NRNP 6540 Week 6 Incontinence Visit Note Example

Urinary Incontinence Visit Note: Urgency, Leakage on Coughing, and a Long Walk to the Bathroom in a 77-Year-Old Woman

Student Name

College of Nursing, Walden University

NRNP 6540: Advanced Nurse Practice in Primary Care Adult Gerontology II

Instructor Name

Month Day, Year

Urinary Incontinence Visit Note: Urgency, Leakage on Coughing, and a Long Walk to the Bathroom in a 77-Year-Old Woman

Subjective

R.K., a composite 77-year-old retired librarian, reports leakage of urine for about a year, now daily and bothersome enough that she has stopped going to her book club. Most episodes come with a strong, sudden urge and trouble reaching the bathroom in time; she sometimes leaks on the way. She also leaks a small amount when she coughs or sneezes. She wakes twice a night to void.

Bladder diary, kept for three days at the last visit's request: 10 to 12 voids a day, many small volumes; 3 to 5 leakage episodes a day, most preceded by urgency and two with coughing; about 2 liters of fluid daily, including three cups of coffee and most of her water after 6 p.m.; 2 nighttime voids.

Working through DIAPPERS, the mnemonic for reversible contributors: Delirium: none. Infection: no dysuria or fever; urinalysis to be checked. Atrophic vaginitis: vaginal dryness reported. Pharmaceuticals: furosemide taken in the evening, and she has not been told why the timing matters. Psychological: no depression. Excess urine output: evening fluid load and the evening diuretic. Restricted mobility: knee osteoarthritis slows her walking, and her bathroom is at the far end of the hall from her armchair. Stool impaction: bowel movements every three to four days with straining, a form of constipation that worsens urgency. The review turns up three reversible contributors, constipation, the evening diuretic, and slow walking, plus atrophic change.

Objective

Abdomen: soft, mild left lower quadrant fullness consistent with stool, no suprapubic mass. Pelvic examination: atrophic changes of the vulva and vagina with pale, thin mucosa; no significant pelvic organ prolapse. Cough stress test, performed with a full bladder while standing: a small spurt of leakage coincident with coughing, confirming a stress component. Mobility: Timed Up and Go of 15 seconds, with a slow start due to knee stiffness. Post-void residual by bladder scan: 40 mL, low, which argues against overflow incontinence and makes antimuscarinic therapy safer from a retention standpoint. Neurologic screen of the lower extremities normal, including perineal sensation, which matters because a neurologic cause would change the evaluation (Dains et al., 2020). Urinalysis: negative.

Assessment

Mixed urinary incontinence, urge predominant, with a functional component. The urge component is shown by leakage preceded by sudden urgency and by frequent small voids; the stress component by leakage on coughing confirmed on examination; the functional component by slowed mobility and the distance to her bathroom, which turn an urge she could otherwise manage into leakage (Lukacz et al., 2017). Constipation, the evening diuretic, evening fluid load, and genitourinary atrophy are contributors that can be reversed or reduced. A low residual volume excludes overflow incontinence.

Plan

Behavioral measures first, since they are first-line for urge, stress, and mixed incontinence in women and carry no side effects (Lukacz et al., 2017): bladder training with scheduled voiding, starting every two hours and extending gradually; urge suppression techniques, stopping and contracting the pelvic floor when urgency hits rather than rushing; pelvic floor muscle training taught at this visit, with referral to a pelvic floor physical therapist; moving most fluid intake earlier in the day and reducing coffee to one cup in the morning.

Reversible contributors: move furosemide to the morning, after confirming with her cardiologist that the indication still stands; treat constipation with fiber, fluids timed earlier, and a gentle osmotic laxative; start low-dose vaginal estrogen for genitourinary atrophy, which can reduce urgency and recurrent infections.

Function: a bedside commode at night and moving her armchair closer to the bathroom; physical therapy for knee strength also shortens the walk.

Medication, discussed with its risks: if urgency persists after eight to twelve weeks of behavioral measures, a bladder medication may help. Antimuscarinic drugs such as oxybutynin are strongly anticholinergic and the American Geriatrics Society advises avoiding them in older adults because of cognitive effects, constipation, and falls (2023 American Geriatrics Society Beers Criteria Update Expert Panel, 2023). A beta-3 agonist such as mirabegron avoids anticholinergic effects and would be preferred, with blood pressure monitored.

What matters to her: she wants to return to her book club and to her sister's house for Sunday dinner without worrying about leakage. Those two outings are the measure of success she chose, alongside the diary. Absorbent products designed for urine were discussed for use in the meantime, since she had been using menstrual pads, which hold less and irritate the skin. Follow-up: six weeks with a repeat bladder diary.

References

2023 American Geriatrics Society Beers Criteria Update Expert Panel. (2023). American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 71(7), 2052-2081. https://doi.org/10.1111/jgs.18372

Dains, J. E., Baumann, L. C., & Scheibel, P. (2020). Advanced health assessment and clinical diagnosis in primary care (6th ed.). Elsevier.

Lukacz, E. S., Santiago-Lastra, Y., Albo, M. E., & Brubaker, L. (2017). Urinary incontinence in women: A review. JAMA, 318(16), 1592-1604. https://doi.org/10.1001/jama.2017.12137