U
Unilateral Neglect
Impairment in sensory and motor response, mental representation, and spatial attention of the body and the corresponding environment characterized by inattention to one side and overattention to the opposite side; left-side neglect is more severe and persistent than right-side neglect
Defining Characteristics
Appears unaware of positioning of neglected limb; difficulty remembering details of internally represented familiar scenes that are on the neglected side; displacement of sounds to the nonneglected side; distortion of drawing on the half of the page on the neglected side; failure to cancel lines on the half of the page on the neglected side; failure to eat food from portion of the plate on the neglected side; failure to dress neglected side; failure to groom neglected side; failure to move eyes, head, limbs, trunk in the neglected hemispace, despite being aware of a stimulus in that space; failure to notice people approaching from the neglected side; lack of safety precautions with regard to the neglected side; marked deviation of the eyes to the nonneglected side to stimuli and activities on that side; marked deviation of the head to the nonneglected side to stimuli and activities on that side; marked deviation of the trunk to the nonneglected side to stimuli and activities on that side; omission of drawing on the half of the page on the neglected side; perseveration of visual motor tasks on nonneglected side; substitution of letters to form alternative words that are similar to the original in length when reading; transfer of pain sensation to the nonneglected side; use of only vertical half of page when writing
Related Factors (r/t)
Brain injury from cerebrovascular problems; brain injury from neurological illness; brain injury from trauma; brain injury from tumor, hemianopsia
NOTE: Because the right hemisphere plays a role in focusing attention while the left hemisphere specializes in global attention, unilateral neglect is more common if neurological pathology occurs in the right hemisphere of the brain, which results in left-sided neglect.
Client Outcomes
Client Will (Specify Time Frame)
• Use techniques that can be used to minimize unilateral neglect
• Care for both sides of the body appropriately and keep affected side free from harm
• Return to the highest functioning level possible based on personal goals and abilities
Nursing Interventions
• Assess the client for signs of unilateral neglect (UN; e.g., not washing, shaving, or dressing one side of the body; sitting or lying inappropriately on affected arm or leg; failing to respond to environmental stimuli contralateral to the side of lesion; eating food on only one side of plate; or failing to look to one side of the body).
Collaborate with physician for referral to a rehabilitation team (including, but not limited to, rehabilitation clinical nurse specialist, physical medicine and rehabilitation physician, neuropsychologist, occupational therapist, physical therapist, and speech and language pathologist) for continued help in dealing with UN.
• Use the principles of rehabilitation to progressively increase the client’s ability to compensate for UN by using assistive devices, feedback, and support.
• Set up the environment so that essential activity is on the unaffected side:
Place the client’s personal items within view and on the unaffected side.
Position the bed so that client is approached from the unaffected side.
Monitor and assist the client to achieve adequate food and fluid intake.
• Implement fall prevention interventions.
• Position affected extremity in a safe and functional manner.
• Teach the client to be aware of the problem and modify behavior and environment.
Client/Family Teaching and Discharge Planning
• Engage discharge planning specialists for comprehensive assessment and planning early in the client’s stay.
• Encourage family participation in care and exercise.
• Explain pathology and symptoms of unilateral neglect to both the client and family.
• Teach the client how to scan regularly to check the position of body parts and to regularly turn head from side to side for safety when ambulating, using a wheelchair, or doing self-care tasks.
• Reinforce the client’s use of adaptive devices such as prisms prescribed by rehabilitation professionals.
Impaired Urinary Elimination
Related Factors
Anatomic obstruction; multiple causality; sensory motor impairment; urinary tract infection
Client Outcomes
Client Will (Specify Time Frame)
Nursing Interventions
• Question the client regarding the following:
Presence of bothersome symptoms such as incontinence, dribbling, frequency, urgency, dysuria, and nocturia
Presence of pain in the area of the bladder
The pattern of urination, and approximate amount
Possible aggravating and alleviating factors for urinary problems
• Ask the client to keep a bladder diary/bladder log.
