Impaired urinary elimination is a condition that affects a patient’s ability to effectively void urine, which can stem from various underlying causes ranging from physical obstructions to neurological conditions. This issue can significantly diminish a patient’s quality of life, leading to discomfort, embarrassment, and potential health complications if not properly addressed. As nurses, we play a critical role in assessing, understanding, and managing impaired urinary elimination through comprehensive care plans. This article delves into the nursing diagnosis of impaired urinary elimination, providing a detailed nursing care plan to guide effective interventions and improve patient outcomes.
Causes (Related to)
Impaired urinary elimination is not a disease itself but rather a symptom of an underlying issue. Identifying the root cause is crucial for effective management. Several factors can contribute to this condition:
- Sensory-Motor Impairment: Conditions affecting the nervous system, such as stroke, spinal cord injuries, or multiple sclerosis, can disrupt the signals between the brain and bladder, leading to impaired bladder control.
- Anatomical Abnormalities (Obstruction): Blockages in the urinary tract, such as an enlarged prostate (benign prostatic hyperplasia or BPH), urethral strictures, or tumors, can obstruct urine flow.
- Urinary Tract Infections (UTIs): Infections can cause inflammation and irritation of the bladder and urethra, leading to urgency, frequency, and pain during urination.
- Renal Diseases: Conditions affecting the kidneys, such as chronic kidney disease, can alter urine production and bladder function.
- Congenital Disorders: Birth defects affecting the urinary tract structure can lead to lifelong urinary elimination issues.
- Weakened Bladder Muscles: Aging, pregnancy, and childbirth can weaken the pelvic floor and bladder muscles, contributing to incontinence and incomplete bladder emptying.
- Medications: Certain medications, particularly those with anticholinergic effects (like some antihistamines, antidepressants, and antispasmodics), can interfere with bladder muscle contractions and urinary elimination.
- Neurological Conditions: Neurological disorders like Parkinson’s disease and dementia can affect bladder control and the ability to recognize the urge to urinate.
Signs and Symptoms (As evidenced by)
Recognizing the signs and symptoms of impaired urinary elimination is the first step towards accurate diagnosis and intervention. These symptoms can be categorized as subjective (what the patient reports) and objective (what the nurse observes or measures).
Subjective: (Patient reports)
- Urgency: A sudden, compelling need to urinate that is difficult to postpone.
- Hesitancy: Difficulty initiating urination, often with a delay before the urine stream starts.
- Dysuria: Painful or uncomfortable urination, often described as burning.
- Nocturia: Frequent urination at night, typically defined as waking up two or more times to void.
Objective: (Nurse assesses)
- Bladder Distention: A palpable swelling in the lower abdomen above the pubic bone, indicating urine retention in the bladder.
- Retention as detected through bladder scanning: Using a bladder scanner to measure the volume of urine remaining in the bladder after voiding (post-void residual or PVR). A high PVR volume indicates ineffective bladder emptying.
- Incontinence: Involuntary leakage of urine, which can manifest as urge incontinence (leakage associated with urgency), stress incontinence (leakage with coughing, sneezing, or physical exertion), or overflow incontinence (leakage due to bladder overfilling).
- Use of Catheterization: Current use of an indwelling catheter (Foley) or intermittent catheterization to manage urinary retention.
- Frequency: Voiding more often than normal, typically defined as more than eight times in 24 hours.
Expected Outcomes
Establishing clear and measurable expected outcomes is essential for guiding nursing care and evaluating its effectiveness. For patients with impaired urinary elimination, common goals include:
- Patient will verbalize techniques to prevent urinary infection and retention, demonstrating an understanding of self-care strategies.
- Patient will demonstrate how to properly self-catheterize or clean an indwelling catheter, ensuring competence in managing their urinary drainage system if applicable.
- Patient will achieve a normal elimination pattern, as evidenced by voiding at appropriate intervals without excessive frequency or urgency.
- Patient will verbalize dietary and lifestyle changes to incorporate to improve urinary elimination, such as adjusting fluid intake and avoiding bladder irritants.
Nursing Assessment
A thorough nursing assessment is the foundation of effective care planning. It involves gathering comprehensive data to understand the patient’s specific urinary elimination issues.
1. Identify causes of impaired urinary elimination. A detailed patient history is crucial to pinpoint potential underlying causes. Inquire about pre-existing conditions such as UTIs, cystitis, multiple sclerosis, paralysis, dementia, enlarged prostate, stroke, urologic surgeries, and chronic kidney disease, as these are frequently associated with urinary elimination problems.
