JMJ MARIST BROTHERS

Notre Dame of Dadiangas University

Marist Avenue, General Santos City
College of Health and Sciences

A CASE STUDY ON DIURNAL ENURESIS

Submitted to

Jules Alexis B. Dajay, RN, MAN

Presented By
Acharon, Diether, SN
Arizala, Jude Michael Alex, SN
Balaba, Renz Kamille, SN
Basangan, Siparah Richaine, SN

October, 2021
 Table of Contents

Title Page

Title Page i

ii
Table of Contents
iii

Chapter I Introduction 3

Etiology, Incidence and Epidemiology of the Case

Chapter II Objectives 5

Chapter III Anatomy and Physiology 7

Chapter IV Pathophysiology 10

Chapter V Medical & Nursing Management 12

Laboratory and Diagnostic Studies 12

Medical Management 14

16
Drug Studies

32
Nursing Management

35
Prognosis
Chapter VI Gordon’s Functional Health Pattern 38

Prioritization of Problems 65

Nursing Care Plans 73

Health Teachings 100

References 102
Curriculum Vitae 104
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Chapter I

INTRODUCTION

Etiology, Incidence, and Epidemiology of the Case

This chapter presents the definition of the disease, the signs and symptoms

present, the cause, and as well as the review of related literature and studies of the

topic.

Diurnal enuresis also known as daytime wetness is the unintentional flow of pee

during waking hours in a person of sufficient bladder control. There are two types of

diurnal enuresis which is the primary and secondary diurnal enuresis. The primary

diurnal enuresis is an incontinence that lasts past the age at which a child would

normally be expected to be toilet trained while, the secondary diurnal enuresis is an

incontinence in a child who has effectively toilet trained and has had at least three

months of dry days. Daytime wetness should be regarded as a problem in any child

over the age of four who wets most days, a child who was previously continent, or a

child whose parents are concerned about the problem, regardless of the child's age

(Cincinnati’s Children, 2018).

Daytime wetting affects girls twice as much as boys. Daytime wetness affects

approximately 3 to 4% of children aged 4 to 12. It is particularly common among

elementary school-aged youngsters (Cincinnati’s Children, 2018).

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Many children who have daytime urine accidents have a parent or other relative

who did, too. Other common causes of daytime wetting include: Constipation (stool in

the colon can create pressure on the bladder and cause spasms, which lead to daytime

wetting); Poor bathroom habits, such as not emptying the bladder completely or “holding

it” for too long; A urinary tract infection &; Children with medical conditions such as

cerebral palsy, Down syndrome and attention deficit / hyperactivity disorder (ADHD)

may continue to have daytime wetting at a later age than other children (Cincinnati’s

Children, 2018).
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Chapter II

OBJECTIVES

This chapter presents the general and specific objectives for this case study.

General Objectives:

The ultimate goal of this study is to elevate the level of knowledge, awareness

and have a thorough understanding with regards to Diurnal Enuresis; its nature,

causes, clinical manifestations, management and prognosis in order to increase

competency in health, preventing disease and rehabilitating patients through a case

presentation.

Specific Objectives:

After the case presentation, the student nurses will be able to:

● Present an introduction of Diurnal Enuresis;

● State the general and specific objectives of the study;

● Enumerate the obtained initial database;

● Discuss the past and present illness of the patient;

● Discuss the basic background of the anatomy and physiology of the

● system involved;

● Trace the pathophysiology of the Diurnal Enuresis through the

schematic diagrams;

● Compare the clinical manifestations of Diurnal Enuresis based

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on the theories and actual observations;

● Explain the assessment and diagnostic findings;

● Interpret the laboratory results and the nurses’ responsibilities;

● Discuss the medical and nursing management of Diurnal Enuresis;

● Outline the drug study from the patient’s medication;

● Develop the discharge planning of the patient;

● Explain the Gordon’s Functional Health Pattern of the Patient; and

● Construct an individual nursing care plan for a patient with Diurnal Enuresis.
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Chapter III

ANATOMY & PHYSIOLOGY

This chapter includes the anatomy and physiology of the system involved in the

case of diurnal enuresis to better understand the case study and its affected parts of the

system being discussed.

Anatomy and Physiology of the Urinary System

The urinary system is composed of

the kidneys, renal pelvis, ureters, bladder,

and the urethra. The ureters, urinary

bladder, and urethra together form the

urinary tract, which acts as a plumbing

system to drain urine from the kidneys,

store it, and then release it during urination.

It's main function is to do filtering and

eliminating wastes from the body, and the

Figure 1. Anatomy of Urinary
urinary system also maintains the homeostasis System

of water, ions, pH, blood pressure, calcium

(Taylor, 2021).

The kidneys are a pair of bean-shaped organs found along the posterior wall of

the abdominal cavity, the left kidney is located slightly higher than the right kidney

because the right side of the liver is much larger than the left side. The kidneys
 8

function is to filter metabolic wastes, excess ions, and chemicals from the blood to

form urine. The ureters are a pair of tubes that carry urine from the kidneys to the

urinary bladder, the ureters are about 10 to 12 inches long and run on the left and

right sides of the body parallel to the vertebral column. Gravity and peristalsis of

smooth muscle tissue in the walls of the ureters

move urine toward the urinary bladder. The ends

of the ureters extend slightly into the urinary

bladder and are sealed at the point of entry to the

bladder by the ureterovesical valves, these valves

prevent urine from flowing back towards the

kidneys. The urinary bladder is a sac-like

hollow organ used for the storage of urine, it is

Figure 2. Anatomy of Kidney located along the body’s midline at the inferior end

of the pelvis. Urine entering the urinary bladder from the ureters slowly fills the hollow

space of the bladder and stretches its elastic walls, the walls of the bladder allow it to

stretch to hold anywhere from 600 to 800 milliliters of urine. The urethra is the tube

through which urine passes from the bladder to the exterior of the body. The female

urethra is around 2 inches long and ends

inferior to the clitoris and superior to the

vaginal opening, while in males the urethra is

around 8 to 10 inches long and ends at the

tip of the penis and it also carries sperm out

of the body through the penis.

