Nursing care plan- Urinary Incontinence r/t Neuromuscular Impairment

vpheesun · Feb 20, 2011

Hi, I'm a nursing student in first quarter and I need your help with nursing diagnosis, please.

Below, I have basic assessment related to my nursing diagnosis. I did not include VS, or other assessment because I don't think it's necessary. Could you check my nursing diagnosis below and check if it makes sense.

Thank you so much!

Urinary Incontinence r/t Neuromuscular Impairment, aeb involuntary leakage of urine

Areas: Elimination

1.BASIC ASSESSMENT DATA

- Activity/Rest: Bedbound, transfer with assist of 2, use of gait belt, wheelchair support, muscle strength on left side is weak, no weight bearing, need partial assist for ADLS

- Elimination: Incontinent urine and bowel movement

- Prevention of Hazards:Skin: redness on both buttocks

2.COMPREHENSIVE ASSESSMENT DATA

a) Medical Diagnosis

*CVA

*Hemiplegia

*Bladder Neoplasm

b) Medication

*Phenytoin ER 100mg Cap 3 caps PO qhs

*Gabapentin 300mg Cap 1 cap PO tid

*Vicodin (hydrocodone/acetaminophen) 5/500 Tab 2 tabs PO q6h

c) Lab Values

*Potassium: 5.0 mEq/l

3.RATIONALES

*Medical Dx:

oCVA: neurologic deficit caused by sudden, focal interruption of cerebral blood flow to one area of the brain. This will cause immobility to control functions one side of the body including loss of the ability to sense the need to go to the bathroom and the ability to control the muscles

oHemiplegia: Total paralysis of the left side of the body acquired from a CVA, immobility caused by muscle spasm and weakness. Urinary incontinence led from physical immobility and loss of control of sphincter.

oBladder Neoplasm:

*Meds: (side effects that related to your nursing diagnosis)

oGabapentin: To treat neuropathic pain and parasthesias

oPhenytoin: treatment/prevention of tonic-clonic seizures and complex partial seizures by altering ion transport; management of neuropathic pain, including rigeminal neuralgia. May decrease synaptic transmission, which is the process whereby one neuron communicates with other neurons or effectors, such as muscle cell

oVicodin (Hydrocodone/acetaminophen): sedatives, which may cause or exacerbate retention and overflow incontinence

4.NURSING DIAGNOSIS

*Urinary Incontinence r/t Neuromuscular Impairment, aeb involuntary leakage of urine

5.GOALS, INTERVENTIONS

Goals

Short Term:

Establish voiding schedule

Long Term:

Manage incontinence so that social functioning is maintained

Interventions

1.Assess intake/output for 3 days

2.Change brief q2h and maintain perineal skin integrity

3.Maintain positive regard when incontinence occurs

4.Encourage to drink 450ml of fluid with each meal to find voiding pattern

5.Consult with physical therapist