Impairments in urinary elimination can be due to urinary incontinence or urinary retention and all refer to the inability to pass urine effectively. Get to know the nursing care plan and management of clients with urinary elimination problems. Learn about the nursing assessment, nursing diagnosis, goals, and interventions for clients with urinary elimination and urinary retention.
Table of Contents
- What is urinary incontinence?
- What is urinary retention?
- Nursing Care Plans and Management
- Nursing Problem Priorities
- Nursing Assessment
- Nursing Diagnosis
- Nursing Goals
- Nursing Interventions and Actions
- 1. Assessing Urinary Patterns and Etiology
- 2. Establishing Normal Urinary Elimination
- 3. Initiating Interventions for Urinary Retention
- 4. Preventing Urinary Tract Infections (UTIs)
- 5. Maintaining Skin Integrity
- 6. Providing Client and Caregiver Education
- Recommended Resources
- See also
What is urinary incontinence?
Urinary incontinence, also known as overactive bladder, is the involuntary loss of urine due to difficulties controlling the bladder, frequently seen in older individuals, particularly women. This condition often leads to feelings of embarrassment and a loss of independence, as issues such as wet clothing, urine odor, and the need for assistance with toileting can arise. Over time, the inability to control urination can negatively impact a person’s self-image and social interactions, as well as affect their work performance, resulting in feelings of shame and a diminished sense of self. Age, gender, and the number of vaginal deliveries are established risk factors that explain the increased prevalence in women. For men with urinary incontinence, comorbid conditions are a big risk factor. There are different types of urinary incontinence, but the most common are:
Functional urinary incontinence
Functional urinary incontinence refers to difficulties in reaching or using the toilet when required, despite having normal neurological control mechanisms for urination and the ability to fill, store, and recognize the urge to void urine. Numerous factors may contribute to functional urinary incontinence, including environmental barriers and physical issues that inhibit swift movements to the bathroom or undressing for toilet use. Such physical issues can stem from musculoskeletal problems like back pain or arthritis, or neurological conditions such as Parkinson disease or multiple sclerosis.
Urge urinary incontinence
Urge urinary incontinence is characterized by unexpected bladder contractions, often strong enough to overpower the sphincter muscles that control urine flow from the bladder through the urethra. The client is aware of the need to void but cannot reach a toilet in time. This “overactive” bladder condition can arise from spinal cord injuries, pelvic surgery, central nervous system disorders like Alzheimer, multiple sclerosis, and Parkinson disease, or due to conditions like interstitial cystitis, urinary tract infections, or pelvic radiation, and even excessive consumption of alcohol.
Reflex urinary incontinence
Reflex urinary incontinence occurs due to a disruption in the normal neurological mechanisms that control the contractions of the detrusor muscle and the relaxation of the sphincter. This condition is generally linked to issues with the central nervous system, resulting from factors such as stroke, Parkinson disease, brain tumors, spinal cord injuries, or multiple sclerosis. Individuals with reflex incontinence tend to urinate regularly without consciously recognizing the need to do so, with a consistent urine volume each time, both day and night. The amount of residual urine typically measures less than 50 mL. Urodynamic tests show that detrusor muscle contractions occur once the bladder reaches a specific volume.
Stress urinary incontinence
Stress urinary incontinence occurs when urine leaks when pressure is exerted on the bladder by coughing, sneezing, laughing, exercising, or lifting something heavy. It predominantly affects women who have had vaginal deliveries due to decreasing ligament and pelvic floor support of the urethra and decreasing or absent estrogen levels within the urethral walls and bladder base.
Overflow urinary incontinence
Overflow urinary incontinence is the involuntary release of urine caused by an overfilled bladder, often in people who cannot fully empty their bladders. This is commonly caused by benign prostatic hyperplasia in men. Other factors include spinal cord injuries, multiple sclerosis, diabetes mellitus, and bladder obstruction (Tran & Puckett, 2022).
Mixed urinary incontinence
Mixed urinary incontinence refers to the occurrence of multiple types of incontinence – usually stress and urge incontinence. It is usually characterized by involuntary leakage associated with exertion, effort, sneezing, or coughing (Vasavada & Kim, 2023).
What is urinary retention?
Urinary retention, or ischuria, is the inability to fully empty the bladder, and it may or may not coexist with urinary incontinence. Chronic urine retention, however, can lead to overflow incontinence. It can be caused by factors such as immobility, medical conditions like BPH, disk surgery, or hysterectomy, and side effects of various medications including anesthetics, antihypertensives, and antihistamines. These medications may interfere with nerve signals crucial for relaxing the sphincters that enable urination, potentially leading to bladder distention and occasional incontinence. If left untreated, urinary retention can result in severe complications like bladder damage and chronic kidney failure, hence it needs prompt and appropriate management.
Nursing Care Plans and Management
Nursing care planning goals for managing impairments in urinary elimination focus on promoting optimal urinary function and addressing underlying causes. Interventions may include implementing a regular toileting schedule, providing privacy and comfort during toileting, encouraging adequate fluid intake, assisting with mobility and positioning, monitoring urinary output and bladder function, performing bladder scans or catheterizations as necessary, and educating the client on proper hygiene and techniques to promote urinary elimination.
Nursing Problem Priorities
The following are the nursing priorities for clients with problems in urinary elimination:
- Restoring optimal urine function. Optimal urine function directly impacts the client’s quality of life. Restoring it to its most functional helps alleviate discomfort and embarrassment, allowing the client to maintain their dignity and self-worth.
- Impaired skin integrity. Prolonged exposure to urine can lead to skin irritation and breakdown, especially among older adults or immobile clients. Preventing skin breakdown is crucial to maintain the client’s comfort and avoid infections.
- Preventing infection. Incontinence or retention can increase the risk of urinary tract infections, Nursing interventions should also focus on preventing and monitoring for signs of infection.
- Psychological support. Impaired urinary elimination, especially incontinence, can cause embarrassment, anxiety, and depression. Addressing psychological well-being may improve the client’s quality of life.
Here are the common signs and symptoms for clients with problems with urinary elimination:
- Reports of urine leakage. Unintentional discharge or leakage of urine.
- Leakage of urine during physical activities. Incontinence occurs during actions like coughing, sneezing, or exercising.
- The urgency to urinate cannot be controlled. Strong and sudden urge to urinate that is difficult to postpone or control.
- Frequent urination. Need to urinate more often than usual.
- Dampness or wetness in the underwear or clothing. Presence of moisture or wet spots in the undergarments or clothing.
- Skin irritation or infection around the genital area. Redness, itching, or infection of the skin in the genital region.
- Difficulty initiating urination. Struggles to start the flow of urine.
- Weak or interrupted urine flow. A urine stream that is weak, intermittent, or stops and starts.
- The sensation of incomplete bladder emptying. Feeling that the bladder is not fully emptied after urination.
- Increased frequency of urination. Need to urinate more frequently than usual.
- The urgency to urinate that cannot be relieved. A strong and immediate urge to urinate that cannot be alleviated.
- Lower abdominal discomfort or pain. Mild to moderate pain or discomfort in the lower abdomen.
- Distended or bloated lower abdomen. Swelling or bloating in the lower abdominal area.
- Urinary tract infection or recurrent urinary tract infections. Inflammation and infection of the urinary tract, often lead to repeated infections.
Following a thorough assessment, a nursing diagnosis is formulated to specifically address the challenges associated with urinary incontinence and urinary retention based on the nurse’s clinical judgement and understanding of the patient’s unique health condition. While nursing diagnoses serve as a framework for organizing care, their usefulness may vary in different clinical situations. In real-life clinical settings, it is important to note that the use of specific nursing diagnostic labels may not be as prominent or commonly utilized as other components of the care plan. It is ultimately the nurse’s clinical expertise and judgment that shape the care plan to meet the unique needs of each patient, prioritizing their health concerns and priorities.
The following are the common goals and expected outcomes for impaired urinary elimination:
- The client will demonstrate proper bladder emptying techniques, including double voiding and complete emptying of the bladder, to prevent urinary retention and reduce the risk of urinary tract infections, as evidenced by maintaining a post-void residual volume of less than 50 mL and reporting clear, odor-free urine.
