Nurse's Pocket Guide

Related Factors
Bladder outlet obstruction; fecal impaction
Urethral obstruction; severe pelvic prolapse
Detrusor external sphincter dyssynergia; detrusor hypocontractility
Side effects of anticholinergic/decongestant medications; calcium
channel blockers
Defining Characteristics
SUBJECTIVE
Reports involuntary leakage of small volumes of urine
Nocturia
OBJECTIVE
Bladder distention
High post-void residual volume
Observed involuntary leakage of small volumes of urine
Desired Outcomes/Evaluation
Criteria—Client Will:
• Verbalize understanding of causative factors and appropriate
interventions for individual situation.
• Demonstrate techniques/behaviors to alleviate/prevent overflow
incontinence.
• Void in sufficient amounts with no palpable bladder distention;
experience no post-void residuals greater than 50 mL;
have no dribbling/overflow.
Actions/Interventions
NURSING PRIORITY NO.1.To assess causative/contributing factors:
• Review client’s history for 1) bladder outlet obstruction (e.g.,
prostatic hypertrophy, urethral stricture, urinary stones or
tumors); 2) nonfunctioning detrusor muscle (i.e., sensory or
motor paralytic bladder due to underlying neurologic disease);
or 3) atonic bladder that has lost its muscular tone (i.e.,
chronic overdistention) to identify potential for/presence of
conditions associated with overflow incontinence.
• Note client’s age and gender. Urinary incontinence due to
overflow bladder is more common in men because of the
prevalence of obstructive prostate gland enlargement.
• Review medication regimen for drugs that can cause/exacerbate
retention and overflow incontinence (e.g., anticholinergic
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
Diagnostic Studies Pediatric/Geriatric/Lifespan Medications 733
overflow URINARY INCONTINENCE