U
Unilateral Neglect
NANDA-I
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 (Jepson, Despain & Keller, 2008).
NOC (Nursing Outcomes Classification)
Body Image, Body Positioning: Self-Initiated, Mobility, Self-Care: Activities of Daily Living (ADLs)
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• 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). Many tests for UN exist, but there is no consensus about which is the most valid. Joint assessments of UN that include both clinical observation and precise testing perform better than either used alone (Jepson, Despain, & Keller, 2008; Ting et al, 2011). EB: There is no difference in gender and UN in a sample of 155 women and 157 men with acute stroke (Kleinman et al, 2008). EB: UN was identified in 70 of 71 clients using NIHSS.
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. EB: There is some evidence that rehabilitation for unilateral spatial neglect using tools such as visual scanning and prism adaptation improves performance, but its effect on disability is not clear. Further studies are needed (Ting et al, 2011).
• Use the principles of rehabilitation to progressively increase the client’s ability to compensate for UN by using assistive devices, feedback, and support. EB: Studies demonstrate that recovery from UN generally occurs in first 4 weeks after stroke with much more gradual recovery after that (Osawa & Maeshima, 2009).
• 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.
Helps in focusing attention and aids in maintenance of safety.
• Implement fall prevention interventions. Clients with right hemisphere brain damage are twice as likely to fall as those with left hemisphere damage (Jepson, Despain, & Keller, 2008).
• Position affected extremity in a safe and functional manner. EB: A study found that clients with UN had higher rates of shoulder-hand complications than those without UN (Wee & Hopman, 2008). EB: Clients with neglect had significantly lower FIM (functional independence measure) motor scores than those with aphasia (Gialanella & Ferlucci, 2010).
• Teach the client to be aware of the problem and modify behavior and environment. EB: Awareness of the environment decreases risk of injury. There is some evidence that use of scanning techniques may decrease visual neglect (Ting et al, 2011).
Home Care:• Many of the previously listed interventions may be adapted for use in the home care setting.
• Position bed at home so that client gets out of bed on unaffected side. Positioning the bed so that the client gets out on the unaffected side can increase safety.
Client/Family Teaching and Discharge Planning:
• Engage discharge planning specialists for comprehensive assessment and planning early in the client’s stay. EB: A study demonstrated that clients with UN have longer length of stay and less likelihood of discharge to home than subjects without UN (Cumming et al, 2009).
• Encourage family participation in care and exercise. EB: UN improved in clients who participated in exercise training with their family members (Osawa & Maeshima, 2009).
• 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 (Shiraishi et al, 2008).
References
Cumming, T.B., et al. Hemispatial neglect and rehabilitation in acute stroke. Arch Phys Med Rehabil. 2009;90(11):1931–1936.
Gialanella, B., Ferlucci, C. Functional outcome after stroke in patients with aphasia and neglect: assessment by the Motor and Cognitive Functional Independence Measure Instrument. Cerebrovasc Dis. 2010;30(5):440–447.
Jepson, R., Despain, K., Keller, D.C. Unilateral neglect: assessment in nursing practice. J Neurosci Nurs. 2008;40(3):142–149.
Kleinman, J.T., et al. Gender differences in unilateral spatial neglect within 24 hours of ischemic stroke. Brain Cogn. 2008;68:49–52.
Osawa, A., Maeshima, S. Family participation can improve unilateral spatial neglect in patients with acute right hemispheric stroke. Eur Neurol. 2009;63:170–175.
Shiraishi, H., et al. Long-term effects of prism adaptation on chronic neglect after stroke. NeuroRehabilitation. 2008;23(2):137–151.
Ting, D.S.J., et al. Visual neglect following stroke: current concepts and future Focus. Surv Ophthalmol. 2011;56(2):114–134.
Wee, J.Y.M., Hopman, W.M. Comparing consequences of right and left unilateral neglect in a stroke rehabilitation population. Am J Phys Med Rehabil. 2008;87(11):910–920.
Impaired Urinary Elimination
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• 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. EB: Use of a bladder diary may reduce client 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).
• 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. A palpable kidney or bladder provides direct evidence of a dilated urinary collection system (Policastro et al, 2011). If signs of urinary obstruction are present, refer to a urologist. Unrelieved obstruction of urine can result in renal damage, and if severe, renal failure (Policastro et al, 2011). Refer to the nursing care plan for Urinary Retention if retention is present.
Check for costovertebral tenderness. Costovertebral tenderness is seen with pyelonephritis and kidney stones (Gupta & Trautner, 2011).
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 (Norrby, 2011).
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.
Urinary Tract Infection
Consult the physician for a culture and sensitivity testing and antibiotic treatment in the individual with evidence of a symptomatic urinary tract infection. UTI is a transient, reversible condition that is usually associated with urgency or urge urinary incontinence (French et al, 2009; Norrby, 2011). Eradication of UTI will alleviate or reverse symptoms of suprapubic pressure and discomfort, urgency, daytime voiding frequency, and dysuria (French et al, 2009; Norrby, 2011).
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. There are a variety of typical and unexpected symptoms in women with a history of recurring UTI (French et al, 2009).
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. Asymptomatic bacteriuria may be associated with cloudy or malodorous urine, but these signs alone do not justify antimicrobial therapy when balanced against the potential adverse effects of treatment, including adverse side effects of the various antibiotics and encouragement of colonization of the urine with antibiotic-resistant bacterial strains (Ariathianto, 2011; Norrby, 2011).
Refer the individual with chronic lower urinary tract pain to a urologist or specialist in the management of pelvic pain. Bladder pain and storage symptoms, in the absence of an acute urinary infection, may indicate the presence of interstitial cystitis, a chronic condition requiring ongoing treatment (Interstitial Cystitis Association, 2011).
Geriatric: 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. Elderly persons often experience atypical symptoms with a UTI or pyelonephritis (Nazarko, 2009).
• 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. EBN: A systematic literature review reveals that consumption of 400 mg of cranberry tablets, 8 to 10 oz of cranberry juice, or an equivalent portion of foods containing whole cranberries or blueberries exerts a bacteriostatic effect on Escherichia coli, the most common pathogen associated with urinary infection among community-dwelling adult women (Masson et al, 2009).
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 (Buhr, Genao, & White, 2011; Norrby, 2011).
Recognize that UTIs in elderly men are typically associated with prostatic hyperplasia, or strictures of the urethra. Refer to a urologist (Norrby, 2011).
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. Drinking water helps dilute the urine and ensures more frequent urination, allowing bacteria to be flushed from the urinary tract before an infection can begin. Note: Some references no longer recommend increased fluid intake (Norrby, 2011).
Wipe from front to back. This helps prevent bacteria in the anal region from spreading to the vagina and urethra.
Wear panties with a cotton crotch. This allows air to circulate in the area and decreases moisture in the area, which predisposes to infection.
Avoid potentially irritating feminine products. Using deodorant sprays, bubble baths, or other feminine products, such as douches and powders, in the genital area can irritate the urethra. There are multiple commonsense measures that can be utilized to decrease the incidence of urinary tract infections (Gupta & Trautner, 2011; Mayo Clinic, 2012; Nazarko, 2009).
Recommend that cranberry juice, cranberry tablets, or blueberries be used to prevent recurrent UTIs (see the geriatric interventions discussed previously). EB: There is some evidence that cranberry juice may decrease the number of symptomatic UTIs over a 12-month period, especially for women with recurrent UTIs (Jepson & Craig, 2008). An in vitro study found that cranberry juice blocked bacterial adhesion and biofilm formation on the bladder (Shmuely et al, 2012). A study of college-aged women who drank cranberry juice twice daily did not find a decreased incidence of UTI at 6 months (Barbosa-Cesnik et al, 2011).
• 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.
Sexually active women have the highest incidence of urinary tract infections (Norrby, 2011). The vagina and periurethral area can become colonized with organisms from the intestinal flora, such as E. coli, and increase the risk of urinary tract infections (Gupta & Trautner, 2011).
• Teach clients with spinal cord injury and neurogenic bladder dysfunction to consume cranberry extract tablets or cranberry juice on a daily basis. Limited evidence suggests that regular consumption of cranberry extract tablets experience fewer UTIs than clients who do not routinely consume cranberry extract tablets (Hess et al, 2008).
• Teach all persons to recognize hematuria and to promptly seek care if this symptom occurs.
References
Ariathianto, Y. Asymptomatic bacteriuria—prevalence in the elderly population. Aust Fam Physician. 2001;40(10):805–809.
Barbosa-Cesnik, C., et al. Cranberry juice fails to prevent recurrent urinary tract infection: results from a randomized placebo-controlled trial. Clin Infect Dis. 2011;52(1):23–30.
Bright, E., Drake, M.J., Abrams, P. Urinary diaries: evidence for the development and validation of diary content, format, and duration. Neurourol Urodynam. 2011;30(3):348–352.
Buhr, G.T., Genao, L., White, H.I. Urinary tract infections in long-term care residents. Clin Geriatr Med. 2011;27(2):229–239.
French, L., et al. Urinary problems in women. Prim Care. 2009;36(1):53–71. [viii].
Gupta, K., Trautner, B. Urinary tract infections, pyelonephritis, and prostatitis. In Longo D.L., et al, eds.: Harrison’s principles of internal medicine, ed 18, New York: McGraw-Hill, 2011.
Hess, M.J., et al. Evaluation of cranberry tablets for the prevention of urinary tract infections in spinal cord injured patients with neurogenic bladder. Spinal Cord. 2008;46(9):622–626.
Interstitial Cystitis Association. Pain and IC. Retrieved May 14, 2012, from http://www.ichelp.org/Page.aspx?pid=821.
Jepson, R.G., Craig, J.C., Cranberries for preventing urinary tract infections. Cochrane Database Syst Rev 2008;(1):CD001321.
Masson, P., et al. Meta-analyses in prevention and treatment of urinary tract infections. Infect Dis Clin North Am. 2009;23(2):355–385.
Mayo Clinic, Prevention of urinary tract infections, 2012 Retrieved May 2, 2012, from http://www.mayoclinic.com/health/urinary-tract-infection/DS00286/DSECTION=prevention
Nazarko, L. Urinary tract infection: diagnosis, treatment and prevention. Br J Nurs. 2009;18(19):1170–1174.
Norrby, S.R. Approach to the patient with urinary tract infection. In Goldman L., Schafer A., eds.: Goldman’s Cecil medicine, ed 24, St Louis: Saunders/Elsevier, 2011.
Policastro, M., et al, Urinary obstruction. 2012 Medscape Reference. Retrieved April 18, 2012, from http://emedicine.medscape.com/article/778456-overview
Shmuely, H., et al. Cranberry components for the therapy of infectious disease. Curr Opin Biotechnol. 2012;23(2):148–152.
Readiness for enhanced Urinary Elimination
NANDA-I
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• 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. EB: A study demonstrated that women overestimated daytime urinary frequency from recall. Use of a bladder diary results in increased accuracy of reporting of bladder symptoms (Stay, Dwyer, & Rosamilia, 2009).
Pediatric:• Encourage children and adolescents to maintain normal weight because obesity has been related to cancers of the urinary tract. EB: A large study found an increase in cancer of the bladder, ureter, and renal pelvis in adolescents who were obese at the age of 17 and developed cancer years later (Leiba et al, 2012). Refer to care plan Imbalanced Nutrition: more than body requirements.
• 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 (usually taken in 500-mg doses with each meal). EBN: Systematic literature review reveals that consumption of 400 mg of cranberry tablets, 8 to 10 oz of cranberry juice, or an equivalent portion of foods containing whole cranberries or blueberries exerts a bacteriostatic effect on Escherichia coli, the most common pathogen associated with urinary infection among community-dwelling adult women (Masson et al, 2009).
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 (Newman & Willson, 2011). Adequate fluid helps wash out bacteria from the urethra to prevent UTIs, helps prevent kidney stones, and potentially protects the client from development of cancer of the bladder from exposure to carcinogens concentrated in the urine (Newman & Willson, 2011).
Recommend the client have a physical exam, a metabolic panel of laboratory tests, and a urinalysis done yearly. A urinalysis includes tests for red blood cells and white blood cells, which can help identify cancer of the bladder and infection in the urinary tract, respectively. The urinalysis also includes testing for proteinuria, which can be found with damage to the kidney. The metabolic panel includes tests of blood urea nitrogen and serum creatinine, levels of which will be elevated if the client has early kidney damage (Lin & Denker, 2011).
Recommend that the client not hold urine for long periods of time before emptying the bladder. It is normal to urinate every 3 to 4 hours. Stasis of urine in the bladder leads to an increased chance of a urinary tract infection and may predispose to stone formation (Seifter, 2011). Note: Nurses frequently are busy with clients and forget or ignore the urge to urinate. This can predispose nurses to urinary tract infections.
Recommend that the client with frequency, urgency in the morning, or possible incontinence consider reducing or eliminating caffeine intake. Caffeine is a known irritant of the urinary tract and can cause incontinence symptoms (Wyman, 2008).
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 Constipation. Constipation predisposes the individual to urinary retention, and it increases the risk of urinary infection.
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. Smoking is a known risk factor for chronic kidney disease (Rezonzew et al, 2012). Smoking may increase the severity and risk of urinary incontinence, and it is clearly linked with an increased risk for bladder cancer (Lodovici & Bigagli, 2009).
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. EB: A study demonstrated that people who ate more processed meats, had an increased risk of developing cancer of the bladder (Wu et al, 2012).
References
Leiba, A., et al, Overweight in adolescence is related to increased risk of future urothelial cancer 2012 Apr 18. doi:10.1038/oby.2012.83. [[Epub ahead of print]].
Lin, J., Denker, B. Azotemia and urinary abnormalities. In Longo D.L., et al, eds.: Harrison’s principles of internal medicine, ed 18, New York: McGraw-Hill, 2011.
Lodovici, M., Bigagli, E. Biomarkers of induced active and passive smoking damage. Int J Environ Res Public Health. 2009;6(3):874–888.
Masson, P., et al. Meta-analyses in prevention and treatment of urinary tract infections. Infect Dis Clin North Am. 2009;23(2):355–385.
Newman, D., Willson, M. Review of intermittent catheterization and current best practices. Urol Nurs. 2011;31(1):12–48.
Rezonzew, G., et al. Nicotine exposure and the progression of chronic kidney disease: role of the alpha7-nicotinic acetylcholine receptor. Am J Physiol Renal Physiol. 2012;303(2):F304–F312.
Seifter, J. Urinary tract obstruction. In Longo D.L., et al, eds.: Harrison’s principles of internal medicine, ed 18, New York: McGraw-Hill, 2011.
Stay, K., Dwyer, P.L., Rosamilia, A. Women overestimate daytime urinary frequency: the importance of the bladder diary. J Urol. 2009;181(5):2176–2180.
Wu, J.W., et al. Dietary intake of meat, fruits, vegetables, and selective micronutrients and risk of bladder cancer in the New England region of the United States. Br J Cancer. 2012;106(11):1891–1898.
Wyman, J. Urinary stress incontinence. In: Ackley B., et al, eds. Evidence-based nursing care guidelines: medical-surgical interventions. Philadelphia: Mosby, 2008.
Urinary Retention
NANDA-I
NOC (Nursing Outcomes Classification)
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• 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. A history of difficulty voiding, pain, infection, or decreased urine volume is common in clients with urinary obstruction (Seifter, 2012).
• 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
Urinary retention is related to multiple factors affecting either detrusor contraction strength or urethral resistance to urinary outflow (Feliciano et al, 2008; Ismail & Emery, 2008; Policastro et al, 2011).
• 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. Acute onset of obstruction with inability to void is associated with significant pain; partial obstruction causes minimal pain, and this may delay diagnosis (Policastro et al, 2011). Bladder distention is associated with pain overlying the bladder (Seifter, 2012).
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. A palpable kidney or bladder provides direct evidence of a dilated urinary collection system (Policastro et al, 2011).
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. As urine backs up in the urinary tract, the pressure increases inside the ureters, which results in pressure on the nephrons, damaging the nephrons, and decreasing glomerular blood flow (Policastro et al, 2011).
Note results of laboratory tests including serum electrolytes, and BUN/creatinine, along with calcium, phosphate, magnesium, uric acid, and albumin. Serum electrolytes (sodium, potassium, chloride, bicarbonate, BUN, creatinine) as well as calcium, phosphate, magnesium, uric acid, and albumin should be measured. Elevations of BUN and creatinine and changes in electrolytes may be caused by renal failure secondary to obstruction (Policastro et al, 2011).
Monitor for signs of dehydration, peripheral edema, elevating blood pressure, and heart failure. The kidney can develop concentrating defects associated with partial obstruction of urine flow, resulting in symptoms that indicate renal insufficiency (Policastro et al, 2011).
• 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. EB: A study demonstrated that women overestimated daytime urinary frequency from recall. Use of a bladder diary results in increased accuracy of reporting of bladder symptoms (Stav, Dwyer, & Rosamilia, 2009).
Consult with the physician concerning eliminating or altering medications suspected of producing or exacerbating urinary retention. Observational studies suggest that medications may play a role in approximately10% of all cases of urinary retention. The most commonly implicated drug classes include antipsychotics, antidepressants, anticholinergic respiratory agents, opioid analgesics, alpha-adrenergic agonists, benzodiazepines, nonsteroidal antiinflammatory drugs, antimuscarinics, and calcium channel blockers (Verhamme et al, 2008).
• 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.
These modifiable factors predispose the client to acute urinary retention by overdistending the bladder and decreasing muscle contraction (Mayo Clinic, 2011).
• 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. Attempting urination in complete privacy and placing the feet solidly on the floor help relax the pelvic muscles and may encourage voiding. Warm water also stimulates the bladder and may produce voiding; the cooling experienced by leaving the tub or shower may again inhibit the bladder.
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. An indwelling catheter provides continuous drainage of urine; however, the risks of serious urinary complications with prolonged use are significant. EB: One study found that the risk of genitourinary trauma was as common as symptomatic urinary tract infection (Leuck et al, 2012).
Utilize a silver alloy-coated urinary catheter if possible. EBN: A systematic review found that use of the silver alloy catheter was associated with reduced catheter-associated urinary tract infection (Beattie & Taylor, 2011).
• 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. The long-term indwelling catheter is inevitably associated with bacterial colonization, with formation of a biofilm on the catheter surfaces (Norrby, 2011). Most bacteriuria does not produce significant infection, and attempts to eradicate bacteriuria often produce subsequent morbidity because resistant bacteria are encouraged to reproduce while more easily managed strains are eradicated. Intermittent catheterization was preferred in a rehabilitation setting because it improves client quality of life and diminishes the time required to recover spontaneous voiding with a postvoid residual volume <150 mL (Tang et al, 2006).
• 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. EBN: These strategies are supported by sufficient evidence to recommend routine use (Gould et al, 2010; Parker et al, 2009; Willson et al, 2009). Numerous nursing studies have demonstrated that nurse controlled methods to decrease the length of catheterization such as chart reminders and computerized interventions lead to decreased incidences of catheter-associated urinary tract infections (Andreessen, Wilde, & Herendeen, 2012; Bernard, Hunger, & Moore, 2012). Strategies that lack sufficient evidence to support routine use include: (1) application of antimicrobial ointments during routine meatal care, (2) application of antimicrobial ointments or creams to the urethral meatus, (3) adding hydrogen peroxide or silver sulfadiazine or slow-releasing silver ions to the catheter drainage bag, (4) frequent drainage bag changes, or (5) one-way catheter valves (Willson et al, 2009).
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. EBN: Factors associated with an increased risk of postoperative urinary retention included preoperative voiding difficulty, advanced age, total amount of fluid replacement during a 24-hour postoperative period, type of anesthesia, pain management medications, and route and length of medication administration (Baldini et al, 2009). EBN: A study demonstrated increased urinary retention after transurethral resection of the prostate in clients with preoperative increased prostate size, urinary tract infection, and clot retention (McKinnon et al, 2011).
Remove the indwelling urethral catheter at midnight in the hospitalized postoperative client to reduce the risk of acute urinary retention. CEB: Removal of indwelling catheters at midnight in clients undergoing urologic surgery offers several advantages over morning removal, including a larger initial voided volume and earlier hospital discharge with no increased risk for readmission compared with those undergoing morning removal (Griffiths, Fernandez, & Murie, 2004).
Perform a bladder scan of the bladder before considering inserting a catheter to determine postvoid residual volume following surgery. EBN: A study demonstrated a significant decrease in the number of catheterizations when ultrasonic bladder scanning was done to monitor postoperative urinary retention (Cutright, 2011). Another study found that in hip fracture clients, use of bladder scanning and intermittent catheterization resulted in less retention after surgery, versus just inserting a retention catheter (Johansson & Christensson, 2010). A meta-analysis of many studies found that performing bladder scanning was effective in decreasing urinary catheterization and development of a urinary tract infection (Palese et al, 2010).
• Aggressively assess elderly clients, particularly those with dribbling urinary incontinence, UTI, and related conditions for urinary retention. Elderly women and men may experience urinary retention with few or no apparent symptoms; a urinary residual volume and related assessments are necessary to determine the presence of retention in this population (Johansson & Christensson, 2010; Ostaszkiewicz, O’Connell, & Ski, 2008).
• Assess elderly clients for impaction when urinary retention is documented or suspected. Fecal impaction and urinary retention frequently coexist in elderly clients and, unless reversed, may lead to acute delirium, UTI, or renal insufficiency (Waardenburg, 2008).
• Monitor elderly male clients for retention related to prostatic enlargement (BPH or prostate cancer). Prostate enlargement in elderly men increases the risk of acute and chronic urinary retention.
• Encourage the client to report any inability to void.
Maintain an up-to-date medication list; evaluate side effect profiles for risk of urinary retention. New medications or changes in dose may cause urinary retention.
Refer the client for physician evaluation if urinary retention occurs. Identification of cause is important. Left untreated, urinary retention may lead to UTI or kidney failure.
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. Double voiding promotes more efficient bladder evacuation by allowing the detrusor to contract initially and then rest and contract again (Mayo Clinic, 2011).
• Teach the client with urinary retention and infrequent voiding to urinate by the clock. Timed or scheduled voiding may reduce urinary retention by preventing bladder overdistention (Mayo Clinic, 2011).
• 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.
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