• For interventions on urinary incontinence, refer to the following nursing diagnosis care plans as appropriate: Stress Incontinence, Urge urinary Incontinence, Reflex Incontinence, Overflow Incontinence, or Functional Incontinence.
Perform a focused physical assessment including inspecting the perineal skin integrity, percussion, and palpation of the lower abdomen looking for obvious bladder distention or an enlarged kidney.
Check for costovertebral tenderness.
Review results of urinalysis for the presence of urinary infection: WBCs, RBCs, bacteria, positive nitrites. If urinalysis results are not available, request a midstream specimen of urine (urine obtained during voiding, discarding the first and last portions) for a urinalysis.
If blood or protein is present in the urine, recognize that both hematuria and proteinuria are serious symptoms, and the client should be referred to a urologist to receive a workup to rule out pathology.
Consult the physician for a culture and sensitivity testing and antibiotic treatment in the individual with evidence of a symptomatic urinary tract infection.
Teach the client to recognize symptoms of UTI: dysuria that crescendos as the bladder nears complete evacuation; urgency to urinate followed by micturition of only a few drops; suprapubic aching discomfort; malaise; voiding frequency; sudden exacerbation of urinary incontinence with or without fever, chills, and flank pain.
Recognize that a cloudy or malodorous urine, in the absence of other lower urinary tract symptoms, may not indicate the presence of a urinary tract infection and that asymptomatic bacteriuria, in the elderly, does not justify a course of antibiotics.
Refer the individual with chronic lower urinary tract pain to a urologist or specialist in the management of pelvic pain.
Perform urinalysis in all elderly persons who experience a sudden change in urine elimination patterns such as new-onset incontinence, lower abdominal discomfort, acute confusion, or a fever of unclear origin.
• Encourage elderly women to drink at least 10 oz of cranberry juice daily, regularly consume one to two servings of fresh blueberries, or supplement the diet with cranberry concentrate capsules as ordered.
Refer the elderly woman with recurrent urinary tract infections to her physician for possible use of topical estrogen creams for treatment of atrophic vaginal mucosa from decreased hormonal stimulation, which can predispose to UTIs.
Recognize that UTIs in elderly men are typically associated with prostatic hyperplasia, or strictures of the urethra. Refer to a urologist.
Client/Family Teaching and Discharge Planning
• Teach the client/family methods to keep the urinary tract healthy. Refer to Client/Family Teaching in the care plan Readiness for enhanced Urinary Elimination.
• Teach the following measures to women to decrease the incidence of urinary tract infections:
Urinate at appropriate intervals. Do not ignore need to void, which can result in stasis of urine.
Drink plenty of liquids, especially water.
Wear panties with a cotton crotch.
Avoid potentially irritating feminine products.
Recommend that cranberry juice, cranberry tablets, or blueberries be used to prevent recurrent UTIs (see the geriatric interventions discussed previously).
• Teach the sexually active woman with recurrent urinary tract infections prevention measures including:
Void after intercourse to flush bacteria out of the urethra and bladder.
Use a lubricating agent as needed during intercourse to protect the vagina from trauma and decrease the incidence of vaginitis.
• Teach clients with spinal cord injury and neurogenic bladder dysfunction to consume cranberry extract tablets or cranberry juice on a daily basis.
• Teach all persons to recognize hematuria and to promptly seek care if this symptom occurs.
Readiness for enhanced Urinary Elimination
A pattern of urinary functions that is sufficient for meeting eliminatory needs and can be strengthened
Defining Characteristics
Amount of output is within normal limits; expresses willingness to enhance urinary elimination; fluid intake is adequate for daily needs; positions self for emptying of bladder; specific gravity is within normal limits; urine is odorless; urine is straw colored
Client Outcomes
Client Will (Specify Time Frame)
• Urinate every 3 to 4 hours while awake
• Remain free of undetected symptoms of a urinary tract infection or cancer of the kidney or bladder
• Drink fluids at a sufficient level to have straw-colored urine
Nursing Interventions
• Question the client regarding any bothersome urinary symptoms such as frequency, nocturia, urgency, dysuria, or retention of urine.
