I

Client Will (Specify Time Frame)

• Assess and support family strengths of commitment, appreciation, and affection toward each other, positive communication, time together, a sense of spiritual well-being, and the ability to cope with stress and crisis. EBN: Nurses may be more successful in contributing to improved health care outcomes when they engage their clients more in their own health and wellness and encourage them to build on their strengths (Rotegård, Ruland, & Fagermoen, 2011).

 Assess for suicidal ideation and make appropriate referral for clients with schizophrenia and bipolar disorder. EB: Clients with schizophrenia have an 8.5-fold greater risk of suicide than the general population (Kasckow, Felmet, & Zisook, 2011). EB: Bipolar disorder is associated with a high risk for suicidal acts (Oquendo et al, 2011).

 Assess women with mood disorders for reproductive and metabolic disorders and make appropriate referrals for treatment. EB: Women with mood disorders, especially bipolar disorder (BD), have been shown to have high rates of reproductive and metabolic dysfunction. Many of the psychotropic medications used in the treatment of BD are associated with weight gain, insulin resistance, and dyslipidemia. These metabolic side effects further compound the neuroendocrine system dysregulation in women with BD (Kenna, Jiang, & Rasgon, 2009).

 Assess and make appropriate referrals for clients with obesity and depression. EB: The marked alteration of body weight (and appetite) is one of the most frequent of the nine symptoms of major depressive episodes, and these symptoms occur during recurrent episodes of depression with a remarkably high consequence (Rihmer et al, 2008).

 Assess lymphocyte counts and make appropriate referrals for clients with bulimia nervosa (BN), who may present with psychopathological variables associated with psychological instability (depression, hostility, impulsivity, self-defeating personality traits, and borderline personality symptoms). EB: In this study of clients with BN and psychological instability, hostility was negatively correlated with the number of helper T-cells (CD4+). These results support the idea that hostility, as an expression of disturbed interpersonal relationships, could play a role as a modulator of immune activity in clients with BN (Vaz-Leal et al, 2007).

• Use empathetic communication and encourage the client and family to verbalize fears, express emotions, and set goals. Be present for clients physically or by telephone. CEB: This study of social support by telephone demonstrated that therapeutic presence facilitated outcomes that included problem solving, adaptive behavior change, and diminished distress (Finfgeld-Connett, 2005). Presence involves knowing the uniqueness of the person, listening intently, and mutually defining changes in the provision of confident caring (Caldwell et al, 2005).

• Empower the client to set realistic goals and to engage in problem solving. EBN: This case study assesses how individuals who have had a stroke use continued problem solving and goal setting. It demonstrates that health care workers need to empower individuals to make decisions about their care so the individuals can achieve life satisfaction (Western, 2007).

• Encourage expression of positive thoughts and emotions. EB: Negative emotions contribute to disturbed personal identity and poor coping (Wegge, Schuh, & Dick, 2012).

• Encourage the client to use spiritual coping mechanisms such as faith and prayer. CEB: Prayer is a powerful way of coping and is practiced by all Western religions and several Eastern traditions (Mohr, 2006). In this study spirituality and religiosity helped clients with schizophrenia cope with their illness (Mohr et al, 2010).

• Help the clients with serious and chronic conditions such as depression, cancer diagnosis, and chemotherapy treatment to maintain social support networks or assist in building new ones. EBN: Health care providers can encourage social support networks to help clients cope with the negative aspects of cancer and chemotherapy (Mattioli, Repinski, & Chappy, 2008).

 Refer women facing diagnostic and curative breast cancer surgery for psychosocial support. EB: Psychological distress is a central experience for women facing diagnostic and curative breast cancer surgery. Psychosocial interventions are recommended for both groups (Schnur et al, 2008).

 Refer for cognitive-behavioral therapy (CBT). EBN: CBT approaches in adult acute inpatient settings can help clients to cope by facilitating client-caregiver engagement and improving hope-inspiring interventions to reduce distress (Forsyth et al, 2008).

 Refer clients with borderline personality disorder (BPD) and dual-diagnosed BPD and substance-dependent female clients for dialectical behavior therapy (DBT) and psychoanalytical-orientated day-hospital therapy. EB: Dialectical behavior therapy included treatment components such as prioritizing an hierarchy of target behaviors, telephone coaching, group skills training, behavioral skill training, contingency management, cognitive modification, exposure to emotional cues, reflection, empathy, and acceptance. DBT seemed to be helpful on a wide range of outcomes, such as admission to hospital or incarceration in prison. Psychoanalytic-orientated day-hospital therapy also seemed to decrease admission and use of prescribed medication and to increase social improvement and social adjustment (Binks et al, 2006). Two randomized controlled trials in 59 clients, female only, with BPD and substance abuse provided the best evidence-based data for the effectiveness of DBT. For dual-focus schema therapy, a single randomized controlled trial indicated a curative effect in a small group of clients with personality disorder and substance dependence (Kienast & Foerster, 2008).

