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

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