Figure 3. Anatomy of Ureter,

Urinary Bladder & Urethra
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The kidneys maintain the homeostasis of several important internal conditions by

controlling the excretion of substances out of the body. The filtration process

happens inside the kidneys, as blood flows through the glomerulus, much of the

blood’s plasma is pushed out of the capillaries and into the capsule, leaving the blood

cells and a small amount of plasma to continue flowing through the capillaries. The

liquid filtrate in the capsule flows through a series of tubules lined with filtering cells

and surrounded by capillaries, the cells surrounding the tubules selectively absorb

water and substances from the filtrate in the tubule and return it to the blood in the

capillaries. At the same time, waste products present in the blood are secreted into

the filtrate and by the end of this process, the filtrate in the tubule has become urine

containing only water, waste products, and excess ions. The blood exiting the

capillaries has reabsorbed all of the nutrients along with most of the water and ions

that the body needs to function (Taylor, 2021)

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CHAPTER IV

PATHOPHYSIOLOGY

This chapter presents the pathophysiology of the disease process including the

factors, causes, signs and symptoms that leads to the disease.

Figure 4. Pathophysiology of Diurnal

Enuresis
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Textual Discussion

Diurnal enuresis is an unintended leakage of urine during waking hours in an

individual old enough to maintain bladder control. Primary diurnal enuresis is

incontinence that persists beyond the age when a child otherwise would be expected to

be toilet trained. Secondary diurnal enuresis is incontinence in a child who was toilet

trained successfully and experienced at least 3 consecutive months of dry days.

(Robson, 2020).

The patient is an 6-year-old boy who was diagnosed with attention-

deficit/hyperactivity disorder who presented with daytime and night-time wetting. The

patient's symptoms continued to increase to the point at which he was constantly wet,

and he no longer made any attempts to void on his own.

The prevalence of daytime wetting varies by age and gender. Most children

brought to the attention of a pediatrician are in kindergarten or elementary school.

Approximately 3% to 4% of children between the ages of 4 and 12 years wet during the

day. Shows age-specific prevalence data for children who wet at least once every 2

weeks. Daytime wetting is twice as common among girls.

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Chapter V

Medical and Surgical Management

This chapter presents the medical and surgical management of the disease, the

laboratory and diagnostic tests, as well as the drug studies, ideal nursing management

and the prognosis of the disease.

Ideal Laboratory and Diagnostic Tests

In diagnosing diurnal enuresis the physician will take a medical history and

perform a physical exam to rule out any medical disorder that may be causing the

incontinence. Other testing include the following:

Urinalysis- A urinalysis involves checking the appearance, concentration and

content of urine and it's used to detect and manage a wide range of disorders, such as

urinary tract infections, kidney disease and diabetes. During a urinalysis, a clean urine

sample is collected into a specimen cup and analyzed with a visual exam, a dipstick test,

and a microscopic exam. Urinalysis is one of the basic tests for enuresis, results such

as urethral obstruction may be associated with red blood cells in the urine and can be

related to enuresis (Robson, 2020).

Urodynamic studies- Urodynamic tests are used to diagnose urinary

incontinence or other urinary symptoms, the test focuses on how well the bladder,

sphincters, and urethra hold and release urine. These tests can show how well the

bladder works and why there could be leaks or blockages (Cleveland Clinic, 2021).
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Cystometry- Cystometry is a test used to look for problems with the filling and

emptying of the bladder. It is a useful test in diurnal enuresis because it enables the

health professionals if the patient has urinary incontinence. A flexible, thin plastic

catheter is then slowly inserted through the urethra and into the bladder, measurements

will then be taken of how much, if any, urine remains in the bladder and bladder

pressure (Midmichigan Health, 2021).

Electromyography- Electromyography uses sensors to measure the electrical

activity of the muscles and nerves in and around the bladder and the sphincters. If there

is a suspicion that the urinary problem is related to nerve or muscle damage, an

electromyogram is done. The test uses electrode patches placed near the urethra and

rectum to record electrical currents when muscles in the pelvic floor contract (Robson,

2020).

Uroflowmetry- Uroflowmetry is a simple, diagnostic screening procedure used to

calculate the flow rate of urine over time, it is noninvasive and may be used to assess

bladder and sphincter function for enuresis. The patient will urinate into special funnel

equipment that will allow measurements to happen, then a computer is used to

automatically measure the amount and flow rate, creating a graph that shows any

changes. Test results will let the provider know if the patient has weak bladder muscles

or some kind of blockage (Marcin, 2017).

Postvoid residual measurement- The post-void residual (PVR) urine test

measures the amount of urine left in the bladder after urination. The test is used to help

evaluate incontinence in women and men and other urination problems.The urine that is
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left is called the postvoid residual, a postvoid residual is five to six ounces or more is a

sign that the bladder is not emptying completely. The test can be measured with a

bladder scanner to see an image of the bladder or it can also be tested by using a

catheter that is placed into the urethra and then into the bladder to remove the excess

urine (Cleveland Clinic, 2021).