• Question the client regarding presence of incontinence. If incontinence is present, refer to the appropriate care plan: Stress urinary Incontinence, Urge urinary Incontinence, Functional urinary Incontinence, or Reflex urinary Incontinence.
• Question the client regarding history of UTIs. If she has had UTIs in the past, provide teaching for prevention as outlined in the care plan Impaired Urinary Elimination.
• Ask the client to complete a bladder diary of diurnal and nocturnal urine elimination patterns and patterns of urinary leakage.
Client/Family Teaching and Discharge Planning
• Teach the client general guidelines for health of the urinary system:
Ensure good hydration. Total daily fluid intake should be approximately 2.7 L per day for women, and 3.7 L per day for men
Recommend the client have a physical exam, a metabolic panel of laboratory tests, and a urinalysis done yearly.
Recommend the client not hold urine for long periods of time before emptying the bladder. It is normal to urinate every 3 to 4 hours.
Recommend that the client with frequency, urgency in the morning, or possible incontinence consider reducing or eliminating caffeine intake.
If the client has constipation at intervals, share measures to alleviate or prevent constipation, including adequate consumption of dietary fluids, dietary fiber, exercise, and regular bowel elimination patterns. See care plan for Constipation.
Advise to stop smoking because of the association with damage to the kidney and bladder, including chronic kidney disease, bladder cancer, urinary incontinence, and bothersome lower urinary tract symptoms in men.
Encourage the client to eat a healthy diet, avoiding processed meats, with sodium nitrate as a preservative, to decrease incidence of cancer of the bladder.
Urinary Retention
Defining Characteristics
Absence of urine output; bladder distention; dribbling; dysuria; frequent voiding; overflow incontinence; residual urine; sensation of bladder fullness; small voiding
Client Outcomes
Client Will (Specify Time Frame)
• Demonstrate consistent ability to urinate when desire to void is perceived
• Measured urinary residual volume of <200 to 250 mL
• Experience correction or relief from dysuria, nocturia, postvoid dribbling, and voiding frequently
Nursing Interventions
• Obtain a focused urinary history including questioning the client about episodes of acute urinary retention (complete inability to void) or chronic retention (documented elevated postvoid residual volumes), also symptoms such as dysuria, nocturia, postvoid dribbling, and voiding frequently.
• Question the client concerning specific risk factors for urinary retention including:
Metabolic disorders such as diabetes mellitus, chronic alcoholism, and related conditions associated with polyuria and peripheral polyneuropathies
Heavy-metal poisoning (lead, mercury) causing peripheral polyneuropathies
Advanced-stage human immunodeficiency virus (HIV)
Medications including antispasmodics/parasympatholytics, alpha-adrenergic agonists, antidepressants, sedatives, narcotics, psychotropic medications, illicit drugs
Recent surgery requiring general or spinal anesthesia
Vaginal delivery within the past 48 hours
Bowel elimination patterns, history of fecal impaction, encopresis
• Complete a pain assessment including pain intensity using a self-report pain tool, such as the 0-10 numerical pain rating scale. Also determine location, quality, onset/duration, intensity, aggravating and alleviating factors, and effects of pain on function and quality of life.
Perform a focused physical assessment including perineal skin integrity and inspection, percussion, and palpation of the lower abdomen looking for obvious bladder distention or an enlarged kidney.
Recognize that unrelieved obstruction of urine can result in renal damage and, if severe, renal failure. Urinary retention can be a medical emergency and should be reported to the primary provider as soon as possible.
Note results of laboratory tests including serum electrolytes, and BUN/creatinine, along with calcium, phosphate, magnesium, uric acid, and albumin.
Monitor for signs of dehydration, peripheral edema, elevating blood pressure, and heart failure.
• Ask the client to complete a bladder diary including patterns of urine elimination, urine loss (if present), nocturia, and volume and type of fluids consumed for a period of 3 to 7 days.
Consult with the physician concerning eliminating or altering medications suspected of producing or exacerbating urinary retention.
