Nursing diagnosis: impaired Urinary Elimination related to Disruption in bladder innervation, Bladder atony, Fecal impaction
Possibly evidenced by
Bladder distention; incontinence or overflow, retention
Urinary tract infections (UTIs)
Bladder, kidney stone formation
Desired Outcomes/Evaluation Criteria—Client Will
Verbalize understanding of condition.
Maintain balanced intake and output (I&O), with clear, odor-free urine; free of bladder distention or urinary leakage.
Verbalize or demonstrate behaviors and techniques to prevent retention and urinary infection.
Nursing intervention with rationale:
1. Assess voiding pattern, including frequency and amount. Compare urine output with fluid intake. Note specific gravity.
Rationale: Voiding pattern identifies characteristics of bladder function, including effectiveness of bladder emptying, renal function, and fluid balance. Note: Urinary complications are a major cause of mortality. Multiple complications can occur when normal innervation to the bladder and urinary sphincter is impaired by urinary incontinence, UTI, upper urinary tract distress, urinary calculi, AD, and bladder cancer (Fonte & Moore, 2008).
2. Palpate for bladder distention and observe for overflow.
Rationale: Bladder dysfunction is variable but may include loss of bladder contraction and inability to relax urinary sphincter, resulting in urine retention and reflux incontinence. Note: Bladder distention can precipitate AD.
3. Encourage fluid intake of 1,500 to 2,000 mL/day, including acid ash juices such as cranberry.
Rationale: Adequate fluid intake helps maintain renal function and reduces risk of infection by decreasing ability of bacteria to adhere to bladder wall (Lynch, 2004; Santillo & Lowe, 2007) and prevents formation of urinary stones. Note: Fluid may be restricted for a period during initiation of intermittent catheterization.
4. Begin bladder retraining per protocol when appropriate, with fluids between certain hours, digital stimulation of trigger area, contraction of abdominal muscles, and so forth.
Rationale: Timing and type of bladder program depends on type of injury—upper or lower neuron involvement. Note: Bladder expression using the Credé maneuver (pushing on the abdomen to forcefully express urine) is included in some programs in an attempt to promote continence and ensure adequate bladder evacuation. Research suggests this maneuver raises intravesical pressures against a closed bladder outlet, raising the risk of vesicoureteral reflux, hernia, rectogenital prolapse, and hemorrhoids (Rigby, 2005).
5. Observe for changes in urine characteristics—cloudy, bloody, foul odor, and so forth. Test urine with dipstick, as indicated.
Rationale: Changes in urine characteristics may indicate UTI and increased risk of sepsis. Multistrip dipsticks can provide a quick determination of pH, nitrite, and leukocyte esterase that suggest presence of infection or urinary disease. Note: Presence of bacteria in urine is not uncommon if client has indwelling catheter or performs intermittent catheterization. If bacteria are present, the client must be assessed for other signs of developing UTI, and medications may be indicated (Rigby, 2005).
6. Cleanse perineal area and keep dry. Provide catheter care, as appropriate.
Rationale: Perineal care decreases risk of skin irritation, breakdown, and development of ascending infection.
7. Monitor blood urea nitrogen (BUN), creatinine, white blood cell (WBC) count, and urinalysis (UA).
Rationale: These laboratory tests reflect renal function and identify complications.
8. Administer vitamin C or urinary antiseptics, such as methenamine mandelate (Mandelamine), as indicated.
Rationale: These medications maintain acidic environment and prevent bacterial growth.
9. Refer for further evaluation for bladder and bowel stimulation.
Rationale: 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.
10. Keep bladder empty by means of indwelling catheter initially. Determine post-void residuals then consider intermittent catheterization program, as appropriate.
Rationale: Bladder scans are useful in determining post-void residuals. During the acute phase, an indwelling catheter is used to prevent urinary retention and to monitor urinary output.
Intermittent catheterization may be implemented to reduce complications associated with long-term use of indwelling catheters. A suprapubic catheter may also be inserted for long-term management.