Voiding cystourethrography- A cystourethrogram is an x-ray test that takes

pictures of the bladder and urethra while the bladder is full and while the patient is

urinating. It is done with a thin flexible tube also known as the urinary catheter, the

urinary catheter inserted through the urethra and into the bladder (Midmichigan Health,

2021).

Ideal Medical Management

Anticholinergic agents. An anticholinergic medication might be helpful in some

patients, especially those with overactive bladder, dysfunctional voiding, or neurogenic

bladder. These medications reduce uninhibited detrusor contractions, increase the

threshold volume at which an uninhibited detrusor contraction occurs, and enlarge the

functional bladder capacity.

Antispasmodic Agents. It blocks the effects of acetylcholine and inhibits involuntary

detrusor muscle contractions.

● Oxybutynin
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○ Oxybutynin should be considered in children who are likely to have small

functional bladder capacity either only at night or throughout the day.

Daytime symptoms that might indicate potential for therapeutic benefit

include frequency, urgency, and incontinence. Nighttime symptoms

include wetting more frequently than once per night. It is not approved for

children younger than 12 years.

● Tolterodine

○ Tolterodine is a competitive muscarinic receptor antagonist for overactive

bladder; it differs from other anticholinergic drugs in that it has selectivity

for the urinary bladder over salivary glands. Tolterodine is used in patients

likely to have small functional bladder capacity either only at night or

throughout the day. Daytime symptoms that may indicate potential for

therapeutic benefit include frequency, urgency, and incontinence.

Nighttime symptoms include wetting more frequently than once per night.

● Flavoxate

○ Flavoxate is used for symptomatic relief of incontinence. It has

anticholinergic effects and exerts a direct effect on muscle. It counteracts

smooth muscle spasm of the urinary tract.

Antidepressants. Specifically tricyclic antidepressants, it works by their antispasmodic

effect on the bladder.

● Imipramine
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○ Imipramine facilitates urine storage by decreasing bladder contractility and

increasing outlet resistance. It inhibits reuptake of norepinephrine or

serotonin at the presynaptic neuron.

Drug Study

Drug Study 1. Desmopressin (DDAVP)

Date Ordered N/A

Generic Name Desmopressin

Brand Name DDAVP

Classification Vasopressin

Dosage and 0.2 mg PO q8h

Frequency

Rationale for Drug Is a synthetic analogue of 8-arginine vasopressin (ADH), is an

Order antidiuretic peptide drug modified by deamination of 1-cysteine

and substitution of 8-L-arginine by 8-D-arginine. ADH is an

endogenous pituitary hormone that has a crucial role in the

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control of the water content in the body.

● Indicated for the treatment of nocturia due to nocturnal

Indications
polyuria in adults who awaken at least 2 times per night

to void (intranasal).

It is contraindicated in individuals with known

Contraindications
hypersensitivity to desmopressin acetate or to any of the

components of DDAVP (desmopressin acetate tablets)

Tablets.

Mechanism of The mechanism of action of this drug upon binding of

Action desmopressin to V2 receptors in the basolateral membrane of

the cells of the distal tubule and collecting ducts of the nephron,

adenylyl cyclase is stimulated. The resulting intracellular

cascades in the collecting duct lead to increased rate of

insertion of water channels, called aquaporins, into the luminal

membrane and enhance the permeability of the membrane to

water.
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Adverse Effects ● Dizziness,

● Unusual tiredness, Weight gain,
● mood change
● severe drowsiness
● muscle weakness
● cramps

Side Effects ● Headache

● Nausea
● Upset stomach
● Flushing of face,
● Diarrhea
1. Assess any breathing problems, and report difficult or
Nursing
labored breathing (dyspnea).
Responsibilities 2. Instruct the patient to report other bothersome side
effects such as severe or prolonged nasal congestion
(when administered intranasally), skin reactions
(flushing), or GI problems (nausea, abdominal cramps).
3. Monitor vital signs of the patient.

4. Be alert for an imbalance in body water and electrolytes

that results in low sodium levels (hyponatremia). Signs
include headache, confusion, listlessness, fatigue,
irritability, muscle abnormalities (weakness, cramps,
spasms), and decreased consciousness that can
progress to coma and seizures. Notify the physician if
these signs occur.
5. Educate the patient about caution during aerobic exercise

and other forms of therapeutic exercise. Terminate

exercise immediately if any untoward responses occur.

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6. Assess administration site during and after IV

administration, and report signs of phlebitis and venous
thrombosis (local pain, swelling, inflammation).

Table 1. Drug Study of desmopressin (DDAVP)

Drug Study 2. oxybutynin (Ditropan xl)

Date Ordered N/A

Generic Name Oxybutynin

Brand Name Ditropan xl

Classification antispasmodics

Dosage and Syrup: 5 mg PO q12hr; may be increased to 5 mg PO q8hr

Frequency
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Rationale for Drug used to treat symptoms of overactive bladder, such as frequent

Order or urgent urination, incontinence (urine leakage), and increased

night-time urination.

Indications treatment of overactive bladder with symptoms of urge urinary

incontinence, urgency, and frequency.

Contraindications ● if a person has untreated or uncontrolled narrow-angle

glaucoma, a blockage in the digestive tract (stomach or

intestines), or if they are unable to urinate.