- The client will actively participate in the identification and management of factors contributing to urinary incontinence, including keeping a bladder diary, identifying triggers, and seeking appropriate treatment options, as evidenced by documenting potential causes and implementing interventions to manage incontinence.
- The client will adhere to a prescribed fluid intake and voiding schedule, monitoring their input and output to maintain a balanced fluid balance, prevent bladder distension, and minimize urinary leakage, as evidenced by maintaining a voiding frequency of every 2 to 3 hours and reporting no episodes of urinary leakage or bladder distension.
- The client will demonstrate an understanding of the rationale behind prescribed treatments for incontinence and retention, including medications, exercises, and lifestyle modifications, by explaining the purpose and benefits of the recommended interventions to the healthcare provider.
- The client will verbalize understanding of their condition, including the underlying causes and potential consequences of urinary incontinence and retention, as evidenced by accurately explaining the condition and its impact on their daily life during education and counseling sessions with healthcare providers.
Nursing Interventions and Actions
Therapeutic nursing interventions for clients with impaired urinary elimination may include:
1. Assessing Urinary Patterns and Etiology
A complete assessment of a client’s urinary function includes the nursing history, physical assessment and examination of the urine, and related data from any diagnostic tests and procedures taken.
Assess the voiding pattern (frequency and amount). Compare urine output with fluid intake. Note specific gravity.
The nurse identifies the client’s normal voiding pattern and frequency, and appearance of the urine. This identifies characteristics of bladder function (effectiveness of bladder emptying, renal function, and fluid balance). The nurse may ask the client how often they urinate during a 24-hour period, if this pattern has changed recently, and if the client needs to void and get up from bed during the night.
Palpate for bladder distension and observe for overflow.
Bladder dysfunction is variable but may include loss of bladder contraction and inability to relax the urinary sphincter, resulting in urine retention and reflux incontinence. Bladder distension can precipitate autonomic dysreflexia. The bladder is only palpable if it is moderately distended, and feels like a smooth, firm, round mass rising out of the abdomen, usually at midline. In urinary retention, the bladder is firm and distended and may be displaced to one side of the midline.
Note reports of urinary frequency, urgency, burning, incontinence, nocturia, and size or force of the urinary stream.
This provides information about the degree of interference with elimination or may indicate a bladder infection. Fullness over the bladder following void is indicative of inadequate emptying or retention and requires intervention. Frequency, nocturia, urgency, and dysuria often are manifestations of underlying conditions such as UTI. enuresis, retention, and neurogenic bladder may be either a manifestation or the primary problem affecting urinary elimination.
Review drug regimen, including prescribed, over-the-counter (OTC), and street.
A number of medications such as some antispasmodics, antidepressants, and narcotic analgesics; OTC medications with anticholinergic or alpha agonist properties; or recreational drugs such as cannabis may interfere with bladder emptying. Many medications contribute to urinary incontinence, directly or indirectly. Medications must always be considered as the cause of new-onset urinary incontinence, especially in older adults, in whom polypharmacy is often encountered.
Assess the availability of toileting facilities and barriers that affect toileting.
The client may need a bedside commode if mobility limitations interfere with getting to the bathroom. Access to public restrooms and sanitary facilities should also be considered when outside the home. At home, some environmental factors that interfere with toileting include the distance to the bathroom from living areas or bedrooms; barriers such as stairways, scatter rugs, clutter, or narrow doorways that interfere with bathroom access; and the lighting, especially night lighting.
Assess the client’s usual pattern of urination and occurrence of incontinence.
Many clients are incontinent only in the early morning when the bladder has stored a large urine volume during sleep. The clinical presentation of urinary incontinence can be varied in many respects. The client may have minor, situational, severe, constant, and debilitating complaints. Many older adults experience transient episodes of incontinence that tend to be abrupt in onset.
Assess the client for the following common assessment findings:
A strong desire to void may be caused by inflammation or infections in the bladder or urethra. It is common in people who have poor external sphincter control and unstable bladder contractions.
This refers to a painful or difficult voiding. The client may report a burning sensation that accompanies or follows voiding. It can be severe, like a hot poker, or more subdued.
Voiding that occurs more than usual when compared with the person’s regular pattern or the generally accepted norm of voiding once every 3 to 6 hours. The client’s total fluid intake and output may be normal.
This means an undue delay and difficulty in initiating voiding. Often, urinary hesitancy is associated with dysuria.
This is a large volume of urine or output voided at any given time. Polyuria can follow excessive fluid intake or may be associated with diseases such as diabetes mellitus, diabetes insipidus, and chronic nephritis.
A small volume of urine or output between 100 to 500 mL/24 hours or less than 30 mL an hour for an adult. This often indicates impaired blood flow to the kidneys or impending renal failure and must be reported promptly to the healthcare provider.
This refers to the lack of urine production. This may necessitate kidney failure and may require the use of renal dialysis.
Excessive urination at night that interrupts sleep. It refers to voiding at night two or more times and is expressed in terms of the number of times the client gets out of bed to void.
This refers to red blood cells (RBCs) in the urine. Hematuria should be evaluated as per the American Urological Association hematuria guidelines.
Observe for cloudy or bloody urine and foul odor. Dipstick urine as indicated.
Signs of the urinary tract or kidney infection that can potentiate sepsis. Multistrip dipsticks can provide a quick determination of pH, nitrite, and leukocyte esterase suggesting the presence of infection. A dipstick test for blood detects primarily the peroxidase activity of erythrocytes, but myoglobin and hemoglobin can also catalyze this reaction (Queremel Milani & Jialal, 2023).
Obtain periodic urinalysis and urine culture and sensitivity as indicated.
These tests monitor renal status. A colony count over 100,000 indicates the presence of infection requiring treatment. UTIs can cause irritative voiding symptoms and urge incontinence. Local inflammation can serve as a bladder irritant, causing uninhibited bladder contractions. Cultures may show bacterial growth in clients whose urinalysis shows little or no evidence of inflammation.
Monitor BUN, creatinine, and white blood cell (WBC) counts.
These reflect renal function and identify complications. BUN and creatinine levels should be checked when poor kidney function, obstructed ureters, or urinary retention is suggested. The creatinine clearance test uses 24-hour urine and serum creatinine levels to determine glomerular filtration rate, a sensitive indicator of renal function.
Measure residual urine via postvoid catheterization or ultrasound.
Measuring residual urine via postvoid catheterization or ultrasound is helpful in detecting the presence of urinary retention and the effectiveness of a bladder training program. The use of ultrasound is noninvasive, reducing the risk of colonization of the bladder. The nurse may also catheterize the client after voiding. The amount of urine voided and the amount obtained are measured and recorded.
Perform incontinence screening procedures fo female clients annually.
The Women’s Preventive Services Initiative (WPSI), a national coalition of women’s health professional orgnizations and client representatives, recommends screening women for urinary incontinence annually. Screening ideally should assess whether women experience urinary incontinence and whther it affects their activities and quality of life.
Provide validated and reliable questionnaires during assessment.
Incontinence histories can be very complex and time consuming. Most centers use some form of incontinence questionnaire as an aid. Sending the questionnaire to clients in advance so that they can give appropriate time and thought to their answers amy be beneficial. Parts of the questionnaire should deal with the client’s quality of life, sexual and lifestyle issues, and the relationship of these factors to the incontinence episodes.
Assess the onset and duration of incontinence symptoms.
Many cases of urinary incontinence are seen as gradually progressive. Progression from very mild symptoms to more severe and debilitating urine loss may take years. In other clients, the symptoms may appear suddenly and may or may not be associated with a predisposing event.
Determine the client’s weight and BMI.
Obesity is an important contributor to stress incontinence, and the presence of obesity may influence management decisions. The magnitude of weight loss was associated with a reduction in urinary incontinence prevalence.
Perform neurological assessment tests.
