Nursing Care Plan for Urinary Incontinence
Assessment
Client Identity
Incontinence in general usually frequent or likely to occur in elderly (age above 65 years), especially in women, but do not rule out the possibility of elderly men are also at risk of experiencing.
a) History of the present illness
Include disorders associated with impaired perceived today. What is the frequency of incontinence, is there anything that precedes incontinence (stress, fear, laughter, movement), fluid intake, age / physical condition, the power of encouragement / flow of fluid with respect to a number of micturition. Is there any use of diuretics, feels the urge to urinate before going on incontinence, whether there is an inability.
b) The client's health history
Ask the client, if the client had experienced a similar illness earlier, history and records urinary elimination of the client, if ever happens trauma / injury genitourinary, renal surgery, urinary tract infections and is hospitalized.
c) Family health history
Ask if there are other family members who suffer from similar diseases with clients and whether there is a history of congenital or hereditary disease, congenital kidney disease / not innate.
Physical Examination
General conditions
Clients seem weak and vital signs of an increase due to the response of the occurrence of incontinence.
Systemic examination:
B1 (breathing)
Assess respiratory disturbance in the pattern of breath, cyanosis due to decreased oxygen supply. Assess chest expansion, is there any abnormalities in the percussion.
B2 (blood)
Increased blood pressure, usually the patient was confused and agitated.
B3 (brain)
Consciousness is usually fully conscious. Clients seem weak and vital signs of an increase due to the response of the occurrence of incontinence.
B4 (bladder):
Inspection: check the color, odor, amount of urine usually pungent odor due to the activities of microorganisms (bacteria) in the bladder and accompanied by a discharge of blood if any lesions in the bladder, supra pubic area enlarged lesions on the urethral meatus, many urinating and pain during urination indicates dysuria due of infection, whether the client previously catheterized.
Palpation: pain in supra pubic region / pelvis, such as a burning sensation when urinating on external urera / can also outside when urinating.
B5 (bowel)
Bowel, is there an increase or decrease, presence of abdominal tenderness, abnormalities percussion, palpation of the kidney abnormalities.
B6 (bone)
Examination of muscle strength and compare it with the other extremity, is there pain in the joints.
Laborat and Radiological Examination
a) Urinalysis
- Hematuria.
- Polyuria.
- Bacteriuria.
- IVP (intravenous pyelographi), to predict the location of the kidney and ureter.
- VCUG (Voiding Cystoufetherogram), examine the size, shape, and function VU, see obstruction (especially prostate obstruction), examines the PVR (Post Voiding Residual).
- Sterile.
- Growth was significantly (100,000 colonies / ml).
- Organisms.
Nursing Diagnosis for Urinary Incontinence
- Risk for infection related to incontinence, immobility in a long time.
- Risk for Impaired Skin Integrity related to constant irrigation by urine.
- Risk for Ineffective Management of Therapeutic Regimen related to insufficient knowledge about the causes of incontinence, containment procedures, recovery of bladder training program, signs and symptoms of complications, as well as community resources.
- Impaired social interaction related to the social pattern changes secondary to deficits self-care functions.