Mechanism of Exerts antispasmodic and antimuscarinic effects on smooth

Action muscle; delays desire to void, increases bladder capacity, and

decreases uninhibited contraction; decreases frequency and

urgency

● rash
Adverse Effects
● hives
● swelling of the eyes, face, lips, tongue, or throat
● hoarseness
● difficulty breathing or swallowing
● frequent, urgent, or painful urination
● fast, irregular, or pounding heartbeat
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● dry mouth
Side Effects
● blurred vision
● dry eyes, nose, or skin
● stomach pain
● constipation
● diarrhea
● nausea
● heartburn
● gas
● change in ability to taste food
● headache
● dizziness
● weakness
● confusion
● sleepiness
● difficulty falling asleep or staying asleep
● nervousness
● flushing
● swelling of the hands, arms, feet, ankles, or lower legs
● back or joint pain

Nursing 1. Assess the patient’s medical history, especially of: active

Responsibilities internal bleeding, blockage/slowed movement of the

stomach/intestines (such as gastric retention, paralytic

ileus), certain bladder problems (urinary retention,

bladder outflow obstruction, stress incontinence)

2. Be alert for decreased sweating and increased body

temperature (hyperthermia).
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3. Notify physician of a prolonged or persistent elevation in

body temperature.

4. Monitor changes in mood and behavior, including

confusion, agitation, and hallucinations.

5. Tell the patient’s significant others to immediately report

any alarming adverse effects

6. Monitor patients vital signs before and after administering

the medication.

Table 2. Drug Study of oxybutynin (Ditropan xl)

Drug Study 3. imipramine (Tofranil)

Date Ordered N/A

Generic Name imipramine

Brand Name Tofranil

Classification Antidepressants

For enuresis:
Dosage and
10-25 mg PO qHS initially; may increase by 10-25 mg q1-2
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Frequency week

6-12 years: Not to exceed 50 mg or 2.5 mg/kg/day HS

12-14 years: Not to exceed 75 mg/day

Rationale for Drug Imipramine facilitates urine storage by decreasing bladder

Order contractility and increasing outlet resistance. It inhibits reuptake

of norepinephrine or serotonin at the presynaptic neuron.

Indications For the relief of symptoms of depression and as temporary

adjunctive therapy in reducing enuresis in children aged 6 years

and older

Contraindications ● Person with overactive thyroid gland

● Person with schizophrenia, manic-depression and

suicidal thoughts

● Person with alcoholism and alcohol intoxication

● Person with serotonin syndrome, a type of disorder with

high serotonin levels

● Person with increased pressure in the eye, closed angle

glaucoma and at risk of angle-closure glaucoma due to

narrow angle of anterior chamber of eye

● Person with heart attack within the last 30 days, abnormal

heart rhythm, chronic heart failure and orthostatic

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hypotension

● Person with stroke

● Person with paralysis of the intestines, blocked bowels

with decreased peristaltic movement and chronic

idiopathic constipation

● Person with liver problems, decreased kidney function

● Person with enlarged prostate, recent operation and

seizures

● Person who is pregnant

● Person with CYP2D6 poor metabolizer

Mechanism of Imipramine works by inhibiting the neuronal reuptake of the

Action neurotransmitters norepinephrine and serotonin 5,10. It binds

the sodium-dependent serotonin transporter and sodium-

dependent norepinephrine transporter, reducing the reuptake of

norepinephrine and serotonin by neurons.

Adverse Effects Cardiovascular: Orthostatic hypotension, hypertension,

tachycardia, palpitation, myocardial infarction, arrhythmias, heart

block, ECG changes, precipitation of congestive heart failure,

stroke.

Psychiatric: Confusional states with hallucinations,

disorientation, delusions; anxiety, restlessness, agitation;

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insomnia and nightmares; hypomania; exacerbation of

psychosis.

Neurological: Numbness, tingling, paresthesias of extremities;

incoordination, ataxia, tremors; peripheral neuropathy;

extrapyramidal symptoms; seizures, alterations in EEG patterns;

tinnitus.

Anticholinergic: blurred vision, disturbances of accommodation,

mydriasis; constipation, paralytic ileus; urinary retention, delayed

micturition, dilation of the urinary tract.

Allergic: Skin rash, petechiae, urticaria, itching,

photosensitization; edema (general or of face and tongue); drug

fever; cross-sensitivity with desipramine.

Hematologic: Bone marrow depression including

agranulocytosis; eosinophilia; purpura; thrombocytopenia.

Gastrointestinal: anorexia, epigastric distress, diarrhea; peculiar

taste, stomatitis, abdominal cramps, black tongue.

Endocrine: Gynecomastia in the male; breast enlargement and

galactorrhea in the female; increased or decreased libido,

impotence; testicular swelling; elevation or depression of blood

sugar levels; inappropriate antidiuretic hormone (ADH) secretion

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syndrome.

Side Effects Nervous: headache, dizziness, drowsiness

Gastrointestinal: dry mouth, constipation, nausea, vomiting, loss

of appetite, weight gain/loss, stomach cramps

Dermatologic: increased sweating

Nursing 1. Monitor for therapeutic effectiveness: May not occur for 2

Responsibilities wk or more.

2. Prevent serious adverse effects by accurate early

reporting to physician about patient's response to drug.

3. Note that dose sensitivity and adverse effects are most

likely to occur in adolescents and older adults; use a

lower initial dose in these patients.

