Student Nurses Community

NURSING CARE PLAN Functional Urinary Incontinence

ASSESSMENT

SUBJECTIVE:
I feel the urge to
void, but I cant
reach the toilet on
time, as verbalized
by the patient

DIAGNOSIS

INFERENCE

PLANNING

Functional
urinary
incontinence
related to
neuromuscul
ar limitation
(left sided
weakness)

Muscle weakness

After 48 hours of
nursing interventions,
the patient will be
able to:

Impairment of
mobility and
dexterity

Inability to reach
the toilet in time

OBJECTIVES:
Weakened
muscle tone (left
side is weak)

Urine leakage

Urine leakage/
passing of urine in
inappropriate
places

experience fewer
episodes (or no
episodes) of
incontinence
Use adaptive
equipment to
reduce or
eliminate
incontinence
related to
impaired mobility
or dexterity
Use portable
urinary collection
devices or urine
containment
devices when
access to the
toilet is not
feasible

INTERVENTIONS

Independent:
Perform a focused
history of the
incontinence
including duration,
frequency and
severity of leakage
episodes, and
alleviating and
aggravating factors.
Complete a bladder
log of diurnal and
nocturnal urine
elimination patterns
and patterns of
urinary leakage.
Assess patient's
recognition of need to
urinate
Assess client for
established/chronic
incontinence: stress
urinary incontinence,

RATIONALE

The history
provides clues to
the causes, the
severity of the
condition, and its
management.
The bladder log
provides a more
objective
verification of urine
elimination
patterns as
compared with the
history and a
baseline against
which the results of
management can
be evaluated.
Patients with
functional
incontinence are
incontinent
because they
cannot get to an

EVALUATION

After 48 hours
of nursing
interventions,
goal met. Fewer
episodes of
incontinence
were noted;
patient was able
to use adaptive
equipment and
portable urinary
collection
devices.

Student Nurses Community

urge urinary
incontinence, reflex,
or extraurethral
("total") urinary
incontinence. If
present, begin
treatment for these
forms of urine loss.
Assess client for
mobility, including
ability to rise from
chair and bed; ability
to transfer to toilet
and ambulate; and
need for physical
assistive devices
such as a cane,
walker, or wheel
chair.
Assess client for
dexterity, including
the ability to
manipulate buttons,
hooks, snaps, Velcro,
and zippers needed
to remove clothing.
Consult physical or
occupational
therapist to promote
optimal toilet access
as indicated.

appropriate place
to void.
Institutionalized
patients are often
labeled
"incontinent"
because their
requests for
toileting are
unmet. Elderly
patients with
cognitive
impairment may
recognize need to
void, but may be
unable to express
the need.
Functional
incontinence often
coexists with
another form of
urinary leakage,
particularly among
the elderly
Functional
continence requires
the ability to gain
access to a toilet
facility, either
independently or
with the assistance

Student Nurses Community

Provide an
appropriate, safe
urinary receptacle
such as a 3-in-1
commode, female or
male hand-held
urinal, no-spill urinal,
or containment
device when toileting
access is limited by
immobility or
environmental
barriers.
Assist the person to
alter their wardrobe
(Select loose-fitting
clothing with stretch
waist bands rather
than buttoned or
zippered waist;
minimize buttons,
snaps, and multilayered clothing; and
substitute Velcro or
other easily loosened
systems for buttons,
hooks, and zippers in
existing clothing.)
Assist the client with
limited mobility.
assist the client to

of devices to
increase mobility
Functional
continence requires
the ability to
remove clothing to
urinate
These receptacles
provide access to a
substitute toilet
and enhance the
potential for
functional
continence
To maximize
toileting access.
To obtain
evaluation for a
physical therapist
and to obtain
assistive devices as
indicated. Shoes
with a nonskid sole
maximize traction
when arising from
a chair and
transferring to the
toilet.
A toileting schedule

Student Nurses Community

select shoes with a

nonskid sole
Establish a toileting
schedule.
Perform perineal skin
care, including
routine cleansing
following incontinent
episodes, daily
cleaning and drying
of perineal skin, and
use of moisture
barriers as indicated.
Dependent:
Encourage prescribed
use of
sympathomimetics
and estrogens as
ordered

assures the patient

of a specified time
for voiding, and
reduces episodes
of functional
incontinence.
Routine cleansing
and daily cleaning
with appropriate
products help
maintain integrity
of perineal skin and
prevent secondary
cutaneous
infections
To increase
sphincter tone and
improve muscle
tone.