The sensation of the perineum and perianal area should be tested with a soft touch and light prick. Using a cotton swab, the anal wink pelvic floor reflex can be elicited by stroking laterally to the anal canal. The bulbocavernosus reflex can be elicited by gently tapping the clitoris with a cotton swab in the female client.
Perform a paper towel test for a client with stress incontinence.
A paper towel test provides a quick estimate of the degree of stress urine loss. The client is asked to cough repetitively and forcefully with a paper towel held a short distance from the urethra. The area of each visible spread of the liquid on the towel is calculated for each known volume. The area of staining on the paper towel used by the client with incontinence can be measured and the volume of the loss estimated.
2. Establishing Normal Urinary Elimination
Most interventions to establish normal urinary elimination include independent nursing functions such as promoting adequate fluid intake, maintaining normal voiding habits, and assisting with toileting.
Begin bladder retraining per protocol when appropriate.
Timing and type of bladder program depend on the type of injury (upper or lower neuron involvement). Bladder retraining requires the client to postpone voiding, resist or inhibit the sensation of urgency, and void according to a timetable rather than the urge to void. The goals are to gradually lengthen the intervals between urination to correct the client’s frequent urination, stabilize the bladder, and diminish urgency.
Start habit training along with bladder training.
This refers to scheduled toileting and attempts to keep clients dry by having them void at regular intervals, such as every two to four hours. The goal is to keep the client dry and is a common therapy for frail older adults and those who are bedridden or have cognitive impairment.
Limit the use of Crede’s maneuver as much as possible.
Credé’s maneuver should be used with caution because it may precipitate autonomic dysreflexia. The Crede maneuver involves manual compression of the bladder and can be useful in clients with decreased bladder tone or areflexia and low outlet resistance (Carter & Moberg, 2023).
Encourage adequate fluid intake (2 to 4 L per day), avoiding caffeine and use of aspartame, and limiting intake during late evening and at bedtime. Recommend the use of cranberry juice/vitamin C.
Sufficient hydration promotes urinary output and aids in preventing infection. When a client is taking sulfa drugs, sufficient fluids are necessary to ensure adequate excretion of the drug, reducing the risk of cumulative effects. Aspartame, a sugar substitute (e.g., Nutrasweet), may cause bladder irritation leading to bladder dysfunction. Clients at risk for UTI or urinary calculi should increase their fluid intake to dilute urine and increase the frequency of their urination, which helps in reducing the risk of UTI as well as stone formation.
Teach Kegel exercises.
These exercises improve pelvic floor muscle tone and ureterovesical junction sphincter tone, thereby reducing or eliminating episodes of incontinence. The client can identify the perineal muscles by tightening the anal sphincter as if to control the passage of gas or hold a bowel movement. There are two types of exercises: a quick contraction followed by immediate relaxation and a long contraction followed by relaxation.
- Instruct the client to contract their pelvic floor muscle (PFM) by pulling their rectum, urethra, and vagina up inside, and contracting the PFM. this is followed by relaxation.
- Advise to complete 45 of the quick and 45 of the long contractions exercises daily. The long contractions may be lengthened up to 10 seconds gradually.
- Instruct to perform a PFM contraction when initiating any activity that increases intra-abdominal pressure.
Catheterize as indicated.
Catheterization may be necessary as a treatment and for evaluation if the client is unable to empty the bladder or retains urine. This is performed only when absolutely necessary because the danger exists of introducing microorganisms into the bladder.
Teach self-catheterization and instruct in the use and care of indwelling catheters.
This method helps clients maintain autonomy and encourages self-care. An indwelling catheter may be required, depending on the client’s abilities and degree of urinary problem. The care of an indwelling catheter is directed toward the prevention of infection and encouraging urinary flow through the drainage system. It includes encouraging large amounts of fluid intake, changing the retention catheter and tubing, maintaining the patency of the drainage system, preventing contamination of the drainage system, and teaching these measures to the client.
Keep the bladder deflated by means of an indwelling catheter initially. Begin intermittent catheterization program when appropriate.
An indwelling catheter is used during the acute phase for the prevention of urinary retention and for monitoring output. Intermittent catheterization may be implemented to reduce complications usually associated with the long-term use of indwelling catheters. A suprapubic catheter may also be inserted for long-term management. Clean intermittent self-catheterization can also be performed by the client, especially those who have some form of neurogenic bladder dysfunction. A clean or medical aseptic technique is used.
Administer medications as indicated.
The goal of pharmacologic therapy is to improve the symptoms of frequency, nocturia, urgency, and urge incontinence. These include anticholinergics, antispasmodics, tricyclic antidepressants (TCAs), and beta-3-adrenergic receptor agonists.
- Antispasmodics (oxybutynin, flavoxate hydrochloride,)
These drugs reduce bladder spasticity and associated symptoms of frequency, urgency, incontinence, and nocturia. Oxybutynin causes direct smooth muscle relaxation of the urinary bladder. Flavoxate is used for symptomatic relief of dysuria, urgency, nocturia, and incontinence.
- Anticholinergics (dicyclomine, darifenacin, propantheline, hyoscyamine sulfate, and tolterodine)
These agents represent first-line medicinal therapy in women with urge incontinence. Anticholinergic suppresses involuntary bladder contraction of any etiology and increases the urine volume at which first involuntary bladder contraction occurs.
- Tricyclic antidepressants (imipramine, amitriptyline)
TCAs function to increase norepinephrine and serotonin levels and exhibit an anticholinergic and direct muscle relaxant effect on the urinary bladder. However, due to their black box warning, the use of TCAs is often avoided.
- Beta-3 agonists (mirabegron, vibegron)
These agents cause relaxation of the detrusor smooth muscle of the urinary bladder and increase bladder capacity.
Refer for further evaluation for bladder and bowel stimulation.
Clinical research is being conducted on the technology of electronic bladder control. The implantable device sends electrical signals to the spinal nerves that control the bladder and bowel. Early results look promising. Electrical stimulation is known to elicit a passive contraction of the PFM, thus re-educating these muscles to provide enhanced levels of continence. This modality is often used with biofeedback-assisted pelvic muscle exercise training and voiding schedules.
Refer to a urinary continence specialist as indicated.
Collaboration with specialists is helpful for developing an individual plan of care to meet clients’ specific needs using the latest techniques, and continence products. In more complicated cases of urinary incontinence, collaboration among primary care providers and specialists is needed to deliver seamless, quality care to clients.
Instruct the client about vaginal cone retention exercises.
Vaginal cone retention exercises are an adjunct to the Kegel exercises. Vaginal cones of varying weight are inserted intravaginally twice a day. The client tries to retain the cone for 15 minutes by contracting the pelvic muscles.
Interventions for functional urinary incontinence
Complete a focused record of the incontinence including duration, frequency, and severity of leakage episodes, and alleviating and aggravating factors.
This provides evidence of the causes, the severity of the condition, and its management. The following mnemonic, DIAPPERS, may be helpful in remembering the functional contributors to incontinence:
- D – Delirium
- I – Infection
- A – Atrophic urethritis or vaginitis
- P – Pharmacologic agents
- P – Psychiatric illness
- E – Endocrine disorders
- R – Reduced mobility or dexterity
- S – Stool impaction
Assess the client’s recognition of the need to void.
Clients with functional urinary incontinence are incontinent because they are unable to get to an appropriate place to void. In some cases, functional incontinence may result from problems with thinking or communicating. A person with Alzheimer disease or other forms of dementia, for example, may not think clearly enough to plan trips to the restroom, recognize the need to use the restroom or find the restroom. People with severe depression may lose all desire to care for themselves, including using the restroom.
Assess the client for potentially reversible causes of acute/transient urinary incontinence.
Transient or acute incontinence can be reduced or eliminated by reversing the underlying cause. Transient urinary incontinence is often seen in both older adults and hospitalized clients. Conditions such as bladder cancer, bladder stones, and foreign bodies can irritate the bladder, resulting in involuntary bladder contractions and incontinence. Stones or neoplasms may also result in incontinence due to obstruction.
Assess the availability of functional toileting facilities (working toilet, bedside commode).