2. Assess voiding pattern and symptoms. A detailed assessment of the patient’s voiding habits and symptoms provides critical diagnostic clues. Ask about specific symptoms: dribbling and incomplete emptying may suggest prostate issues; frequency and burning are typical of UTIs; back or flank pain can indicate kidney involvement. Encourage the patient to maintain a voiding diary to track patterns of urination, fluid intake, and episodes of incontinence over a period of 24-72 hours.
3. Monitor lab work and urinalysis. Laboratory tests are essential for identifying infections and assessing kidney function. A urinalysis and urine culture can confirm or rule out a UTI. Assess kidney function through blood tests (e.g., creatinine, BUN) to detect acute or chronic renal disease. For male patients, a prostate-specific antigen (PSA) blood test might be relevant to assess prostate inflammation or enlargement.
4. Review medications. Medication reconciliation is important, as many drugs can affect urinary elimination. Pay particular attention to medications with anticholinergic side effects, including antipsychotics, tricyclic antidepressants, antiparkinson drugs, antihistamines, and antispasmodics. Document all medications, dosages, and timing of administration.
5. Compare intake and output. Fluid balance monitoring is crucial. Compare the patient’s fluid intake (type and amount, including caffeine, water, soda, alcohol) with their urine output over 24 hours. Note the color, clarity, and concentration of urine (clear, amber, concentrated). This comparison helps assess hydration status and kidney function.
6. Assess for issues with catheterization. For patients using catheters, assess their catheter care practices. Observe patients performing self-catheterization to ensure proper technique and hygiene to prevent infection. For patients with indwelling catheters, evaluate the ongoing necessity of the catheter, as prolonged use increases infection risk.
7. Review diagnostic tests. Explore prior diagnostic findings. Urodynamic testing, cystoscopy, and imaging studies of the kidneys, ureters, and bladder (KUB X-ray, CT scan, ultrasound) can reveal structural abnormalities, diseases, or cancers contributing to urinary problems. Review reports from these tests for relevant information.
Nursing Interventions
Nursing interventions are designed to address the identified causes and symptoms of impaired urinary elimination, promoting bladder health and improving patient comfort and control.
1. Educate on bladder training. For patients with incontinence or overactive bladder (OAB), bladder training can help increase bladder capacity and control. Instruct patients to keep a voiding diary to record leakage episodes and voiding intervals. Based on this, establish a fixed voiding schedule, gradually increasing the intervals between bathroom visits by 15 minutes each week, aiming for 2-3 hour intervals. Encourage patients to adhere to the schedule, voiding at set times even without a strong urge, and to use urge suppression techniques (e.g., deep breathing, pelvic floor contractions) if urgency arises before the scheduled time.
2. Encourage water intake. Unless contraindicated by other health conditions (like heart failure or kidney disease), promote adequate daily fluid intake, typically 1500-2000 mL. Counterintuitively, limiting fluids can worsen urinary problems by concentrating urine and irritating the bladder. Proper hydration maintains renal function and helps flush out bacteria and waste.
3. Limit other fluids. Advise patients to reduce or avoid bladder irritants like coffee, caffeine, carbonated beverages, and alcohol. These substances can exacerbate bladder symptoms like frequency, urgency, and incontinence. Also, limit sugary drinks like soda and sweet tea, which can contribute to kidney stones and bladder irritation.
4. Educate on supplements. For patients with recurrent UTIs, discuss the potential benefits of cranberry supplements. While cranberry juice may be less effective and can irritate the bladder due to acidity, concentrated cranberry supplements have shown some promise in preventing (but not treating) UTIs by preventing bacteria from adhering to the urinary tract walls. However, emphasize that research is ongoing, and supplements are not a substitute for medical treatment of active infections.
5. Have the patient demonstrate catheterization techniques. For patients who self-catheterize or manage indwelling/suprapubic catheters, regular education and assessment of their technique are crucial to prevent infection. Observe return demonstrations of catheter care, ensuring they use sterile technique for intermittent catheterization, clean peri-urethral area daily with mild soap and water, and maintain the drainage bag of indwelling catheters below bladder level to prevent backflow and infection.
6. Use bladder scanning. In hospital settings, utilize bladder scanners to monitor for urinary retention, especially in post-operative patients or those with neurological conditions. This non-invasive ultrasound device quickly and accurately measures post-void residual (PVR) volume, helping to determine the need for interventions like catheterization. Perform PVR measurements after voiding to assess bladder emptying effectiveness.