4. Monitor hepatic and renal function, CBC with differential,

and fluid and electrolyte balance periodically.

5. Monitor HR and BP frequently. Orthostatic hypotension

may be marked in pretreatment hypertensive or cardiac

patients.

6. Monitor for potential signs of toxicity such as QRS

prolongation (to 100 millisecond or greater), arrhythmias,

hypotension, respiratory depression, altered level of

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consciousness, seizures. Overdose onset may be

sudden.

7. Note that during the first 2 wk of therapy, older adults

may develop confusion, restlessness, disturbed sleep,

forgetfulness. Symptoms last 3–20 d. Report to physician.

8. Weigh patient under standard conditions biweekly: report

a gain of 0.5–1.0 kg (1 ½–2 lb) within 2–3 d and frank

edema.

9. Monitor urinary and bowel elimination, at least until

maintenance dosage is stabilized, to detect urinary

retention or frequency, constipation, or paralytic ileus.

10. Encourage to report signs of cholestatic jaundice such as

flu-like symptoms, yellow skin or sclerae, dark urine, light-

colored stools, pruritus.

11. Notify physician of extrapyramidal symptoms (tremors,

twitching, ataxia, incoordination, hyperreflexia, drooling)

in patients receiving large doses and especially in older

adults.

12. Monitor diabetic patients for loss of glycemic control.

Hyperglycemia or hypoglycemia occur in some patients.

13. Inspect oral mucosa frequently, especially gingival

surfaces under dentures.

14. Encourage the patient and family to change position

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slowly and in stages, especially from lying down to

upright posture and dangle legs over bed for a few

minutes before walking.

15. Inform not to use OTC drugs while on a TCA without

physician approval.

16. Educate to avoid exposure to strong sunlight because of

potential photosensitivity. Use sunscreen with at least

SPF of 12–15 if allowed.

Table 3. Drug Study of imipramine (Tofranil)

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Drug Study 4. tolterodine tartrate (Detrol)

Date Ordered N/A

Generic Name tolterodine tartrate

Brand Name Detrol

Anticholinergic
Classification

Dosage and Child 5–17 years: 1 mg once daily, dose to be taken at bedtime,

Frequency then increased if necessary up to 2 mg twice a day

Rationale for Drug To control urge urinary incontinence, urgency, and frequency

Order

Indications Detrol tablets are indicated for the treatment of overactive

bladder with symptoms of urge urinary incontinence, urgency,

and frequency

Contraindications ● Tolterodine is contraindicated in patients who have

 30

demonstrated hypersensitivity to the drug or its

ingredients;

● Due to the anticholinergic effects, tolterodine is

contraindicated in patients with urinary retention;

● Tolterodine is contraindicated in patients with

uncontrolled narrow or closed-angle glaucoma;

● Tolterodine has a direct antispasmodic effect on smooth

muscle that can delay gastric emptying and is therefore

contraindicated for use in patients with gastric retention;

Mechanism of It works by preventing spasms of the bladder muscle which can

Action help to reduce the episodes of urinary incontinence or reduce

the feeling of urgency that bladder spasms can cause.

Adverse Effects Lymphatic: swelling of the face, throat, tongue, lips, and eyes;

Resp: difficulty of breathing, difficulty swallowing.

Side Effects CNS: headache, dizziness;

EENT: blurred vision, dry eyes;

GI: dry mouth, constipation, dyspepsia.

1. Assess dizziness that might affect gait, balance, and

Nursing
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Responsibilities other functional activities. Report balance problems and

functional limitations to the physician, and caution the

patient and family/caregivers to guard against falls and

trauma;

2. Monitor signs of urine retention (difficult urination, painful

or distended abdomen). Excessive urinary retention may

require dose adjustment by physician;

3. Advise patient to increase fluid intake and dietary fiber to

avoid constipation;

4. Instruct patient and family/caregivers to report other

troublesome side effects such as severe or prolonged

headache, blurred vision, dry eyes, or GI problems (dry

mouth, indigestion).

Table 4. Drug Study of tolterodine tartrate (Detrol)

Ideal Nursing Management

The Ultimate goal of the nursing management is to make sure that the patient will have

an optimal voiding pattern; patient will be free from infection; patient will understand and

act on urge to void; patient will have decreased number of incontinent episodes.
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1. Perform physical assessment, noting signs of rash or irritation of the genital area

● Skin irritation may cause a child to hold urine if there is pain with voiding.

Observe for signs of sexual abuse.

2. Obtain history from patients and parents/caregivers. Note any changes in home or

social situation that may cause stress.

● Help determine cause of symptoms: social or emotional stress and changes in

family dynamics can cause children to have wetting accidents

3. Assess abdomen

● Look for signs of distention

● Listen – auscultate for bowel sounds

● Feel- palpate for distended bladder or signs of constipation. Note presence of

tenderness

● Chronic constipation can be a factor in causing enuresis. A large mass of stool in

the colon puts pressure on the bladder, which may lead to a diminished ability to

control urine or a decreased capacity to hold urine.

4. Collect sample and monitor results for urinalysis

● To determine if a urinary tract infection is the cause of symptoms

5. Administer medication as appropriate

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● Antibiotics may be given if the cause of enuresis is determined to be urinary tract

infection.

● The medication desmopressin may be given for low levels of vasopressin, a

hormone that tells the kidneys to slow urine production.

● Imipramine may be given to help stimulate vasopressin secretion and decrease

REM sleep so the patient wakes with an urge to void.