A bedside commode is necessary for an immobile client. Environmental factors must be assessed, such as access to toilets, chair or bed height, toilet height, and sufficient space in the toilet to accommodate equipment such as walking aids and wheelchairs, floor surfaces, and unambiguous signage that may affect continence (Yates, 2019).
Assess the client for established/chronic incontinence: stress urinary incontinence, urge urinary incontinence, reflex, or extra urethral (“total”) urinary incontinence. If present, begin treatment for these forms of urine loss.
Functional incontinence is often accompanied by another form of urinary leakage, particularly among older adults. Functional incontinence may be accompanied by severe cognitive impairment that makes it difficult for the client to identify the need to void or physical impairments that make it difficult for the client to reach the toilet in time.
Assess the client’s ability to get to a toileting facility, both independently and with help.
This information allows the nurse to plan for assistance with transfer to a toilet or bedside commode. Functional continence requires the client to be able to get to a toilet either independently or with assistance. Clients who are weakened by a disease or impaired physically may require assistance with toileting.
Evaluate the home, acute care, or long-term care environment for convenience to toileting facilities, giving special consideration to the following:
Functional continence demands access to the toilet; environmental barriers blocking this access can produce functional incontinence. The ability to successfully toilet requires competence in the physical, functional, and cognitive domains, along with the need for a familiar environment to toilet (Yeung et al., 2019).
- Distance of toilet from bed, chair, and living quarters
- Characteristics of the bed, including the presence of side rails and distance of the bed from the floor
- Characteristics of the pathway to the toilet, including barriers such as stairs, loose rugs on the floor, and inadequate lighting
- Characteristics of the bathroom, including patterns of use; lighting; the height of the toilet from the floor; the presence of handrails to assist transfers to the toilet; and breadth of the door and its accessibility for a wheelchair, walker, or other assistive devices
Assess the client’s normal pattern of urination and an episode of incontinence.
This information is the source for an individualized toileting program. Many clients are incontinent only in the early morning when the bladder has collected a large urine volume during sleep. Clients with cognitive impairment may require assistance with voiding from nursing personnel or family members.
Assess the client’s need for physical assistive devices such as a cane, walker, or wheelchair.
Functional continence requires the ability to gain access to a toilet facility, either independently or with the assistance of devices to increase mobility. If there are physical barriers, toileting aids, easily removed clothing, and wiping aids can help. Removing clutter, ensuring good lighting, and mobility aids can also assist the client during toileting difficulties (Continence Foundation of Australia, 2022).
Assess the client for dexterity, including the strength to manage buttons, hooks, snaps, Velcro, and zippers needed to remove clothing. Consult physical or occupational therapists to promote optimal toilet access as indicated.
Functional continence requires the ability to remove clothing to urinate. Skills specific for independent toileting, which includes undressing and getting to the toilet, are unique and should not be combined during assessment with all the other ADL abilities. More specifically, dressing and personal hygiene can be classified as early loss ADL on a hierarchy scale.
Assess cognitive status with cognitive assessment tools as designated.
Functional continence needs satisfactory mental acuity to respond to sensory input from a filling urinary bladder by locating the toilet, and moving to it, and emptying the bladder. The Revised Hasegawa’s Dementia Scale (HDS-R) consists of 9-language-related questions regarding orientation, memory retention, and calculation. This scale is used to assess a client’s cognitive function (Koitabashi & Uchida, 2019).
Monitor older adults for dehydration in the long-term care facility, acute care facility, or home.
Dehydration can intensify urine loss, produce acute confusion, and increase the risk of morbidity and mortality, especially in frail older adults. Polyuria can cause excessive fluid loss, leading to intense thirst, dehydration, and weight loss.
Set a toileting schedule.
A toileting schedule guarantees the client a designated time for voiding and reduces episodes of functional incontinence. Habit training, also known as scheduled toileting, attempts to keep clients dry by having them void at regular intervals, such as every 2 to 4 hours. The goal is to keep the client dry and is a common therapy for frail older adults and those who are bedridden or have Alzheimer disease.
Eliminate environmental barriers to toileting in acute care, long-term care, or home setting. Help the client remove loose rugs from the floor and improve lighting in hallways and bathrooms.
Loose rugs and inadequate lighting can be a barrier to functional continence. The toilet should contain an easily accessible call signal to call for help if needed. The client should also be encouraged to use handrails placed near the toilet.
Place an appropriate, safe urinary receptacle such as a 3-in-1 commode, female or male hand-held urinal, no-spill urinal, or containment device when toileting access is limited by immobility or environmental barriers. Provide privacy.
The client must take this alternative toileting facility. Some people may be ashamed when using a toilet in a more open area. For clients who are unable to use toileting facilities, the nurse must provide urinary equipment close to the bedside, such as urinals, bedpans, or commodes, and provide necessary assistance to use them as needed.
Assist the person to change their clothing to maximize toileting access. Select loose-fitting clothing with stretch waistbands rather than buttoned or zippered waist; minimize buttons, snaps, and multilayered clothing; and substitute Velcro or other easily loosened systems for buttons, hooks, and zippers in existing clothing.
Clothing can be a barrier to functional continence if it takes time to remove before voiding. Women may find skirts or dresses easier to wear while implementing a toileting program. Pants with elastic waistbands may be easier for men and women to remove for toileting. Adaptive clothing designed for clients with specific mobility or health challenges can be helpful because they feature easy-open fasteners or open-back designs, which makes dressing and undressing more convenient.
Start a prompted voiding program or patterned urge response toileting program for older adults with functional incontinence and dementia in the home or long-term care facility:
Prompted voiding or patterned urge response toileting has been revealed to considerably lessen or eliminate functional incontinence in selected clients in the long-term care facility and in the community setting. A level A guideline from the American College of Obstetricians and Gynecologists (ACOG) recommends behavioral therapy, including bladder training and prompted voiding, as a non-invasive method for improving symptoms of urge and mixed incontinence in women.
- Ascertain the frequency of current urination using an alarm system or check and change the device.
- Note urinary elimination and incontinent patterns on a bladder log to use as a baseline for assessment and evaluation of treatment efficacy
- Start a prompted toileting program based on the results of this program; toileting frequency may vary from every 1.5 to 2 hours, to every 4 hours
- Praise the client when toileting occurs with prompting
- Refrain from any socialization when incontinent episodes occur; change the client and make them comfortable
Tell the client to limit fluid intake 2 to 3 hours before bedtime and to void just before bedtime.
Restricting fluid intake and voiding before bedtime reduces the need to disrupt sleep for voiding. Regulation of fluid intake, particularly during nighttime, can help reduce the need to void during the night. If the client has been prescribed diuretics, instruct that they take this early in the morning to avoid disrupting their sleep if they take the medication at night.
Interventions for urge urinary incontinence
Determine the client’s episodes of incontinence.
Urge incontinence happens when the bladder muscle abruptly contracts. The client may report feeling the need suddenly to urinate but being unable to get to the bathroom in time. Urge incontinence is a type of uncontrolled urine loss that cannot be prevented. The entire contents of the client’s bladder are lost rather than a few drops of urine.
Tell the client to keep a daily diary indicating voiding frequency and patterns.
This information enables the nurse to recognize patterns in voiding. This information will allow for an individualized treatment plan. The client may be voiding as often as every two hours. Voiding diaries should record the volume and type of fluid intake and the frequency and volume of voids. Episodes of nocturia and incontinence should be recorded, including an estimate of the volume; associated activities such as coughing, straining, and dishwashing; and associated symptoms such as urgency.
Observe the results of cytometry or cystometrography (CMG).
Diagnostic testing is used to measure bladder pressures and fluid volume during filling, storage, and urination. The results of this test may show the underlying problem leading to urge incontinence. CMG is used to assess the first sensation of filling, fullness, and urge. Bladder compliance and the presence of uninhibited detrusor contractions can be noted during this filling CMG. water is the most common filling medium.
Promote access to toilet facilities, and instruct the client to make scheduled trips to the bathroom.