7. Educate on proper hygiene. Educate female patients on hygiene practices to reduce UTI risk. Instruct them to wipe from front to back after voiding or defecation, void immediately after sexual intercourse, wear cotton underwear and loose-fitting clothing to promote airflow and reduce moisture, and change out of wet swimwear promptly.
8. Refer to urology. For persistent or complex urinary elimination problems, refer patients to a urologist. A urologist can conduct specialized diagnostic testing (e.g., urodynamics, cystoscopy) and offer advanced treatments for pain, incontinence, and retention, including medications, pelvic floor therapy, and surgical options.
9. Educate on pelvic floor exercises. Teach both men and women how to perform Kegel exercises to strengthen pelvic floor muscles, improving bladder support and sphincter control. Instruct patients to identify pelvic floor muscles (as if stopping urine midstream), contract and hold for 3-5 seconds, then relax, repeating 10 repetitions, three times daily. Emphasize consistency for best results.
10. Educate on medications. Explain prescribed medications for urinary elimination issues. For retention, alpha-blockers like Flomax (tamsulosin) relax bladder neck and prostate muscles to improve urine flow. For overactive bladder, anticholinergics like Ditropan (oxybutynin) reduce bladder spasms and urgency. Discuss medication purpose, dosage, administration, and potential side effects.
11. Use incontinence supplies. For patients experiencing incontinence, recommend appropriate incontinence products like pads or adult diapers to manage leakage and maintain dignity. Educate on proper use and skin care to prevent skin breakdown.
Nursing Care Plans
Nursing care plans provide a structured framework for organizing assessments, interventions, and expected outcomes for patients with impaired urinary elimination. Here are three example care plans addressing different underlying causes.
Care Plan #1
Diagnostic statement:
Impaired urinary elimination related to bladder irritation secondary to infection as evidenced by urgency and frequency.
Expected outcomes:
- Patient will demonstrate voiding frequency no more than every 2 hours, indicating improved bladder control and reduced irritation.
- Patient will report an absence of urinary urgency, reflecting resolution of infection-related bladder spasms.
- Patient will be free from urinary tract infection, as evidenced by negative urine culture and resolution of UTI symptoms.
Assessment:
1. Assess for predisposing factors of the patient’s UTI. Identify risk factors that increase UTI susceptibility. Inquire about a history of UTIs, urinary catheterization, sexual activity, STIs, pregnancy, genitourinary surgeries, or recent antibiotic use.
2. Monitor signs and symptoms of UTI. Regularly assess for UTI symptoms. Note reports of frequent urination, urgency, dysuria (burning), and changes in behavior or functional decline in older adults, which may be subtle UTI indicators.
3. Review laboratory findings.
- Urinalysis: Check for red blood cells (RBCs) or white blood cells (WBCs), indicating inflammation or infection.
- Bacteria in the urine: Evaluate bacterial counts; >105 CFU/mL typically confirms UTI.
- Urine culture and sensitivity: Review culture results to identify the specific bacteria and guide antibiotic selection based on sensitivity.
- White blood cell count: Monitor WBC count for leukocytosis, a systemic sign of infection.
Interventions:
1. Encourage the patient to increase oral fluid intake. Promote high fluid intake (2-3 liters/day) to flush bacteria from the urinary tract.
2. Instruct the patient to empty the bladder every 2 to 3 hours. Regular voiding prevents urine stasis and bacterial overgrowth.
3. Recommend taking cranberry, prune juice, or vitamin C 500 to 1000 mg/day. Discuss acidifying urine to inhibit bacterial growth. Suggest cranberry supplements or prune juice (though juice can irritate some bladders), or Vitamin C to lower urine pH.
4. Administer antibiotics as ordered. Administer prescribed antibiotics promptly and educate on completing the full course to eradicate infection.
5. Teach the following measures to women to decrease the incidence of UTIs:
- Urinate at appropriate intervals: Avoid delaying urination to prevent urine stasis.
- Drink plenty of water: Dilute urine and facilitate bacterial flushing.
- Wipe from front to back: Prevent fecal bacteria from reaching the urethra.
- Wear cotton underwear: Promote airflow and reduce perineal moisture.
- Avoid potentially irritating feminine products: Eliminate douches, sprays, and powders that can irritate the urethra.
- For sexually active women, advise:
- Void after intercourse: Flush out bacteria introduced during sex.
- Use lubricant during intercourse: Reduce vaginal trauma.
- Watch for vaginitis signs and treat promptly.
- Avoid diaphragms with spermicide: Spermicides can alter vaginal flora.
