Neurogenic bladder is defined as an interruption of normal bladder innervation because of lesions on or insults to the nervous system. Neurogenic bladder dysfunctions have been categorized in two ways: according to the response of the bladder to the insult (classification I) or according to the lesion’s level (classification II).
Many complications can result in patients with neurogenic bladder, such as bladder infection and skin breakdown related to incontinence. In addition, urolithiasis (stones in the urinary tract) is a common complication. Patients with spinal lesions above T7 are also at risk for autonomic dysreflexia, a life-threatening complication. Autonomic reflexia results from the body’s abnormal response to stimuli such as a full bladder or a distended colon. It results in severely elevated blood pressure, flushing, diaphoresis, decreased pulse, and a pounding headache. Chronic renal failure (CRF) can also result from chronic overfilling of the bladder, causing backup pressures throughout the renal system.
Nursing care plan assessment and physical examination
Take a full history of urinary voiding, including night/day patterns, amount of urine voided, and number of urinary emptyings per day. Most patients will describe a history of urinary incontinence and changes in the initiation or interruption of urinary voiding. Elicit an accurate description of the sensations during bladder filling and emptying. In patients with spastic neurogenic bladder, expect the patient to describe a history of involuntary or frequent scanty urination without a sensation of bladder fullness. In patients with flaccid neurogenic bladder, expect overflow urinary incontinence. Also ask patients if they have a history of frequent urinary tract infections, a complication that often accompanies neurogenic bladder.
Evaluate the extent of the patient’s CNS involvement by performing a complete neurological assessment, including strength and motion of extremities and levels of sensation on the trunk and extremities. With a spastic neurogenic bladder, the patient may have increased anal sphincter tone so that when you touch the abdomen, thigh, or genitalia, the patient may void spontaneously. Often, the patient will have residual urine in the bladder even after voiding. In patients with a flaccid neurogenic bladder, palpate and percuss the bladder to evaluate for a distended bladder; usually, the patient will not sense bladder fullness in spite of large bladder distension because of sensory deficits. In patients with urinary incontinence, evaluate the groin and perineal area for skin irritation and breakdown.
The patient will likely view neurogenic bladder dysfunction as one more manifestation of an already uncontrollable situation. Anxiety about voiding will be added to the anxiety about the underlying cause of the dysfunction. Urinary incontinence leads to embarrassment over the lack of control and concern over the odor of urine that often can permeate clothing and linens. Patients who perceive that the only alternative is urinary catheterization have concerns about being normally active with a catheter and may also fear sexual dysfunction.
Nursing care plan primary nursing diagnosis: Altered urinary elimination related to incontinence or retention secondary to trauma or CNS dysfunction.
Nursing care plan intervention and treatment plan
The goals for the medical management of patients include maintaining the integrity of the urinary tract, controlling or preventing infection, and preventing urinary incontinence. Many of the nonsurgical approaches to managing neurogenic bladder depend on independent nursing interventions such as the Crede method, Valsalva’s maneuver, or intermittent catheterization. If all attempts at bladder retraining or catheterization have failed, a surgeon may perform a reconstructive procedure, such as correction of bladder neck contractures, creation of access for pelvic catheterization, or other urinary diversion procedures. Some surgeons may recommend
implantation of an artificial urinary sphincter if urinary incontinence continues after surgery.
Focus on bladder training. The patient may notice bladder dysfunction initially during the acute phase of the underlying disorder, such as during recovery from a spinal cord injury. During this time, an indwelling urinary catheter is frequently in place. Ensure that the tubing is patent to prevent urine backflow and that it is taped laterally to the thigh (in men) to prevent pressure to the penoscrotal angle. Clean the catheter insertion site with soap and water at least two times a day. Before transferring the patient to a wheelchair or bedside chair, empty the urine bag and clamp the tubing to prevent reflux of urine. Encourage a high fluid intake (2 to 3 L/day) unless contraindicated by the patient’s condition.
Bladder retraining should stimulate normal bladder function. For the patient with a spastic bladder, the object of the training is to increase the control over bladder function. Encourage the patient to attempt to void at specific times. Various methods of stimulating urination include applying manual pressure to the bladder (Crede’s maneuver), stimulating the skin of the abdomen or thighs to initiate bladder contraction, or stretching the anal sphincter with a gloved, lubricated finger. If the patient is successful, measure the voided urine and determine the residual volume by performing a temporary urinary catheterization. The goal is to increase the times between voidings and to have a concurrent decrease in residual urine amounts. Teach the patient to assess the need to void and to respond to the body’s response to a full bladder, as the usual urge to void may be absent. When the residual urine amounts are routinely less than 50 mL, catheterization is usually discontinued.
If bladder training is not feasible (this is more frequently experienced when the dysfunction is related to a flaccid bladder), intermittent straight catheterization (ISC) is necessary. Begin the catheterizations at specific times and measure the urine obtained. Institutions and agencies have varied policies on the maximum amount of urine that may be removed through catheterization at any one time. Self-catheterization may be taught to the patient when she or he is physically and cognitively able to learn the procedure. If this procedure is not possible, a family member may be taught the procedure for home care. Sterile technique is important in the hospital to prevent infection, although home catheterization may be accomplished with clean technique.
If the patient demonstrates signs and symptoms of autonomic dysreflexia, place the patient in semi-Fowler’s position, check for any kinking or other obstruction in the urinary catheter and tubing, and initiate steps to relieve bladder pressure. These interventions may include using the bladder retraining methods to stimulate evacuation or catheterizing the patient. The anus should be checked to ascertain if constipation is causing the problem, but perform fecal assessment or evacuation cautiously to prevent further stimulation that might result in increased autonomic dysreflexia. Monitor the vital signs every 5 minutes, and seek medical assistance if immediate interventions do not relieve the symptoms.
The patient’s psychosocial state is essential for health maintenance. Teaching may not be effective if there are other problems that the patient believes have a higher priority. The need for a family member to perform catheterization may be highly embarrassing for both the patient and the family. Because anxiety may cause the patient to have great difficulty in performing catheterization, a relaxed, private environment is necessary. Some institutions have patient support groups for people who have neurogenic bladders; if a support group is available, suggest to the patient and significant other that they might attend. If the patient has more than the normal amount of anxiety or has ineffective coping, refer the patient for counseling.
Nursing care plan discharge and home health care guidelines
The patient and significant others need to understand that, although they have achieved a bladder program in the hospital, their daily rhythm may be quite different at home. They need to be encouraged to adapt the pattern of bladder evacuation to the family schedule. Teach the patient the medication dosage, action, side effects, and route of all prescribed medications.
Discuss potential complications, particularly urinary tract infection, and encourage the patient to report signs of infection to the physician immediately. Teach the patient and significant others preventive strategies, such as keeping equipment clean, good hand-washing techniques, and adequate fluid intake to limit the risk of infection. Refer the patient to an appropriate source for catheterization supplies if appropriate, or refer the patient to social service for help in obtaining supplies. Discuss the potential for sexual activity with the patient; if possible, have a nurse of the same gender talk with the patient to answer questions and provide support.