Scheduled voiding allows for frequent bladder emptying. Timed, frequent voiding can be used to minimize incontinence, especially if the bladder is kept empty before incontinence-producing activities. Another method of bladder training is to maintain the prearranged schedule and disregard the unscheduled voids.
Aid the client with developing a bladder training program that includes voiding at scheduled intervals, and gradually increasing the time between voidings.
A bladder training program helps increase bladder capacity through the regulation of fluid intake, pelvic exercises, and scheduled voiding. A regular schedule of voiding helps decrease detrusor overactivity and increase bladder fluid volume capacity. Bladder training generally consists of self-education, scheduled voiding with conscious delay of voiding, and positive reinforcement.
Administer medications as ordered:
Anticholinergics lessen or block detrusor contractions, thereby reducing the occurrence of incontinence. Propantheline bromide decreases the rate of urge incontinence by 13 to 17%, according to a study. It must be taken on an empty stomach. Tolterodine has also caused a decrease in urge incontinence by 50% and a decrease in urinary frequency by 17%.
- Tricyclic antidepressants
The tricyclics increase serotonin or norepinephrine, which results in the relaxation of the bladder wall and increased bladder capacity. Imipramine is the most widely used TCA for urologic indications. It facilitates urine storage by decreasing bladder contractility and increasing outlet resistance.
Instruct client on pelvic floor exercises.
The client can perform pelvic floor muscle exercises by drawing in or lifting up the muscles of the pelvic floor, as if to control urination or defecation with minimal contraction of abdominal, buttock, or inner-thigh muscles. The client can confirm that she is using the correct muscles at home by periodically performing the contractions during voiding with the goal of interrupting the urinary stream.
Promote biofeedback therapy and assist the client in performing them.
Biofeedback therapy is a form of pelvic floor muscle rehabilitation using an electronic device for clients having difficulty levator ani muscles. Biofeedback therapy is recommended for treatment of urge incontinence. This therapy uses a computer and electronic instruments to relay auditory or visual information to the client about the status of pelvic muscle activity. These devices allow the client to receive immediate visual feedback on the activity of the pelvic floor muscles.
Interventions for reflex urinary incontinence
Ascertain the client’s recognition of the need to urinate.
Clients with neurological impairments may have damaged sensory fibers, and may not have the sensation of the need to void. It is hypothesized that impairments in the higher micturition center due to dementia causes a deficit in the inhibition of the voiding reflex. This results in the onset of dysfunction of urine storage, which may be characterized by frequent urination and urinary incontinence.
Measure and record urine volume with each voiding.
Urine volumes are usually consistent with reflex incontinence. Urine output can be affected by many factors, including fluid intake, body fluid losses through other routes such as perspiration and breathing or diarrhea, and the cardiovascular and renal status of the client. Urine outputs below 30 mL/hour may indicate low blood volume or kidney malfunction.
Review the results of urodynamic studies.
A cystometrogram will measure bladder pressures and fluid volumes during filling, storage, and urination. Electromyography will record detrusor activity during voiding. Test results will indicate the point of coordination between the detrusor muscle and sphincter activity. Urodynamics is a means of evaluating the pressure-flow relationship between the bladder and the urethra for the purpose of defining the functional status of the lower urinary tract.
Ascertain the quantity, frequency, and character of urine, such as color, odor, and specific gravity.
Urinary retention, vaginal discharge, and the presence of a catheter predispose the client to infection, especially if the client has perineal sutures. Normal urine consists of 96% water and 4% solutes. Concentrated urine is darker in color. Dilute urine may appear almost clear, or very pale yellow. Some foods and drugs may affect the color of the urine too. White blood cells, bacteria, pus, or contaminants such as prostatic fluid, sperm, or vaginal drainage may cause cloudy urine.
Monitor time intervals between voiding and document the quantity voided.
Keeping an hourly record for 48 hours can help in establishing a toileting program and gives a clear picture of the client’s voiding pattern. Instructing the client to keep a voiding diary can help as a pre-therapy diagnostic tool, as well as in measuring pots-therapy outcomes. Estimates of voiding frequency and amounts obtained by history alone can be unreliable.
Ask the client about stress incontinence when moving, sneezing, coughing, laughing, and lifting objects.
High urethral pressure can inhibit voiding until abdominal pressure increases enough for urine to be involuntarily lost. Also, hinders bladder emptying. Triggers of stress incontinence are predictable: typically, the client may report involuntary urine loss during coughing, laughing, and sneezing. Incontinence worsens during high-impact sports activities such as golf, tennis, or aerobics.
Allow the client to maintain a “bladder diary.”
Data about fluid intake and voiding patterns provide a basis for planning bladder management techniques. A bladder diary includes recording the time of each micturition, voided volume, fluid intake, episodes of urgency and incontinence, and even pad usage. Two or three days of recording generally provide useful clinical data (Hsiao & Lin, 2022).
Tell the client to limit fluid intake 2 to 3 hours prior to bedtime and to void just before going to bed.
Restricting fluid intake and voiding before going to bed reduces the need to interrupt sleep for voiding. There is less urine production during the night if fluid intake is reduced at night. This leads to fewer instances of waking up to use the toilet, improving sleep quality and reducing disruptions to rest.
Allow voiding at scheduled intervals before predictable urination.
Voiding at regular intervals, based on knowledge of the client’s voiding pattern, lowers the possibility of uncontrolled incontinence. Assist the client who has the urge to void immediately. Delays only increase the difficulty in starting to void, and the desire to void may pass.
For the male client, acknowledge the application of an external catheter.
An external catheter attached to a gravity drainage device enables the client to remain dry. The use of a condom appliance is preferable to the insertion of a retention catheter because the risk of UTI is minimal. The nurse also needs to determine when the client experiences incontinence. Some clients may only require a condom appliance at night.
Catheterize the client at regular intervals if spontaneous voiding is not possible.
Emptying the bladder at regular intervals will reduce incontinence episodes. The risk for infection is noteworthy with indwelling catheters. The nurse may implement automatic stop orders for 48 to 72 hours after catheter insertion. Continue catheter use only with a documented order from the healthcare provider.
3. Initiating Interventions for Urinary Retention
Assess vital signs. Check for changes in mentation, hypertension, and peripheral or dependent edema. Weigh daily. Maintain precise I&O records.
Kidney failure results in reduced fluid excretion and builds up of toxic wastes. It may lead to a complete renal shutdown. Urinary retention may result from diabetes, prostatic enlargement, urethral pathology, trauma, pregnancy, or neurologic disorders.
Palpate and percuss suprapubic area. Examine verbalization of discomfort, pain, fullness, and difficulty of voiding.
A distended bladder could be felt by the client in the suprapubic area. Perception of bladder fullness and bladder distention above the symphysis pubis implies urinary retention. Physical examination should also include a complete abdominal assessment, with palpation and percussion of the bladder and abdominal/pelvic organs; evaluation for flank tenderness; and digital rectal examination for males to assess prostate size.
Monitor urinalysis, urine culture, and sensitivity.
Urinary tract infection can cause retention. Laboratory studies are not required to diagnose urinary retention but may be useful in identifying associated complications. Urinalysis and urine culture should be obtained in clients with urinary retention for the main purpose of evaluating for urinary tract infection.
Monitor blood urea nitrogen (BUN) and creatinine.
This laboratory test will differentiate between renal failure and urinary retention. Elevated BUN and creatinine levels can result from bilateral renal obstructive processes or obstruction in a solitary kidney.
Review previous patterns of voiding.
There is a wide range of “normal” voiding frequencies. Acute urinary retention requires immediate medical intervention. With chronic urinary retention, one is able to urinate but may have trouble starting the stream or emptying the bladder completely. These clients may be more likely to have overflow incontinence, which can rarely be mistaken for continued spontaneous voiding, and sometimes even frequent urination.
Allow the client to keep a record of the amount and time of each voiding. Take down decreased urinary output. Determine specific gravity as ordered.
Retention of urine increases pressure in the kidneys and ureters which may lead to renal insufficiency. Insufficiency of blood circulation to the kidney alters its capability to filter and concentrate substances. A voiding diary can be used to provide a written record of the amount of urine voided and the frequency of voiding.