Care Plan #2
Diagnostic statement:
Impaired urinary elimination related to diminished bladder cues secondary to enlarged prostate as evidenced by large residual urine volumes.
Expected outcomes:
- Patient reports an urge to void, demonstrating improved bladder sensation and awareness.
- Patient empties the bladder more completely, as evidenced by voiding volume ≥ 300 mL and residual volume < 100 mL, indicating reduced retention.
Assessment:
1. Assess benign prostatic hyperplasia (BPH) symptom severity according to the American Urological Association Symptom Index (AUA-SI) for BPH. Use AUA-SI questionnaire to quantify symptom severity (urgency, frequency, weak stream, straining, nocturia, incomplete emptying).
2. Assess for use of medications that may worsen urgency. Identify medications that exacerbate BPH symptoms, such as cold/allergy meds (decongestants), muscle relaxants, and some antidepressants (anticholinergics).
3. Assess urinary elimination, noting obstructive and irritative symptoms. Document obstructive symptoms (hesitancy, weak stream, dribbling, straining) and irritative symptoms (frequency, urgency, nocturia) associated with prostate enlargement compressing the urethra.
4. Assess postvoid residual urine. Measure PVR volume using bladder scan or catheterization to quantify urinary retention.
5. Assess intake and output. Monitor I&O to evaluate bladder emptying effectiveness and fluid balance.
Interventions:
1. Advise the patient to void at least every 4 hours. Scheduled voiding helps prevent bladder overdistention and retention.
2. Encourage oral fluids for adequate hydration, but do not push fluids or overhydrate. Maintain hydration without excessive fluid intake that can worsen retention. Advise limiting fluids before bed and avoiding caffeine/alcohol.
3. Encourage the patient to take medications as prescribed. Educate about BPH medications: 5-alpha-reductase inhibitors (reduce prostate size), alpha-blockers (relax prostate/bladder neck), and phosphodiesterase inhibitors (for BPH and erectile dysfunction).
4. Encourage therapeutic lifestyle modifications. Recommend limiting evening fluids, reducing caffeine/alcohol, and double voiding (voiding, waiting a few minutes, then voiding again) before bed.
5. Encourage the patient to take antibiotics as prescribed. Administer antibiotics if UTI is present or for prophylaxis as ordered, given increased UTI risk with urinary stasis.
Care Plan #3
Diagnostic statement:
Impaired urinary elimination related to diuretic use as evidenced by nocturia and dribbling.
Expected outcomes:
- Patient will verbalize the absence of dysuria, nocturia, and urinary dribbling, indicating improved bladder control and reduced diuretic-related symptoms.
- Patient will demonstrate voiding frequency no more than every 2 hours during daytime hours, reflecting better management of diuretic effects.
Assessment:
1. Ask about urinary elimination. Elicit detailed urinary history: symptoms (incontinence, dribbling, frequency, urgency, dysuria, nocturia), pain, voiding patterns, aggravating/alleviating factors.
2. Discuss timing of medication use with the patient. Determine when diuretics are taken relative to nocturia. Discuss dose timing and potential for adjusting diuretic schedule with the physician.
3. Assess for other potential causes of impaired urinary elimination. Explore other contributing factors: UTI, interstitial cystitis, painful bladder syndrome, dehydration, surgery, neurological conditions (MS, Parkinson’s, stroke), cognitive dysfunction, prostate issues, pregnancy, pelvic trauma, medication side effects.
4. Review the medication regimen for any other drugs that can alter bladder or kidney function. Identify other medications impacting urinary function: ACE inhibitors, beta-blockers, anticholinergics, antihistamines, antiparkinsonian drugs, antidepressants, antipsychotics, sedatives, hypnotics, opioids, caffeine, alcohol.
Interventions:
1. Instruct the patient to take diuretics in the morning unless contraindicated. Morning dosing minimizes nocturia. Consult physician before altering diuretic schedule.
2. Instruct to keep a bladder log. Use a voiding diary to track symptoms, voiding frequency, timing, and fluid intake to monitor diuretic effects and bladder function.
3. As appropriate, assist with developing toileting routines. Implement timed voiding, bladder training, prompted voiding, or habit retraining, especially for managing diuretic-induced frequency and urgency.
4. Encourage fluid intake up to 1,500–2,000 mL/day as indicated, including cranberry juice. Maintain adequate hydration while considering diuretic effects. Cranberry juice may help prevent UTIs.
5. Emphasize the importance of keeping the perineal area clean and dry. Promote perineal hygiene to prevent skin breakdown from incontinence and reduce UTI risk.
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