1300 UNIT X / Promoting Physiologic Health

plan of care in order to follow a program. A bladder training program may include the following: & Education of the client and support people. w Bladder training, which requires that the client postpone voiding, resist or inhibit the sensation of urgency, and void according to a timetable rather than according to the urge to void. The goals are to gradually lengthen the intervals between urination to correct the client's frequent urination, to stabilize the bladder, and to diminish urgency. This form of training may be used for clients who have bladder instability and urge incontinence. Delayed voiding provides larger voided volumes and longer intervals between voiding. Initially, voiding may be encouraged every 2 to 3 hours except during sleep and then every 4 to 6 hours. A vital component of bladder training is inhibiting the urge-to-void sensation. To do this, the nurse instructs the client to practice deep, slow breathing until the urge diminishes or disappears. This is performed every time the client has a premature urge to void. m Habit training, also referred to as timed voiding or scheduled toileting, attempts to keep clients dry by having them void at regular intervals. With habit training, there is no attempt to motivate the client to delay voiding if the urge occurs. This approach can be effective in children who are experiencing urinary dysfunction. Biofeedback therapy in which the child is taught to relax the pelvic floor can also decrease incidents of wetting (Shei Dei Yang & Cheng Wang, 2005). ^ Prompted voiding supplements habit training by encouraging the client to try to use the toilet (prompting) and reminding the client when to void.
PELVIC MUSCLE EXERCISES. Pelvic m u s c l e exercises (PME), or Kegel exercises, help to strengthen pelvic floor muscles and can reduce or eliminate episodes of incontinence. The client can identify the perineal muscles by stopping urination midstream or by tightening the anal sphincter as if to hold a bowel movement.

CLIENT TEACHING Exercises (Kegels)

Pelvic Muscle

h First, sit or lie in a comfortable, relaxed position. is Contract your pelvic muscles whereby you pull your rectum, urethra, and vagina up inside, and hold for a count of 3 to 5 seconds. Then relax the same muscles for a count of 3 to 5 seconds. m Initially perform each contraction 10 times, three times daily. Gradually increase the count to a full 10 seconds for both contraction and relaxation. Develop a schedule that will help remind you to do these exercises, for example, before getting out of bed in the morning, when working at the kitchen sink, or at scheduled times (e.g., 0700, 1200, 1800 hours). s To control episodes of stress incontinence, perform a pelvic muscle contraction when initiating any activity that increases intra-abdominal pressure, such as coughing, laughing, sneezing, or lifting.

The following technique is sometimes used to teach PME. Ask the client to think of the perineal muscles as an elevator. When the client relaxes, the elevator is on the first floor. To perform the exercise, contract the perineal muscles, bringing the elevator to the second, third, and fourth floors. Keep the elevator on the fourth floor for a few seconds, and then gradually relax the area. When the exercise is properly performed, contraction of the muscles of the buttocks and thighs is avoided. PME can be performed anytime, anywhere, sitting or standingeven when voiding. Specific client instructions for performing PME are summarized in Client Teaching.
MAINTAINING SKIN INTEGRITY. Skin that is continually moist becomes macerated (softened). Urine that accumulates on the skin is converted to ammonia, which is very irritating to the skin. Because both skin irritation and maceration predis-

PRACTICE GUIDELINES

Bladder Training
s b Avoid excessive consumption of citrus juices, carbonated beverages (especially those containing artificial sweeteners), alcohol, and drinks containing caffeine because these irritate the bladder, increasing the risk of incontinence. m Schedule diuretics early in the morning, n Explain to clients that adequate fluid intake is required to ensure adequate urine production that stimulates the micturition reflex. m Apply protector pads to keep the bed linen dry and provide specially made waterproof underwear to contain the urine and decrease the client's embarrassment. Avoid using diapers, which are demeaning and also suggest that incontinence is permissible. m Assist the client with an exercise program to increase the general muscle tone and a pelvic muscle exercise program aimed at strengthening the pelvic floor muscles, a Provide positive reinforcements to encourage continence. Praise clients for attempting to toilet and for maintaining continence.

i Determine the client's voiding pattern and encourage voiding at those times, or establish a regular voiding schedule and help the client to maintain it, whether the client feels the urge or not (e.g., on awakening, every 1 or 2 hours during the day and evening, before retiring at night, every 4 hours at night). The stretching-relaxing sequence of such a schedule tends to increase bladder muscle tone and promote more voluntary control. Encourage the client to inhibit the urge-to-void sensation when a premature urge to void is experienced. Instruct the client to practice slow, deep breathing until the urge diminishes or disappears. s b When the client finds that voiding can be controlled, the intervals between voiding can be lengthened slightly without loss of continence. Regulate fluid intake, particularly during evening hours, to help reduce the need to void during the night. n Encourage fluids between the hours of 0600 and 1800.