Use a bladder scan (portable ultrasound instrument) or catheterize the client to measure residual urine if incomplete emptying is presumed.
Retention of urine in the bladder predisposes the client to urinary tract infection and may indicate the need for an intermittent catheterization program. Several commercial products exist to quickly estimate bladder volume. These automated point-of-care devices utilize 3-dimensional ultrasound to estimate bladder volume and can be useful both on presentation and after attempted decompression (Billet & Windsor, 2019).
If an indwelling catheter is in place, assess for patency and kinking.
An occluded or kinked catheter may lead to urinary retention in the bladder. Ensure that the catheter tubing is securely taped or fastened to the client’s body to prevent unnecessary movement or pulling, which could lead to kinks. The urinary drainage bag must be positioned below the level of the bladder to allow gravity to facilitate drainage.
Promote fluids, if not contraindicated.
Unless medically restricted, fluid intake should be at least 1500 mL per 24 hours. Large amounts of fluid ensure a large urine output, which keeps the bladder flushed out and decreases the likelihood of urinary stasis and subsequent infection.
Encourage regular intake of cranberry juice.
Cranberry juice keeps the acidity of urine. This aids in preventing infection. Acidifying clients with indwelling catheters may reduce the risk of UTI and calculus formation. Cranberry, plum, or prune juice tend to increase the acidity of the urine.
Place the client in an upright position to facilitate successful voiding.
An upright position on a commode or in bed on a bedpan increases the client’s voiding success through the force of gravity. Assist the client to a normal position for voiding; standing for male clients, squatting, or leaning slightly forward when sitting for females. These positions enhance the movement of urine through the tract by gravity.
Privacy aids in the relaxation of urinary sphincters. Providing privacy also contributes to the client’s sense of comfort and sense of security. Feeling relaxed and at ease is essential for proper urination, especially for clients with urinary retention. Voiding is a sensitive and potentially embarrassing situation especially if they are experiencing difficulties due to urinary retention.
Encourage the client to void at least every four hours.
Voiding at frequent intervals empties the bladder and reduces the risk of urinary retention. Encourage the client to void on their regular voiding schedule to help maintain it, whether the client feels the urge or not. The stretching-relaxing sequence of such a schedule tends to increase bladder muscle toner and promote more voluntary control.
Encourage the use of the toilet or a commode instead of a bedpan if applicable.
Assist the client with the use of the toilet or bedside commode rather than a bedpan, to provide a more natural setting for voiding. If the client’s condition allows, the male client may stand beside the bed to use the urinal; most men find this position mroe comfortable and natural.
Allow the client to listen to the sound of running water, dip hands in warm water/pour lukewarm water over the perineum.
Provide sensory stimuli that may help the client relax. Pour warm water over the perineum of a female or have the client sit in a warm bath to promote muscle relaxation. Applying a hot water bottle to the power abdomen of both men and women may also foster muscle relaxation.
Offer fluids before voiding.
Sufficient urine volume is necessary to stimulate the voiding reflex. A normal daily intake averaging 1,500 mL of measurable fluids is adequate for most adult clients. Some clients may have increased fluid requirements, requiring a higher daily fluid intake. These include clients who are perspiring excessively or who have abnormal fluid losses through vomiting, gastric suction, diarrhea, or wound drainage.
Perform Credé’s maneuver.
Credé’s method (pressing down over the bladder with the hands) enhances urinary bladder pressure, and this consequently induces relaxation of the sphincter to allow voiding. Clients who have a flaccid bladder may use manual pressure on the bladder to promote bladder emptying. This is not advised without a healthcare provider or nurse’s order and is used only for clients who have lost and are not expected to empty their bladder.
Decompress bladder moderately.
Once a huge amount of urine has accumulated, fast urinary bladder decompression produces pressure on pelvic arteries and may cause venous pooling. Prompt bladder decompression is the mainstay of treatment for nearly all etiologies of urinary retention. This can be accomplished by urethral or suprapubic catheterization.
Encourage the client to take bethanechol as indicated.
Bethanechol stimulates the parasympathetic nervous system to release acetylcholine at nerve endings and to enhance the tone and amplitude of contractions of smooth muscles of the urinary bladder. This agent is used for selective stimulation of the bladder to produce contraction and thereby initiate micturition and empty the bladder.
If incomplete emptying is presumed, catheterize and measure residual urine.
Urinary retention predisposes the client to urinary tract infection and may be a sign of the need for an intermittent catheterization program. Postvoid residual urine (PVR) is normally 50 to 100 mL. However, a bladder obstruction or loss of bladder muscle tone may interfere with the complete emptying of the bladder during urination. PVR is measured to assess the amount of retained urine after voiding and determine the need for interventions.
Secure the catheter of the male client to the abdomen and thigh for the female.
This technique prevents urethral fistula and avoids accidental dislodgement. Ensuring that the catheter is securely taped or fastened to the client’s body aids in preventing unnecessary movement and pulling, which could lead to kinks.
Suggest a sitz bath as ordered.
A sitz bath supports muscle relaxation, reduces edema, and may improve voiding attempts. Warm water increases blood circulation in the pelvic area, which can improve the blood supply to the bladder and surrounding structures. An increased blood supply may enhance bladder function and make urination more efficient.
Assist in the insertion of suprapubic catheter.
A suprapubic catheter is inserted surgically through the abdominal wall above the symphysis pubis into the urinary bladder. The suprapubic catheter may be placed for temporary bladder drainage until the client is able to resume normal voiding or it may become a permanent device, such as in cases with urethral or pelvic trauma.
4. Preventing Urinary Tract Infections (UTIs)
The rate of UTIs is greater in women than men because of the short urethra and its proximity to the anal and vaginal areas. For women who have experienced a UTI, the nurse needs to provide instructions about ways to prevent recurrence. The most frequent healthcare-associated infection is the catheter-associated urinary tract infection (CAUTI). This occurs while an indwelling catheter is in place or within 48 hours of its removal.
Consider a criteria for appropriate catheter insertion.
Catheterization is the only way to treat overflow incontinence. If the underlying cause of the overflow problem can be treated or eliminated, these clients may be able to return to normal voiding, thus the removal of the catheter can occur. If unsuccessful, intermittent catheterization is usually preferred.
Use aseptic technique and sterile equipment during insertion.
The open system of the urinary catheter reuires the nurse to be especially vigilant to ensure sterile technique is maintained when inserting and connecting the catheter and drainage tubing. The closed system has a reduced risk of microorganisms netering the system and infecting the urinary tract.
Use the smallest catheter possible that allows proper drainage.
Determine the appropriate catheter size by the size of the urethral canal. Men frequently require a larger size than women. Adults may use sizes #14 or #16. The lumen of the silicone catheter is slightly larger than that of a same-sized latex catheter. An appropriate size decreases the risk for trauma that can predispose to an infection.
Promote continued mobility unless contraindicated.
Mobility decreases the risk of developing UTIs. Studies suggest that clients with stroke who have indwelling catheters but were able to ambulate have a lower rate of UTI. early ambulation may result in earlier removal of the indwelling catheter which explains the protective effect of ambulation against UTI (Sisante et al., 2015).
Cleanse the perineal area and keep it dry. Provide catheter care as appropriate.
Proper perineal hygiene decreases the risk of skin irritation or breakdown and the development of ascending infection. Vigorous cleansing of the urethral meatus while the catheter is still in place is discouraged because the cleansing action can move the catheter back and forth, increasing the risk of infection. To clean the external catheter surface, the nurse may gently wash it with soap and water or wipes during daily baths.
Maintain unobstructed urine flow and avoid kinking of the tubing.
If the tubing is kinked or there is an obstruction in the flow of the urine, backflow may occur. Bacteria may enter the urinary drainage bag, multiply rapidly, and then migrate to the bladder. By keeping the drainage bag lower than the client’s bladder and not allowing urine to flow back into the bladder, this risk is reduced.
Recommend good hand washing and proper perineal care.