6. Provide education and motivational interventions:

● Keep a calendar of wet and dry days

● Set a toileting schedule

● Avoid caffeine or high-sugar drinks

● Minimize fluid intake in the evening

● Consider enuresis alarms

● Help the child train their body to void at appropriate times.

● Sugar and caffeine can increase urgency and frequency of urination, especially

at night.

● Encourage fluid intake in the daytime hours, but limit fluid in the evenings to

prevent overload during the night.

● Alarms may be placed on the bed to alert or wake the child when they want to

void .

7. Provide education and resources for parents

● Encourage parents/caregivers to be patient with their child.

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● Remind parents/caregivers that the child is not at fault and discourage

punishments which can cause stress and worsen the situation.

● Provide referrals as appropriate for behavioral health or urology specialists if

necessary.
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Prognosis

CRITERIA POOR FAIR GOOD JUSTIFICATION

Duration of Illness ✓ Patient has been diagnosed with

enuresis at the age of 3. Signs and

symptoms are still present at

present - 6 years old. Wherein the

case is considered as chronic.

Onset of Illness ✓ Most kids are fully toilet trained by

age 5, but there's really no target

date for developing complete

bladder control. Between the ages

of 5 and 7, bed-wetting remains a

problem for some children.Hence,

the patient is a 6 year old child,

considered a treatable age.

Precipitating ✓ Age and sex, presence of ADHD.

Factors Patient is a 6 year old male. These

factors can be highly managed. At

early ages, there are still chances of

prevention through toilet training.

The patient is diagnosed with

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ADHD which may contribute to

behavioral problems that may alter

toilet training.

Mood and Affect ✓

In this case, the patient manifests

irritability, decreased interest and

periods of emotional outbursts but

shows positive and happy attitude

towards parents when needs are

attended to.

Willingness to Take ✓ Patient adhere to treatment and

Medications/Compli management of problems when

ance with assisted by parents. Medical needs

Therapeutic are sustained.

Any Depressive ✓ As diagnosed with ADHD, patient

Features manifests depressive features such

as fidgeting, and periods of

inattentiveness.

Family Support ✓ The family, especially parents of the

patient, provides sufficient support

towards the management and

 37

treatment of the patient’s condition.

IMPLICATION
 38

CHAPTER VI

GORDON’S FUNCTIONAL HEALTH PATTERN

This chapter presents the 11 Gordon’s Functional health pattern with patient’s

information, problem list, prioritization of the problems, nursing care plan designed for

the patient and health teachings.

1. Health Perception-Health Management Pattern

Prior to admission

● Patient is a 6 years old male, diagnosed with ADHD;

● Patient reported to his mother that he is constantly voiding in his bed

unintentionally;

Upon admission

● Patient arrived in the ER with his mother and presented with daytime

wetting;

● Patient was shy and shows apprehension while talking with the nurses

and hides behind his mother;

● The patient will not allow the nurses to conduct the assessment procedure;

● Was assisted by his mother to calm down and try to cooperate with the

assessment;

2. Nutritional- Metabolic Pattern

Prior to admission
 39

● The guardian reported that the patient will sometimes lose interest in his

food if the food appearance is not creative;

● The guardian reported that the patient can finish his meal as long as he is

assisted;

● H: 3ft 9 inches; W: 45lbs; BMI= 15.6 (Normal= Pedia)

Upon admission

● Able to empty plate when assisted by his mother;

● Losses interest when food is not visually appealing for him;

● H: 3ft 9 inches; W: 45lbs; BMI= 15.6 (Normal= Pedia).

3. Elimination Pattern

Prior to admission

● Patient arrived at the ER with reports of daytime bedwetting;

● The guardian reported that the patient was toilet trained at age 3 but is

using diapers again due to constant voiding;

● Patient voided during assessment.

Upon admission

● Patient bowel movements were normal;

● Initial evaluation was conducted and it consisted of urinalysis, urine culture,

serum creatinine level, and bladder ultrasound examination;

● Patient is able to pass stool 3x a week and has a urine output of more

than 2.5 liters.

4. Activity-Exercise Pattern

Prior to admission:
 40

● The patient reported that he always wants to take care of himself and do

things on his own independently but her mother is assisting him to the

toilet because he pees unexpectedly during morning while sleeping.

● The mother reported that she aids her son in dressing, washing, feeding,

and especially toileting because he is unable to do so on his own.

Upon admission:

● Lack of focus and paying attention is observed

● Needs assistance in doing basic tasks such as toileting

5. Sleep- Rest Pattern

Prior to admission:

● The patient reported being hesitant to sleep during the night because of

the fear of wetting his bed during day time.

Upon admission:

● Disturbed sleep and urge incontinence is observed

6. Cognitive-Perceptual Pattern

Prior to admission:

● The patient verbalized that he dislikes nurses and only wants to listen to

his mommy

● The patient admits having little or difficulty to have focus and attention

during interviews and irritability during physical examination and medical

treatments.
 41

Upon admission:

● Inaccurate follow-through of instructions is observed

● Restlessness, excessive physical movement, and easily distractedness

are observed.

