Primary Nursing Diagnosis

Altered urinary elimination related to incontinence or retention secondary to trauma or CNS dysfunction

OUTCOMES. Urinary continence; Urinary elimination; Infection status; Knowledge: Disease process, Medication, Treatment regimen; Symptom control behavior

INTERVENTIONS. Urinary retention care; Fluid management; Fluid monitoring; Urinary catheterization; Urinary elimination management

H PLANNING AND IMPLEMENTATION Collaborative

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 non-surgical approaches to managing neurogenic bladder depend on independent nursing interventions such as the Crede method, Valsalva's maneuver, or intermittent catheterization (see below).

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

Pharmacologic Highlights

Medication or Drug Class

Dosage

Description

Rationale

Alpha-adrenerglc drugs

Varies with drug

Pseudoephedrine hydrochloride

Contracts bladder neck and thereby increases bladder outlet resistance

Antimuscarinic

(anticholinergic)

drugs

Varies with drug

Atropine; propantheline (ProBanthine); darifenacin (Enablex); Solifenacin succinate (VESIcare); dicyclomine hydrochloride (Bentyl)

Decrease spasticity and incontinence in spastic neu-rogenic bladder disorders

Other Drugs: Estrogen derivatives; estrogen increases tone of urethral muscle and enhances urethral support; antispasmodic drugs; tricyclic antidepressant drugs to increase norepinephrine and serotonin levels and also have a direct muscle relaxant effect on the urinary bladder.

666 Neurogenic Bladder pelvic catheterization, or other urinary diversion procedures. Some surgeons may recommend implantation of an artificial urinary sphincter if urinary incontinence continues after surgery.

Independent

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.

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