• Advise the male client with urinary retention related to BPH to avoid risk factors associated with acute urinary retention as follows:
Avoid over-the-counter cold remedies containing a decongestant (alpha-adrenergic agonist) or antihistamine such as diphenhydramine that has anticholinergic effects.
Avoid taking over-the-counter dietary medications (frequently contain alpha-adrenergic agonists).
Discuss voiding problems with a health care provider before beginning new prescription medications.
After prolonged exposure to cool weather, warm the body before attempting to urinate.
Avoid overfilling the bladder by regular urination patterns and refrain from excessive intake of alcohol.
• Advise the client who is unable to void specific strategies to manage this potential medical emergency as follows:
Attempt urination in complete privacy.
Place the feet solidly on the floor.
If unable to void using these strategies, take a warm sitz bath or shower and void (if possible) while still in the tub or shower.
Drink a warm cup of caffeinated coffee or tea to stimulate the bladder, which may promote voiding.
If unable to void within 6 hours or if bladder distention is producing significant pain, seek urgent or emergency care.
Perform sterile (in acute care) or clean intermittent catheterization at home as ordered for clients with urinary retention.
• For more information about intermittent catheterization, see care plan Reflex urinary Incontinence.
• Insert an indwelling catheter only as ordered for the individual with urinary retention who is not a suitable candidate for intermittent catheterization, recognizing that the catheter can be a significant cause of harm to the client through development of a catheter-associated urinary tract infection (CAUTI), or through genitourinary trauma when the catheter is pulled on.
Utilize a silver alloy-coated urinary catheter if possible.
• Advise clients with indwelling catheters that bacteria in the urine is an almost universal finding after the catheter has remained in place for more than 1 week and that only symptomatic infections warrant treatment.
• Use the following strategies to reduce the risk for CAUTI whenever feasible:
Insert the indwelling catheter with sterile technique, only when insertion is indicated.
Remove the indwelling catheter as soon as possible; acute care facilities should institute a policy for regular review of the necessity of an indwelling catheter.
Insert a silver alloy catheter for short-term indwelling catheterization (<14 days).
Maintain a closed drainage system whenever feasible.
Maintain unobstructed urine flow, avoiding kinks in the tubing, and keeping the collecting bag below the level of the bladder at all times.
Regularly cleanse the urethral meatus with a gentle cleanser to remove apparent soiling.
Change the long-term catheter every 4 weeks; more frequent catheter changes should be reserved for clients who experience catheter encrustation and blockage.
Place clients managed in an acute or long-term care facility with a CAUTI in a separate room from others managed by an indwelling catheter to reduce the risk of spreading the offending pathogen.
Educate staff about the risks of CAUTI and specific strategies to reduce this risk.
Postoperative Urinary Retention
• Recognize that urinary retention can follow many kinds of surgery and is commonly associated with use of anesthesia and opioid pain medications.
Remove the indwelling urethral catheter at midnight in the hospitalized postoperative client to reduce the risk of acute urinary retention.
Perform a bladder scan of the bladder before considering inserting a catheter to determine postvoid residual volume following surgery.
• Aggressively assess elderly clients, particularly those with dribbling urinary incontinence, UTI, and related conditions for urinary retention.
• Assess elderly clients for impaction when urinary retention is documented or suspected.
• Monitor elderly male clients for retention related to prostatic enlargement (BPH or prostate cancer).
Client/Family Teaching and Discharge Planning
• Teach the client with mild to moderate obstructive symptoms to double void by urinating, resting in the bathroom for 3 to 5 minutes, and then trying again to urinate.
• Teach the client with urinary retention and infrequent voiding to urinate by the clock.
• Teach the client with an indwelling catheter to assess the tube for patency, maintain the drainage system below the level of the symphysis pubis, and routinely cleanse the bedside bag as directed.
• Teach the client with an indwelling catheter or undergoing intermittent catheterization the symptoms of a significant urinary infection, including hematuria, acute-onset incontinence, dysuria, flank pain, or fever.