● The patient shows inappropriate behaviors during medical treatment

7. Self-Perception – Self-Concept Pattern

Prior to admission:

● Stated being easily disgusted and frustrated with self because of being

unable to control voiding activities

● Finds himself different from other children because of his incapability

Upon admission

● Observed fidgeting

● Reports feelings of dread, worry and nervousness about his condition that

might embarrass him to other people

● Observed restlessness and irritability

8. Role-Relationship Pattern

Prior to admission:

● Mother of the patient stated that patient is well-loved and taken care of in

the family

● Mother of the patient stated that patient is an active member of the family

who provides joy and happiness to them

● Mother of the patient stated being able to handle the patient's condition

and is willing to support the child’s needs.

 42

Upon admission:

● Patient stated having good quality times with his parents

● Observed good parental relationship

● Patient stated being happy because of parent’s support towards his needs

and other wants

9. Sexuality-Reproductive Pattern

Prior to admission:

● Patient is a 6 year old child with no sexual concerns, history and problems.

Upon admission:

● Patient is a 6 year old child with no sexual concerns, history and problems.

10. Coping-Stress Tolerance Pattern

Prior to admission:

● The patient feels uncomfortable and ashamed when participating in the

activities.

Upon admission:

● The patient shows irritability, decreased interest during the physical

examination and medical treatment.

● Emotional outburst is observed.

Values-Belief Pattern

Prior to admission:

● The guardian stated that the patient prays every morning and night before

going to sleep.
 43

Upon admission:

● Prays a short prayer before going to bed with his guardian.

 44

GORDON’S FUNCTIONAL HEALTH PATTERN

Functional Cue Cluster Interference Diagnosis Priority Rationale

Health
Pattern

1. Health S: “I don’t want that

Ineffective Ineffective Low This pattern is given
Perception/He thing, I'm scared of it
adherence adherence r/t client- a rate of low
alth and also to everyone
provider relationship because the main
Management that is wearing white.
amb avoidance of cause of the
I want to go home
assistance from patient's ineffective
and hide” as
healthcare providers adherence is due to
verbalized by the
and shy attitude his ADHD. Patients
patient
towards unfamiliar with ADHD are
individuals known to have short
O: Patient is a 6 year
span attention,
old male diagnosed
impulsive, and
with ADHD; patient
hyperactive that
avoids from nurses
makes them wary of
during conduction of
unfamiliar
diagnostic test
surroundings and
(voiding
individuals, this
cystourethrogram);
 45

shows behavior that makes them also to

fails to follow the lose interest with the
assessment things that are being
procedure; patient done to them. In the
follows instructions if end despite the
given by parents; apprehension of the
patient is shy and is patient, he was still
having a hard time able to do the
talking to strangers. diagnostic test with
the assistance of his
mother. The nurses
believe that as the
patient adapts to the
surroundings, his
ineffective
adherence will be
diminished and will
be able to participate
in the treatment
management with
the help of his
mother and the other
 46

healthcare providers.

2. Nutritional
S: “I don’t want to eat Not a problem Not a problem Low This pattern is
Metabolic
anymore, my food considered as not a
Pattern
looks bad mommy. I problem because the
want my food to patient's height and
have stars and cars weight generates a
just like in our house normal BMI result for
but you said that I’m kids, age of 6. In
a good boy so I will addition, the child
still eat even though was diagnosed with
the food is ugly” as ADHD, some
verbalized by the children with ADHD
patient have a short span of
attention and a
O: Patient loses
simple meal can
interest in the meal
make them bored
after a few minutes
but despite the lack
of eating; able to
of interest of the
finish food with
 47

assistance and child, the patient was

persuasion by his still able to finish his
mother; H: 3ft 9 meal with the
inches; W: 45lbs; assistance of his
BMI= 15.6 (Normal= mother. The nurses
Pedia) believe that if the
visual of the food
can be modified the
patient will have
more interest while
eating, at the same
time the lack of
interest on the meal
doesn’t affect the
pattern because his
BMI is still normal.

3. Elimination
S: “Mom, I peed Urge Urinary Total Urinary High 1 This pattern is given
Pattern
again in my pants, Incontinence Incontinence r/t a high 1 because the
what do I do? It’s all urethral obstruction patient cues shows
wet, the nurses will amb day time that his urinary
 48

see it and I think they bedwetting; bilateral incontinence affects

will get mad because mild hydronephrosis his daily lifestyle and
I made a mess in the and trabeculated his own self
bed. Im sorry mom, I bladder with confidence. In
wasn’t able to control inappropriate addition, it can be
it because it just voluntary contraction seen that the cause
really went out and I of urinary sphincter of the urinary
feel like I was gonna incontinence is due
pee” as verbalized to the constant
by the patient urethral obstruction,
a urethral obstruction
O: Patient is a 6 year
can cause a serious
old male presented
complication such as
with day time
putting the
urinating; bowel
individual's kidney at
movement is 3x a
risk of infection and
week and has a
can be deadly for the
urine output of more
patient. The urinary
than 2.5 liters; toilet
incontinence can
trained at the age of
also cause different
3 years but was back
complications such
in diapers at the
as skin problems
 49

present; during because constant

assessment his wet skin may cause
bowel movements rashes, sores and
were normal; The skin infection and
initial evaluation was can even lead to
done and was urinary tract
consisted of a infections. If not
urinalysis, urine given immediate
culture, serum attention and
creatinine level, and management the
bladder ultrasound urinary incontinence
examination: can affect the
different patterns
● Urine studies=
and will put patients'
normal;
life in a constant
● Serum
problem that will
creatinine
alter his comfort.
level= 1.0
mg/dL
(elevated);
● Ultrasound
examination
 50

revealed
bilateral mild
hydronephrosi
s and a
thickened
bladder wall;
● Cystoscopy
revealed a
highly
trabeculated
bladder, as is
seen in either
high-grade
obstruction;
● Urodynamic
studies
revealed a
high-pressure
bladder, poor
emptying, and
inappropriate
voluntary
 51

contraction of
the striated,
urinary
sphincter
during
micturition.