Handwashing and perineal care reduce skin irritation and the risk of ascending infection. No special cleaning other than routine hygienic care is necessary for clients with indwelling catheters, nor is special meatal care recommended. Other studies, however, report that using 2% chlorhexidine gluconate no-rinse wipes during daily baths helps decrease CAUTI rates.
Take a specimen of urine for culture.
A bladder infection can result in a strong urge to urinate; successful management of a urinary tract infection may reduce or improve incontinence. If catheterization can be discontinued, the culture can be obtained in a voided midstream urine specimen. If an indwelling catheter has been in place for two weeks at the onset of the UTI and is still indicated, it should be replaced, and the urine culture should be obtained from the freshly placed catheter (Brusch & Stuart, 2021).
Empty the collection bag regularly.
The nurse must empty the urine drainage or collection bag routinely with a separate, clean collecting container for each client. When draining, the nurse must prevent contact of the drainage spigot with the nonsterile collecting container to avoid ascending of harmful microorganisms into the tubing to the urethra.
Administer anti-infective agents as necessary, such as nitrofurantoin macrocrystals, co-trimoxazole, ciprofloxacin, and norfloxacin.
Bacteriostatic agents inhibit bacterial growth and destroy susceptible bacteria. Prompt treatment of infection is necessary to prevent serious complications of sepsis/shock. Seven days are the recommended duration of antibiotic treatment for clients whose symptoms resolve promptly. For those with a delayed response or with bacteremia, 10 to 14 days of treatment is recommended. If the client is not severely ill, a 5-day regimen of quinolone may be considered.
Remove the catheter as soon as feasible.
Catheters should be kept in place only for as long as needed. Indwelling catheters placed in clients undergoing surgery should be removed as soon as possible postoperatively. Cathter use and duration should be minimized in all clients, especially those at higher risk for CAUTI.
Use alerts in chart or computerized charting system.
This is to inform the healthcare provider of the presence of a catheter and require an order for continued use. Not all providers know which of their clients has an indwelling catheter. As a result, some facilities have incorporated an alert system that requires the provider to take an action after a specified time frame.
Avoid adding antimicrobials or antiseptics to the urine drainage bags.
The Infectious Diseases Society of America (IDSA) guidelines advise against the routine addition of antimicrobials or antiseptics to the drainage bag of clients who are catheterized in an effort to reduce the risk of catheter-associated bacteriuria or CAUTI. This does not have a significant effect on the outcomes of clients with CAUTI.
5. Maintaining Skin Integrity
Protecting the tissue integrity of clients during hospital stays is one of the most important goals in the management of urinary incontinence. When skin integrity is lost, the treatment cost can change dramatically. Additionally, the client may also suffer physical, psychological, social, and economic loss. Nursing interventions and approaches to protecting skin integrity facilitate the prevention of skin integrity deterioration and decrease healthcare costs (Avsar & Karagdag, 2017).
Assess the skin surrounding the client’s catheter, as well as areas that are continually exposed to urine, such as the buttocks or the client’s back.
Skin that is continually moist becomes macerated. Urine that accumulates on the skin is converted to ammonia, which is very irritating to the skin. Because both skin irritation and maceration predispose the client to skin breakdown and ulceration, the client requires meticulous skin care.
Wash, rinse, and dry the client’s perineal area regularly.
To maintain skin integrity, the nurse must wash the client’s perineal area with mild soap and water or a commercially prepared no-rinse cleanser after episodes of incontinence. The nurse then rinses the area thoroughly if soap and water were used, and dries it gently and thoroughly.
Avoid rubbing the skin when drying.
It is important not to rub the skin dry after washing, in oder to avoid additional friction. Simple patting with an absorbent towel should be sufficient to dry the skin and is less damaging than rubbing.
Use gentle bath products for the client’s skin.
Bath oil or shower oil without perfume or other possible allergens, or a pH-neutral cleansing foam applied with a soft cloth are the preferred products for a gentle cleansing of the skin, for both the genital region and the rest of the skin.
Pay attention to skin folds during daily baths.
Continuous moisture on the skin must be prevented by meticulous hygiene measures. It is important to pay special attention to skin folds, including areas under the breasts, arms, and groin, and between the toes. Perspiration, urine, stool, and drainage must be removed from the skin promptly.
Provide hydration to the client’s dry skin.
It is important to hydrate the dry skin with a hydrating topical product. Ointments are too greasy and tend to be too occlusive; therefore, it is better to use a cream. Creams are emulsions of water and oil. When the skin is very dry, it is better to use a rich cream, whereas an oil in water cream may be sufficient when the skin is not extremely dry. Caution must be used in the amount of cream used, especially in skin folds, in order to avoid softening of the skin and maceration. The cream must be applied in a gentle, patting way to avoid friction.
Manage any existing perineal skin excoriation with a vitamin-enriched cream, followed by a moisture barrier.
Moisture barrier ointments are beneficial in protecting perineal skin from urine. The skin may be lubricated with a bland lotion to keep the skin smooth and pliable. Drying agents and powders are avoided. Topical barrier ointments such as petroleum jelly may be helpful in protecting the skin of clients who are incontinent.
Use linens that are effective in absorbing moisture.
Specially designed incontinence drawsheets provide significant advantages over standard drawsheets for incontinent clients confined to the bed. These sheets are like a drawsheet but are double-layered, with a quilted nylon or polyester surface and an absorbent viscose rayon layer below. This sheet helps maintain skin integrity; it does not stick to the skin when wet, decreases the risk of bedsores, and reduces odor.
Avoid vigorous and excessive washing.
Excessive cleansing must be avoided as this contributes to skin dryness and skin irritation. When older adults are admitted at the hospital or to a nursing home, they are often washed more often and more vigorously than they were used to at home. This might be the reason for the increased risk of incontinence-associated dermatitis (IAD) (Beele et al., 2018).
6. Providing Client and Caregiver Education
The client and their caregivers need to understand their condition, potential causes, and management options. The nurse should assess the client’s knowledge and provide appropriate education and communication support.
Explain to the client and caregiver the rationale behind and implementation of a toileting program.
Successful functional continence requires consistency in the use of a toileting program. A stndard voiding program may require assistance from family members if the client has cognitive impairment. Explain that the purpose of this program is to empty the bladder before the bladder reaches critical volume that would cause an urge or stress incontinence episode.
Educate caregivers and family members about the importance of responding immediately to the client’s request for assistance with voiding.
Functional continence is promoted when caregivers respond promptly to the client’s request for help with voiding. The caregiver should assist the client who have the urge to coid immediately. Delays only increase the difficulty in starting to void, and the desire to void may pass if not acted upon urgently.
Advise the client about the benefits of using disposable or reusable insert pads, pad-pant systems, or replacement briefs specifically designed for urinary incontinence (or double urinary and fecal incontinence) as indicated.
Most absorptive products utilized by community-dwelling older adults are not designed to absorb urine, prevent odor, and protect the perineal skin. Absorbent pads that wick moisture away from the body should be used to absorb drainage. Clients who are incontinent need to be checked regularly and have their wet incontinence pads and linens changes promptly, then their skin needs to be cleansed and dried properly.
Educate the client about the effects of extreme alcohol and caffeine intake.
These chemicals are known to be bladder irritants. They can increase detrusor overactivity. Fluids containing caffeine, carbonation, alcohol, or artificial sweeteners should be avoided because they irritate the bladder wall, thus resulting in urinary urgency. Eben chocolate and milk and many over-the-counter medications contain caffeine. These should be slowly decreased if consumed in large amounts to avoid withdrawal responses, such as headache and depression.
Educate the client about Kegel exercises.
Kegel exercises are done to strengthen the muscles of the pelvic floor and can be followed with a minimum of exertion. Two types of Kegel exercises can be taught to the client. One is a quick 2-second contraction where the client squeezes the pelvic muscle quickly and hard and then relaxes immediately. The other is a slow 3 to 5-second long contraction, then the client relxaes after the sustained contraction. When the exercise is properly performed, contraction of the muscles of the buttocks and thighs is avoided.
Explain the importance of absorbent pads in social situations.
Absorbent pads will preserve clothing when the client is in public. The client needs to learn about replacing the pads at regular intervals to prevent skin irritation from exposure to urine and moisture. Absorbent pads should not be used in place of definitive interventions to decrease or eliminate urinary incontinence. Dependency on absorbent pads may be a deterrent to achieving continence, providing the client a false sense of security.
Demonstrate to the client or caregiver intermittent catheterization.
This method drains the bladder at particular periods. The client may perform clean intermittent self-catheterization to retain their independence and gain control of their bladder. Initially, catheterization may be necessary every 2 to 3 hours, increasing 4 to 6 hours.
- Encourage the client to attempt to void first before catheterization.
- If unable to void or to completely empty the bladder, the client may insert the catheter to remove residual urine.
- Instruct the client to gather all necessary supplies and perform hand hygiene.
- The client should cleanse their urinary meatus with a towelette or a soapy washcloth, then rinse with a wet washcloth. Females should clean from front to back.
- The client may assume a semi-reclining position in bed or sitting ina chair. Male clients may prefer to stand over the toilet.
- Instruct the client to apply lubricant to the catheter tip, then insert the catheter until urine flows through.
- For female clients, they may locate their urinary meatus using a mirror or use the “touch” technique by placing their non dominant hand on their clitoris, placing their third and fourth fingers at the vagina, and locating the meatus between the index finger and the third finger.
- For male clients, they should hold their penis with a slight upward tension at a 60 to 90-degree angle to insert the catheter.
- Hold the catheter in place until all urine is drained, then withdraw the catheter slowly.
Work with the client and family to establish a reasonable, manageable voiding program.
Participation in the plan of care promotes additional knowledge and appropriate management. Bladder training generally consists of self-education, scheduled voiding with the conscious delay of voiding, and positive reinforcement. Bladder training requires the client to resist or inhibit the sensation of urgency and postpone voiding.
Educate the client on the importance of caring for the urethral meatus. This should be done twice daily with soap and water and dry thoroughly.
Meatal care reduces the risk of infection. Instruct the client to wash their perineal area with soap and water at least twice a day amd avoid a to-and-fro motion of the catheter. They should dry the area well but avoid applying powder because it may irritate the perineum.
Discuss the importance of adequate fluid intake.
Increased fluid stimulates voiding and decreases the risk of urinary tract infections. The quantity and types of fluids consumed influences urinary voiding symptoms. The recommended amount of fluids consumed in 24 hours totals six to eight glasses for all types of fluid. The benefits of adequate fluid intake include prevention of dehydration, constipation, UTI, and kidney stone formation.
Inform the client and significant other to observe the different signs and symptoms of bladder distention like reduced or lack of urine, urgency, hesitancy, frequency, distention of the lower abdomen, or discomfort.
Knowledge of the signs and symptoms allows the client, significant other, or caregiver to recognize them and seek treatment. The retention of urine can lead to chronic infections that if unresolved predispose the client to renal calculi, pyelonephritis, sepsis, or hydronephrosis. Additionally, urine leakage can lead to perineal skin breakdown.
Instruct the client and significant other to observe the different signs and symptoms of urinary tract infection like chills and fever, frequent urination or concentrated urine, and abdominal or back pain.
Knowledge of the signs and symptoms allows the client, significant other, or caregiver to recognize them and seek treatment. Symptoms of CAUTI are generally nonspecific; most clients present with fever and leukocytosis. Significant pyuria is characterized by more than 50 white blood cells per high-power field (HPF).
Teach the client to achieve an upright position on the toilet if possible.
An upright position is the natural position for voiding and uses the force of gravity. For female clients, squatting or leaning slightly forward while sitting, and for male clients, standing, facilitates the movement of urine through the tract by gravity. If the client is unable to ambulate, they may use a bedside commode for females and a urinal for males while standing at the bedside.
Inform the client about possible surgical treatment as needed.
If prostate enlargement is involved, surgery may be required. Women may need surgery to lift a fallen bladder or rectum. A urethral stent may be required to treat urethral stricture. Surgical care for stress incontinence involves procedures that increase urethral outlet resistance. Surgical care for urge incontinence involves procedures that improve bladder compliance, bladder capacity, or both.
Inform the client of the importance of weight loss in incontinence management.
The benefits of weight loss in clients who are overweight or obese are numerous and encompass improvements in type 2 diabetes mellitus, hypertension, dyslipidemia, and mood. The results should encourage the client to consider weight loss as a first-line treatment for reducing urinary incontinence before embarking on more invasive medical and surgical therapies.
Advice the client and caregivers on home modification for facilitation of self-care.
Teach the client and the family to maintain easy access to toilet facilities, including removing scatter rugs and ensuring that halls and doorways are free of clutter. Suggest graduated lighting for night-time voiding, a dim night light in the bedroom, and low-wattage hallway lighting to help the client reach the toilet even at night safely. Grab bars may be installed in the bathroom and elevated toilet seats as necessary.
Recommended nursing diagnosis and nursing care plan books and resources.
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
- Avsar, P., & Karagdag, A. (2017). Efficacy and Cost-Effectiveness Analysis of Evidence-Based Nursing Interventions to Maintain Tissue Integrity to Prevent Pressure Ulcers and Incontinence-Associated Dermatitis. Worldviews on Evidence-Based Nursing, 15(1).
- Beele, H., Smet, S., Van Damme, N., & Beeckmann, D. (2018). Incontinence-Associated Dermatitis: Pathogenesis, Contributing Factors, Prevention and Management Options. Drugs & Aging, 35.
- Berman, A., Snyder, S., & Frandsen, G. (2016). Kozier and Erb’s Fundamentals of Nursing. Pearson.
- Billet, M., & Windsor, T. A. (2019). Urinary Retention. Emergency Medicine Clinics of North America, 37(4).
- Brusch, J. L., & Stuart, M. (2021, April 1). Catheter-Related Urinary Tract Infection (UTI): Transmission and Pathogens, Guidelines for Catheter Use, Diagnosis. Medscape Reference.
- Carter, G. T., & Moberg, E. A. (2023, May 16). Bladder Dysfunction: Practice Essentials, Pathophysiology, Etiology. Medscape Reference.
- Continence Foundation of Australia. (2022, December 7). Functional incontinence | Urinary. Continence Foundation of Australia.
- Fisher, J. S., & Kim, E. D. (2020, June 1). Urinary Tract Obstruction: Practice Essentials, Background, Pathophysiology. Medscape Reference.
- Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth’s Textbook of Medical-surgical Nursing. Wolters Kluwer.
- Hsiao, S.-M., & Lin, H.-H. (2022). Feasibility and clinical implications of 3-day bladder diary derived classification of female storage lower urinary tract symptoms. Scientific Reports, 12.
- Koitabashi, R., & Uchida, Y. (2019). Analysing the relationship between cognition and urine storage function. International Journal of Urological Nursing, 13(2).
- Queremel Milani, D. A., & Jialal, I. (2023, May 1). Urinalysis – StatPearls. NCBI.
- Serlin, D. C., Heidelbaugh, J. J., & Stoffel, J. T. (2018). Urinary Retention in Adults: Evaluation and Initial Management. American Family Physician, 98(8).
- Sisante, J.-F., Abraham, M., Billinger, S., & Mittal, M. (2015). A Retrospective Cohort Study: Effect of Ambulation on Urinary Tract Infections in Acute Stroke Patients. Stroke, 46.
- Tran, L. N., & Puckett, Y. (2022, August 8). Urinary Incontinence – StatPearls. NCBI.
- Vasavada, S. P., & Kim, D. (2023, May 26). Urinary Incontinence: Practice Essentials, Background, Anatomy. Medscape Reference.
- Yates, A. (2019). Understanding incontinence in the older person in community settings. British Journal of Community Nursing, 24(2).
- Yeung, J., Jones, A., Jhangri, G. S., Gibson, W., Hunter, K. F., & Wagg, A. (2019). Toileting Disability in Older People Residing in Long-term Care or Assisted Living Facilities. Journal of Wound, Ostomy and Continence Nursing, 45(5).