• Refer to the care plans for Readiness for enhanced Communication and Readiness for enhanced Spiritual Well-Being.

Client/Caregiver Will (Specify Time Frame)

Psychosocial

Physiological

Client will (Specify Time Frame)

 Refer to mental health treatment for cognitive-behavioral therapy (CBT). CBT has been beneficial in treating substance use disorders and impulse control disorders (ICDs) (Dempsey, Dyehouse, & Schafer, 2011; O’Sullivan, Evans, & Lees, 2009).

• Implement motivational interviewing for clients with impulse control disorders. Motivational interviewing includes treatment components that involve providing feedback to the client concerning current impulsive behaviors and the likely longer-term effects associated with such behavior (Farmer & Golden, 2009).

• Teach client mindfulness meditation techniques. Mindfulness meditation includes observing experiences in the present moment, describing those experiences without judgments or evaluations, and participating fully in one’s current context. Mindfulness mediation is used to assist the individual to develop an attentional focus on the present that is useful in controlling impulsive behavior (Farmer & Golden, 2009).

• Refer to self-help groups such as Gambler’s Anonymous or Overeaters Anonymous as needed. Methods of psychological and psychosocial management related to specific symptomatology are effective strategies for care of impulse control disorders (Dell’Osso et al, 2008; Gallagher, 2010; Greener, 2011).

• Remove positive reinforcements associated with excessive behavior. Altering reactivity to immediate environmental cues or circumstances is a contingency management approach effective for impulse control disorders (Farmer & Golden, 2009).

• Assist the client to recognize patterns and cues of impulsive behavior. The first step in gaining insight into behaviors is to recognize the causes so long-term therapeutic strategies for stimulus and impulse control can be developed (Dell’Osso et al, 2008).

• Teach clients to utilize urge surfing techniques when impulses are triggered. A core skill associated with urge surfing is the ability to observe within oneself the rise and fall of urges and to “surf” or stay with these urges without acting on them. Urge surfing is a behavioral skill used to facilitate tolerance of urgent action impulses without acting on them (Farmer & Golden, 2009).

• Implement cue elimination procedures as a stimulus control technique. Cue elimination is a stimulus control technique in which cues that signal the availability of rewards for problematic behavior are removed (Farmer & Golden, 2009).

Client Will (Specify Time Frame)

• Take a history and perform a physical assessment focusing on bothersome lower urinary tract symptoms, cognitive status, functional status (particularly physical mobility and dexterity), frequency and severity of leakage episodes, alleviating and aggravating factors, and reversible or modifiable causes of urinary incontinence. EB: The types and causes of urinary incontinence, severity, and any related factors will direct the treatment of urinary incontinence (Vaughan et al, 2011). EBN: The mnemonic TOILETING (Thin, dry urethral and vaginal epithelium, Obstruction from constipation or stool impaction, Infection, Limited mobility, Emotional challenges such as depression, Therapeutic medications, Endocrine disorders, and Delirium) may be used to assess for transient urinary incontinence; toileting assistance or other interventions directed at the underlying cause may be utilized to reverse this incontinence (Dowling-Castronovo & Specht, 2009).

 Consult with the client and family, the client’s physician/provider, and other health care professionals concerning treatment of incontinence in the elderly client undergoing detailed geriatric evaluation.

• Teach the client, the client’s care providers, or the family to complete a bladder diary; each 24-hour period is subdivided into 1- to 2-hour periods and includes number of urinations occurring in the toilet, actual episodes of incontinence and amount of urine leaked, reasons for episode of incontinence, type and amount of liquid intake, number of bowel movements, and incontinence pads or other products used. EBN: A bladder diary provides a detailed account of patterns and factors related to incontinence and captures bladder activity more accurately than questionnaires (Dowling-Castronovo & Specht, 2009).

 Consult with the physician/provider about discontinuing antimuscarinic medications in clients receiving cholinesterase reuptake inhibitors for Alzheimer’s-type dementia. Retrospective clinical evidence suggests that clients receiving both cholinesterase reuptake inhibitors and antimuscarinics experience more rapid functional decline than do clients taking cholinesterase reuptake inhibitors alone (Sink et al, 2008).

• Assess the client in an acute care or rehabilitation facility for risk factors for functional incontinence. EB: Risk factors include dizziness, falls, impaired vision and hearing, amputation, decline in physical function secondary to stroke or other comorbid medical conditions that contribute to frailty such as diabetes, arthritis, COPD, heart failure, venous insufficiency, Parkinson’s disease, dementia, normal-pressure hydrocephalus, and depression (DuBeau et al, 2010).

• Assess the client for coexisting or premorbid urinary incontinence. A history of previous incidences of urinary incontinence predicts a higher risk for persistent urinary leakage and poorer functional outcomes.

• Assess clients, regardless of frailty or age, residing in a long-term care facility for UI. CEB: UI significantly impairs quality of life, even among frail, and functionally or cognitively impaired elders residing in a nursing home (DuBeau, Simon, & Morris, 2006).

• Assess the home, acute care, or long-term care environment for accessibility to toileting facilities, paying particular attention to the following:

EBN: For older adults who may have limited mobility, the nurse must assess environmental barriers that may restrict access to the toilet (Dowling-Castronovo & Specht, 2009).

• Assess the client for mobility, including the ability to rise from chair and bed, transfer to the toilet, and ambulate, and the need for physical assistive devices such as a cane, walker, or wheelchair. Functional continence requires the ability to gain access to a toilet facility, either independently or with the assistance of devices to increase mobility.

 Assess the client for dexterity, including the ability to manipulate buttons, hooks, snaps, loop and pile closures, and zippers as needed to remove clothing. Consult a physical or occupational therapist to promote optimal toilet access as indicated. Functional continence requires the ability to remove clothing to urinate; individuals with compromised visual acuity, dexterity, and mobility will need specific interventions to assist with these challenges to continence (Abrams, Andersson, & Birder, 2010).

• Assess the functional and cognitive status using a tool such as the Mini Mental Status Examination for the elderly client with functional incontinence. Functional continence requires sufficient mental acuity to respond to sensory input from a filling urinary bladder by locating the toilet, moving to it, and emptying the bladder. EB: In a cohort of nondisabled elderly people, those with severe white matter changes (dementia) were found to have more urinary urge incontinence (Poggesi et al, 2008).

• Remove environmental barriers to toileting in the acute care, long-term care, or home setting. Assist the client in removing loose rugs from the floor and improving lighting in hallways and bathrooms. Functional continence requires ready access to a bathroom.

• Provide an appropriate, safe urinary receptacle such as a three-in-one commode, female or male hand-held urinal, no-spill urinal, or containment device when toileting access is limited by immobility or environmental barriers. These receptacles provide access to a substitute toilet and enhance the potential for functional continence.

 Help the client with limited mobility to obtain evaluation by a physical therapist and to obtain assistive devices as indicated; assist the client in selecting shoes with a nonskid sole to maximize traction when arising from a chair and transferring to the toilet. A physical therapist is an important member of the interdisciplinary team needed to manage urinary incontinence in the client with functional impairments.

• Assist the client in altering the wardrobe to maximize toileting access. Select loose-fitting clothing with stretch waistbands rather than buttoned or zippered waist; minimize buttons, snaps, and multilayered clothing; and substitute a loop-and-pile closure or other easily loosened systems such as Velcro for buttons, hooks, and zippers in existing clothing. Clients with impaired dexterity or weakness may benefit from clothing that has been modified or is without buttons and zippers (Cohen, 2008).

• Begin a prompted voiding program or patterned urge response toileting program for the elderly client in the home or a long-term care facility who has functional incontinence and dementia:

EBN: Based on a systematic review of 14 clinical trials, prompted voiding has been shown to improve daytime incontinence and the percentage of appropriate toileting episodes in clients with dementia and functional incontinence (Fink et al, 2008).

Client Will (Specify Time Frame)

• Ask the client to complete a bladder diary/log to determine the pattern of urine elimination, any incontinence episodes, and current bladder management program. An electronic voiding diary may be kept whenever feasible. EB: Use of a bladder diary may reduce client discrepancies in recall and is a valuable tool for assessment of the bladder (Bright, Drake, & Abrams, 2011).

 Consult with the physician concerning current bladder function and the potential of the bladder to produce hydronephrosis, vesicoureteral reflux, febrile urinary tract infection, or compromised renal function. If the client has urinary retention, that reality directs the method of urine management to prevent damage to the renal system from unrelieved obstruction (Dorsher & McIntosh, 2012).

 Consult with the physician and physical therapist concerning the neuromuscular ability to perform bladder management. The type of neurological disorder, and also the level of neurological impairment and the ability to use the hands effectively, determines the method of urine management in reflex incontinence.

• Inspect the perineal and perigenital skin for signs of incontinence-associated dermatitis and pressure ulcers. Urinary and fecal incontinence associated with neurogenic bladder and bowel dysfunction in the client with a paralyzing disorder increases the risk of incontinence-associated dermatitis and pressure ulceration, particularly when a urine containment device such as an adult containment brief or condom catheter is used (Gray et al, 2007). EBN: A research study on use of products to protect skin found that an evidence-based practice of using a product that cleansed and also protected the skin resulted in improved client care (Foxley & Baadjies, 2009).

 In consultation with the rehabilitation team, counsel the client and family concerning the merits and potential risks associated with each possible bladder management program, including spontaneous voiding, intermittent self-catheterization, reflex voiding with condom catheter containment, and indwelling suprapubic catheterization. All bladder management programs carry some risk of urinary incontinence or serious urinary system complications (Newman & Willson, 2011). EB: Spontaneous voiding and intermittent catheterization carry greater risk of urine loss than condom catheter containment or indwelling catheter. A study demonstrated a high rate of infection with indwelling catheter use as compared to other modes of management, and increased rates of complications (Singh et al, 2011). EB: Some studies support the use of suprapubic catheters for long-term treatment of reflex incontinence in spinal cord injury clients (Böthig, Hirschfeld, & Thietje, 2012; Colli & Lloyd, 2011).

Intermittent Self-Catheterization

Condom Catheter

Client Will (Specify Time Frame)

• Take a focused history addressing risk factors for stress incontinence: pregnancy, parity, large babies, forceps or breech deliveries, obesity, chronic cough, physical activity, previous urinary tract or gynecological surgery, medications such as diuretics, lithium, adrenergic blockers, and diabetes and smoking. The most common types of urinary incontinence in adult women are stress, urge, or a combination of both (Bradley et al, 2010). Many women are reluctant to initiate a discussion regarding incontinence; identifying women at risk is essential for effective screening (Keyock & Newman, 2011). EB: Stress incontinence is caused by activities that create an increase in intra-abdominal pressure, such as coughing, sneezing, lifting, jumping, stair climbing, or exercise, whereas urge incontinence is caused by detrusor overactivity; individuals may have mixed incontinence, and it is important to determine which symptom is the most troublesome to the individual in order to treat that first (McKertich, 2008).

• Ask about onset and duration of urinary leakage and related lower urinary tract symptoms, including voiding frequency (day/night), urgency, severity (small, moderate, large amounts) of urinary leakage, and factors provoking urine loss (diuretics, bladder irritants, alcohol), focusing on the differential diagnosis of stress, urge or mixed stress and urge urinary symptoms. Consider using a symptom questionnaire that elicits relevant lower urinary tract symptoms and provides differentiation between stress and urge incontinence symptoms. EB: Stress urinary incontinence is more common in young and middle-aged women (Strothers & Friedman, 2011), is characterized by incontinence in small amounts (drops, spurts), no nocturia or incontinence at night, and incontinence without sensation of urine loss. With urge incontinence, the client has a strong, uncontrolled urge prior to losing a moderate to large volume of urine, and experiences frequency and nocturia (Nygaard, 2010). Clients with mixed urinary incontinence should be treated first for the predominant problem with conservative management for 8 to 12 weeks (Abrams et al, 2010).

• To assess for mixed urinary incontinence (a combination of stress and urge incontinence), ask the following questions: (1) Can you delay urination for a 2-hour movie or car ride? (2) How often do you arise at night to urinate? (3) When you have the urge to urinate, can you reach the toilet without leaking? CEB: These three questions have been found to reliably evaluate the presence of urge incontinence (Gray et al, 2001).

• Assess the severity of incontinence as well as impact on the individual’s lifestyle; inquire about incontinence pad use and change in daily, social, or recreational activities, as well as emotional impact. EB: Incontinence is distressing and may contribute to decreased quality of life (Lasserre et al, 2009); psychological well-being, social interactions and activities, and sexual and interpersonal relationships may be negatively affected (Bartoli, Aguzzi, & Tarricone, 2010).

• Inspect the perineal skin for evidence of incontinence-associated dermatitis, including inflammation, vesicles in skin exposed to urinary leakage, and especially skin folds or denudation of the skin, particularly when incontinence is managed by absorptive pads or containment briefs. Ammonia produced from the breakdown of urea in urine causes an increase in skin pH, which increases the permeability of the skin; excess moisture and damage to the acid mantle further increases permeability and vulnerability to bacterial and fungal infections (Langemo et al, 2011). EBN: Skin exposed to urine or stool will become bright red, and the surface may appear shiny due to serous exudate; inflamed areas of individuals with darker skin tones may be a duller red or hypopigmented when compared to adjacent skin. Inspect the skin for a maculopapular red rash typical of candidiasis (Gray, 2010).

• Attempt to reproduce the sign of stress urinary incontinence by asking the client to perform the Valsalva maneuver or to cough while observing the urethral meatus for urine loss. CEB: Urine loss, the sign of stress urinary incontinence, can be reproduced by asking the client to perform provocative maneuvers (cough or perform Valsalva maneuver) during physical examination. Mild to moderate stress urinary incontinence can be reproduced by asking the client to perform these maneuvers while standing and holding a paper towel in front of the urethral meatus. Urine loss volumes of less than 1 mL can be detected using this technique (Neumann et al, 2004).

 Perform a focused physical assessment, including bladder palpation after voiding to check for retention, inspection of the perineal skin, vaginal examination to determine hypoestrogenic changes in the mucosa (may contribute to urge incontinence), and reproduction of stress urinary incontinence with the cough test. Also, constipation should be assessed. A thorough abdominal and pelvic examination must be completed to accurately assess incontinence; assess for neurological conditions or heart failure (cause of nocturia) as warranted (McKertich, 2008). Imaging studies or urodynamic studies are indicated when stress urinary incontinence is complicated by significant pelvic organ prolapse or neurological disorders, or when conservative management is ineffective (Gray and David, 2005).

• Determine the client’s current use of containment devices; evaluate the devices for their ability to adequately contain urine loss, protect clothing, and control odor. Assist the client in identifying containment devices specifically designed to contain urinary leakage. EB: Recommend the client buy incontinent products specifically designed to contain urine, utilizing hydrogel to contain fluid, and not use sanitary pads. Using a combination of products may be more effective and economic (Fader, Cottenden, & Getliffe, 2008). Recognize that incontinence products may present a significant financial burden to clients, with approximately 70% of expenditures attributed to containment devices, laundry, and dry cleaning expenses, which are often paid out of pocket (Chong, Khan, & Anger, 2011).

• Teach the client to complete a bladder diary by recording voiding frequency, the frequency and degree of urinary incontinence episodes, their association with urgency (a sudden and strong desire to urinate that is difficult to defer), fluid intake, and pad usage over a 3- to 7-day period. An electronic voiding diary may be kept whenever feasible. EB: Use of a bladder diary may reduce patient discrepancies in recall and is a valuable tool for assessment; short (24-hour) duration of the bladder diary may yield inadequate data, and excessive diary duration reduces compliance (Bright, Drake, & Abrams, 2011).

 With the client and in close consultation with the physician, review treatment options, including behavioral management; drug therapy; use of a pessary, vaginal device, or urethral insert; and surgery. Outline their potential benefits, efficacy, and side effects. Behavioral and nonsurgical treatments may improve symptoms in up to 70% of women; referral to a specialist may be indicated if conservative treatment is ineffective (Waetjen, 2008).

• Begin a pelvic floor muscle training program. Pelvic floor muscle training is effective in the treatment of stress, urge, and mixed urinary incontinence; participation in a supervised program for at least 3 months may yield improved outcomes (Dumoulin & Hay-Smith, 2010).

• Teach the client undergoing pelvic floor muscle training to identify, contract, and relax the pelvic floor muscles without contracting distal muscle groups (e.g., abdominal muscles or gluteus muscles) using verbal feedback based on vaginal or anal palpation, biofeedback, or electrical stimulation, utilizing the assistance of an incontinence specialist or physician as necessary. To find the proper muscles, the client may be instructed to think about trying to control the urge to pass gas; women will feel a lifting sensation in the vaginal area and a pulling in of the rectum (Keyock & Newman, 2011). EB: When learning to control pelvic floor muscles, clients may recruit other muscles such as the rectus abdominis or gluteal muscles, which may be counterproductive; these muscles must be relaxed to avoid increasing pressure on the bladder or pelvic floor (Burgio, 2009).

• Incorporate principles of exercise physiology into a pelvic muscle training program using the following strategies:

EB: Pelvic floor muscle training strengthens urethral sphincter tone (Chong, Khan, & Anger, 2011) and is the first-line conservative approach for all types of incontinence and in particular for stress and mixed urinary incontinence; women report an improvement in symptoms and quality of life (Dumoulin & Hay-Smith, 2010).

• Teach the principles of bladder training to women with stress urinary incontinence:

Bladder training reduces the frequency and severity of urinary leakage in women with stress incontinence, urge incontinence, and mixed incontinence. The results of bladder training in ambulatory, community-dwelling women is comparable to that achieved through pelvic floor muscle training (Milne, 2008).

• Teach the client to self-administer duloxetine and imipramine as ordered, and to monitor for adverse side effects. There are no prescriptive drugs approved for use in stress urinary incontinence in the United States. Nevertheless, several agents are sometimes prescribed to highly selected clients with stress urinary incontinence. They include duloxetine (Schagen van Leeuwen et al, 2008) and imipramine (Andersson, 2000).

• Teach the client to self-administer topical (vaginal) estrogens as directed, and to monitor for adverse side effects. Postmenopausal estrogen deprivation may contribute to stress incontinence; topical vaginal medications reverse urogenital atrophic changes and may relieve lower urinary tract dysfunction (Ewies & Alfhaily, 2010).

 Refer the female client with stress urinary incontinence and pelvic organ prolapse who wishes to employ a pessary to manage stress incontinence to a nurse specialist or gynecologist with expertise in the placement and maintenance of these devices. Placement of an appropriately sized dish pessary resolved stress urinary incontinence in 60% of a group of 95 women (Noblett, McKinney, & Lane, 2008).

• Discuss potentially reversible or controllable risk factors, such as weight loss, with the client with stress incontinence and assist the client to formulate a strategy to eliminate these conditions. Although research supports a strong familial predisposition to stress incontinence among women, other risk factors, including obesity, smoking (Mishra et al, 2008), and chronic coughing from smoking, are reversible. EB: Being obese may increase pressure on the pelvic floor and doubles the risk for incontinence (Strothers & Friedman, 2011).

• Provide information about support resources such as the National Association for Continence, The Simon Foundation for Continence, or the Total Control Program.

 Refer the client with persistent stress incontinence to a continence service, physician, or nurse who specializes in the management of this condition.

Client Will (Specify Time Frame)

• Take a focused history addressing onset, diurnal frequency (voiding more than once every 2 hours while awake), nocturia, severity of symptoms, alleviating and aggravating factors, medical history, and current management. A focused history helps determine the cause of urinary incontinence and guides its subsequent management. EB: Incontinence is distressing and may contribute to decreased quality of life (Lassere et al, 2009); psychological well-being, social interactions and activities, and sexual and interpersonal relationships may be negatively affected (Bartoli, Aguzzi, & Tarricone, 2010).

• Inquire about urgency, daytime frequency, nocturia, involuntary leakage, leakage accompanied by or preceded by urgency, and whether the amount of urine loss is a moderate or large volume. Urge urinary incontinence occurs when involuntary leakage of urine is accompanied by or immediately preceded by urgency; overactive bladder is characterized by the storage symptoms of urgency with or without incontinence and is usually accompanied by frequency and nocturia (Abrams et al, 2010). EB: A history of urine loss associated with urgency is the most helpful criterion for diagnosing urge urinary incontinence (Holroyd-Leduc et al, 2008). CEB: To assess for urge urinary incontinence, ask the following questions: (1) Can you delay urination for a 2-hour movie or car ride? (2) How often do you arise at night to urinate? (3) When you have the urge to urinate, can you reach the toilet without leaking? These three questions have been found to reliably evaluate the presence of urge incontinence (Gray et al, 2001).

 In close consultation with a physician or advanced practice nurse, consider administering a symptom questionnaire that elicits relevant lower urinary tract symptoms and differentiates stress and urge incontinence symptoms. EBN: The Urogenital Distress Inventory, short form (UDI-6) is a reliable and valid tool for identifying types of urinary incontinence (Dowling-Castronovo, 2008).

• Assess the severity of incontinence as well as the impact on the individual’s lifestyle; inquire about incontinence pad use and change in daily, social, or recreational activities, as well as emotional impact. EB: Incontinence is distressing and may contribute to decreased quality of life, especially for women with mixed incontinence (Lassere et al, 2009).

 Perform a focused physical assessment, including bladder palpation after voiding to check for retention; bladder scanning for postvoid residual; inspection of the perineal skin; vaginal examination to determine hypoestrogenic changes in the mucosa (may contribute to urge incontinence); pelvic examination to determine the presence, location, and severity of vaginal wall prolapse; and reproduction of stress urinary incontinence with the cough test. Anal tone and constipation should be assessed. A thorough abdominal and pelvic examination must be completed to accurately assess incontinence; assess for neurological conditions or heart failure (cause of nocturia) as warranted (McKertich, 2008).

• Inspect the perineal and perianal skin for evidence of incontinence-associated dermatitis, including inflammation, vesicles in skin exposed to urinary leakage, and especially skin folds or denudation of the skin, particularly when incontinence is managed by absorptive pads or containment briefs. Ammonia produced from the breakdown of urea in urine causes an increase in skin pH, which increases the permeability of the skin; excess moisture and damage to the acid mantle further increases permeability and vulnerability to bacterial and fungal infections (Langemo et al, 2011). EBN: Skin exposed to urine or stool will become bright red and the surface may appear shiny due to serous exudate; inflamed areas of individuals with darker skin tones may be a duller red or hypopigmented when compared to adjacent skin. Inspect the skin for a maculopapular red rash typical of candidiasis (Gray, 2010).

• Teach the client to complete a bladder diary by recording voiding frequency, the frequency and degree of urinary incontinence episodes and their association with urgency (a sudden and strong desire to urinate that is difficult to defer) or other circumstances surrounding the episode, fluid intake, and pad usage over a 3- to 7-day period. An electronic bladder diary may be kept whenever feasible. In addition to these parameters, the client may be asked to record voided volume and fluid intake. A bladder diary provides an important supplement to the oral history; research reveals that clients tend to overestimate voiding frequency when asked to recall voiding behavior (Stav, Dwyer, & Rosamilia, 2009). Bladder diaries can also be used during the course of treatment, to track efficacy of interventions as well as heighten the client’s awareness of precipitating factors for incontinence (Burgio, 2009).

 Review all medications the client is receiving, paying particular attention to sedatives, opioid analgesics, diuretics, antidepressants, psychotropic drugs, and cholinergics. Consult the physician or nurse practitioner about altering or eliminating these medications if they are suspected of affecting incontinence. EB: All medications should be reviewed to determine whether they are contributing to incontinence (Abrams et al, 2010).

• Assess the client for urinary retention (see the care plan for Urinary retention).

• Assess the client for functional limitations (environmental barriers, limited mobility or dexterity, impaired cognitive function; refer to the care plan for Functional urinary Incontinence). EBN: Du Moulin et al (2008) analyzed a group of 2866 clients receiving home care and found that functional impairment (poor mobility) was associated with an increased likelihood of urinary incontinence.

 Consult the physician concerning diabetic management or pharmacotherapy for urinary tract infection when indicated. In specific cases, urgency and an increased risk of urge incontinence may be related to bacteriuria or urinary tract infection (Rodhe et al, 2008) or polyuria from undiagnosed or poorly managed diabetes mellitus.

 Assess for signs and symptoms of atrophic vaginal changes in the perimenopausal or postmenopausal woman, including vaginal dryness, tenderness to touch, mucosal dryness, friability, and discomfort with gentle palpation. Specifically query the woman with atrophic vaginitis concerning associated lower urinary tract symptoms (usually voiding frequency, urgency, and dysuria). Refer the woman with atrophic vaginal changes and bothersome lower urinary tract symptoms to a gynecologist, urologist, or women’s health nurse practitioner for further evaluation and management. EB: Vaginal topical estrogens may reduce urge incontinence, prevent urogenital atrophy, and prevent recurrent urinary tract infections (Hillard, 2010).

• Teach the principles of bladder training to women with urge urinary incontinence.

 With the assistance of an incontinence specialist or physician, teach the client undergoing pelvic floor muscle training to identify, contract, and relax the pelvic floor muscles without contracting distal muscle groups (e.g., abdominal muscles and gluteal muscles). Instruct the client that the pelvic floor muscles are the same ones used to hold gas in the rectum. To locate them, instruct the client to slow down or stop the urine stream when almost finished voiding. Teach them that when they contract the pelvic floor muscles, the client will not see or feel any movement on the outside of their body. Teach the client that these muscles may not be very strong; begin with contracting them 10 times, holding each contraction for 3 seconds and resting for 3 seconds. Gradually work up to holding the contraction for 6 to 10 seconds, then resting for 6 to 10 seconds. Exercise in sets of 10 at first, doing at least 30 to 50 a day. If the client seems to have difficulty isolating these muscles, request a physical therapist or incontinence specialist to use vaginal or anal palpation, biofeedback, or electrical stimulation to assist with feedback. EBN: Educational interventions can assist motivated clients to decrease the incidence of urge incontinence; follow-up from clinicians is essential (Wyman, Burgio, & Newman, 2009). EB: When learning to control pelvic floor muscles, clients may recruit other muscles such as the rectus abdominis or gluteal muscles, which may be counterproductive; these muscles must be relaxed to avoid increasing pressure on the bladder or pelvic floor. Active pelvic floor contraction effects a more complete subsequent relation; detrusor contraction is achieved through pelvic floor muscle relaxation (Burgio, 2009).

• Review with the client the types of beverages consumed, focusing on the intake of caffeine, which is associated with a transient effect on lower urinary tract symptoms. Advise all clients to reduce or eliminate intake of caffeinated beverages or over-the-counter medications of dietary aids containing caffeine. Identify and counsel the client to eliminate other bladder irritants that may exacerbate incontinence, such as smoking, carbonated beverages, citrus, sugar substitutes, and tomato products. EB: Caffeine is a diuretic, is a bladder irritant, increases detrusor pressure, and is a risk factor for detrusor instability; reducing caffeine may decrease both stress and urge incontinence. Decrease caffeine gradually to avoid caffeine withdrawal. Carbonated beverages, citrus fruits, sugar substitutes, and tomato products may be bladder irritants (Burgio, 2009). Chemicals from smoking are bladder irritants (Wyman, Burgio, & Newman, 2009).

• Review with the client the volume of fluids consumed; fluids may be reduced to alleviate urinary frequency, especially in the evening after 6 pm or 3 to 4 hours before bedtime to reduce nocturia. Be aware that adequate fluid intake is essential; six 8-oz glasses per 24 hours, 1500 mL, or 30 mL/kg body weight is recommended. EB: The type and amount of fluid intake is associated with frequency and urge urinary incontinence (Segal, Saks, & Arya, 2011). EBN: Excessive fluid intake may exacerbate incontinence; fluid restriction may cause an increase in urine concentration, which may cause bladder mucosa irritation which promotes urgency, frequency, and urinary tract infection (Wyman, Burgio, & Newman, 2009).

• Teach the client methods to avoid constipation such as increasing dietary fiber, moderately increasing fluid intake, exercising, and establishing a routine defecation schedule. EBN: Women with severe constipation demonstrate changes in pelvic floor neurological function; alleviation of constipation may significantly improve frequency and urgency in older clients (Wyman, Burgio, & Newman, 2009).

• Instruct in techniques of urge suppression. When a strong or precipitous urge to urinate is perceived, teach the client to avoid running to the toilet. Instead, she or he should pause, sit down, relax the entire body, and perform repeated, rapid pelvic muscle contractions until the urge is relieved. Teach the client to utilize distraction: count backwards from 100 by sevens, recite a poem, write a letter, balance a checkbook, do handwork such as knitting, take five deep breaths, focusing on breathing. Relief is followed by micturition within 5 to 15 minutes, using nonhurried movements when locating a toilet and voiding. EB: Urge suppression skills are essential in helping clients to learn a new way of responding to the sense of urgency. Rushing to the toilet increases physical pressure on the bladder, enhances the sensation of fullness, exposes the client to visual cues that can trigger incontinence, and exacerbates urgency (Burgio, 2009).

• Teach the client to use urge suppression strategies on waking during the night. If the urge subsides, the client should be encouraged to go back to sleep. If after a minute or two it does not, clients should be instructed to get up to void to avoid sleep interruption. EB: Behavioral training for urge incontinence can reduce nocturia (Burgio, 2009).

• Teach the client to interrupt or slow the urinary stream during voiding once a day. EB: This exercise provides practice for clients with urge incontinence in occluding the urethra and interrupting detrusor contraction; do not recommend this technique for clients experiencing voiding dysfunction because repeated interruption of the urinary stream may lead to incomplete bladder emptying (Burgio, 2009).

 Teach the client to self-administer antimuscarinic (anticholinergic) drugs as directed. Teach dosage and administration of the medication and the importance of combining pharmacotherapy with scheduled voiding, adequate fluid intake, restriction of bladder irritants, and urge suppression techniques. Antimuscarinic drugs increase bladder capacity, reduce the frequency of incontinence episodes, and diminish voiding frequency. However, they do not cure bladder dysfunction or reduce the time between perception of a strong urge and onset of an overactive detrusor contraction. Approximately two thirds of clients treated with antimuscarinic medication discontinue use within 3 to 4 months; the efficacy of pharmacotherapy for urge incontinence is enhanced when combined with behavioral interventions (Burgio et al, 2010).

• Assist the client in selecting, obtaining, and applying a containment device for urine loss as indicated.

• Provide the client with information about incontinence support groups such as the National Association for Continence and the Simon Foundation for Continence. A helpful website titled Total Control (http://www.totalcontrolprogram.com/Pelvic+Health/Bladder+Health) can be accessed to give support and information to women with incontinence. Knowledge contributes to effective self-management; women with incontinence often do not seek help from others and prefer to self-manage their incontinence (Holroyd-Leduc et al, 2011).