonia contact dermatitis, and monilial rash.
·         Teach the patient to maintain adequate fluid intake (30 ml/kg of body weight/day).
·         Teach the client and family to recognize and manage urinary infection.

Tidak ada komentar: