Alteration in Patterns of Urinary Elimination: Incontinence

Alteration
in Patterns of Urinary Elimination: Incontinence

(_)Actual (_)
Potential

Related
To:
[Check
those that apply]
(_)
Congenital urinary tract anomalies:
________________________________
(_) Disorders of urinary tract:_________

________________________________
(_) Drug therapy
(_) Environmental barriers to bathroom
(_) Estrogen deficiency
(_) Inability to communicate needs

(_) Lack
of privacy

(_) Loss of perineal tissue tone
(_) Neurogenic disorder or injury
(_) Prostatic enlargement
(_) Stress/fear
(_) Other:__________________________
____________________________________

____________________________________

 

As
evidenced by:
[Check
those that apply]
Major:

(
Must be
present
)
(_)
Urgency followed by incontinence.
(_) Other:

 

 

Date &
Sign.
Plan and Outcome
[Check
those that apply]
Target
Date:
Nursing Interventions
[Check
those that apply]
Date

Achieved:

  The
patient will:

(_)
Be continent at all times.

(_) Be continent
during waking hours.

(_) Other:

 

 

  (_)
Montiro I & O, including patterns of urinary
incontinence.

(_)
Instruct to start and stop stream during urination.

(_) Ask physician for
pelvic floor exercises. Order and teach as follows:

_________x__________ (# of times).

(_) Limit fluids 2-3
hours prior to bedtime.

(_) No fluids
after:___________

(_) Awaken patient at
night to void at:_______ or q___hours.

(_) Provide
urinal/bedpan/bedside commode in easy access.

(_) Place call light
within reach at all times.

(_) Provide comfort
measures (sitz baths: warm perineal soaks as needed).

(_)
Other:________________
________________________
________________________
________________________

 

 

 

__________________________
Patient/Significant other signature

 

__________________________
RN signature