4. Activity
S: “I always try to Self-care deficit Self-care deficit: Mod 2 This is given a
Exercise
take care of myself toileting related to moderate 2 priority
Pattern
because I want to be cognitive impairment since the patient has
independent but my as manifested by been diagnosed with
Mommy always inability to get to the ADHD/Hyperactivity
assists me in toilet and day time which is a cognitive
toileting because I bed wetting disorder that causes
accidentally pee in the patient to be
my bed during unstable and lack
morning”As focus. The lack of
verbalized by the focus and attention
patient’s mother. of the patient causes
him to have
O: Lack of focus and
difficulties in finishing
attention is

observed; Patient is
dependent on the
parents in doing
simple tasks. Unable
to do simple tasks
5. Sleep/Rest
S: “My mother wants Disturbed sleep
Pattern
me to sleep early,
but I’m kind of
hesitant because if I
sleep then when I
wake up, my bed is
full of pee. I’ll be too
shy to tell my mom
that I wet my bed
and I am afraid that
she will get angry at
me.” as verbalized
by the patient.
52
simple tasks such as
toileting and getting
to the toilet and the
patient becomes
dependent on the
parents' assistance.
Disturbed sleep High 3 This is given a high 3
pattern pattern related to priority since the
urge incontinence as patient is hesitant to
manifested by fear of sleep early because
wetting bed of the concern of
wetting his bed after
peeing in the
morning. This
problem will give
stress to the patient
and also to the
parent in which the
patient will no longer
have the confidence
 53

to have a nice and

O: Patient is hesitant
good sleep. Hence,
to sleep due to
sleep plays an
concern of daytime
important role to
wetting; taking a long
children’s health
time to sleep
which helps in
because of worrying
having improved
attention, behavior,
learning, memory,
and overall mental
and physical health.

6. Cognitive
“I don't like what the Disturbed thought Disturbed thought Mod 3 This is given a
Perceptual
nurses are doing or process process related to moderate 3 priority
Pattern
asking me. I want mental illness because of his
them to leave secondary to ADHD altered attention
because I dislike as manifested by span and improper
them. All I want to do altered attention behavior, the patient
is listen to my span and is unlikely to comply
mommy. I know inappropriate with the medical
they're trying to help behavior therapy provided by
 54

me, just like my mom the nurses. A person

said, but I'm with ADHD has
becoming tired of trouble with attention
everything they're span or lack of focus
doing and requesting and shows
of me” as verbalized inappropriate
by the patient. behaviors such as
being irritable. These
kinds of behaviors

O: Inaccurate follow- are hindrance in

through of terms of the medical
instructions is process of the
observed; patient whereas the
Restlessness, patient could be
excessive physical more likely not to
movement, and adhere or cooperate
easily distractedness to assessments and
are observed.; The medical procedure.
patient shows
inappropriate
behaviors during

medical process
7.Self-
S: “Uhm, I think I am Fear
Perception/Sel
different from other
f-Concept
children and my
Pattern
friends because I am
not like them. I am
different because I
always get wet on
my bed and I can’t
control it. I always
get annoyed when I
don’t notice that I
already pee. I said to
mommy that I am
really disgusted and
frustrated with this
happening. I am
worried, fearful and
55
Fear related to High 2 This is rated as high
perceived inability to 2 because a child’s
control events as fear may linger and
evidenced by reports continue as he
of feelings of worry, grows. If so, the
nervousness and patient who is just
fearfulness, six years old may
fidgeting, develop further
restlessness and anxiety and
irritability. problems which may
affect his
perspectives about
himself which will
then lead to inability
to cope up with
situations and
problems that arise
 56

nervous that my because of

friends and powerlessness and
playmates will find hopelessness. This
out that I am like this needs a thorough
and I might get assessment and
embarrassed.” as intervention to
verbalized by the provide an early
patient. management of fear
because in this case,
O: Observed
the patient’s positive
nervousness through
self perception and
small movements of
management is
the hands (fidgeting)
much needed in
and observed
order to adhere to
restlessness and
needed treatment of
irritability.
the case. Thus,
leading to a good
and better health
outcome.
 57

8. Role-
S: “My family is my Readiness for Readiness for Low This is rated as low
Relationship
biggest supporter in enhanced family enhanced family because in this case,
Pattern
my life. I love my coping coping a patient needs
mommy so much much family support
because she buys and guidance since
me what I want just the patient is a child.
like the toys that I It is important for the
have. She brings me family and the child
to the doctor when I to be willing and be
am sick. Maybe I will ready to have an
cope up with my enhanced health and
problem through my also, personal
family. I am a lucky growth. Through this,
child! “ as verbalized a patient's problem
by the patient; with self-
Mother of the patient management and
stated “We are really perception may be
concerned about our highly affected
baby boy’s needs because it reflects
and wants. We make potential for personal
sure that he feels growth. Hence,
 58

loved and accepted family plays an

because he’s essential role in this
becoming anxious child’s health crisis
about his condition. which supports and
We don’t consider optimizes wellness.
him as a problem
and a burden to the
family because
honestly, he makes
us happy and joyful.
So whatever this
problem may give
us, we are always
willing to risk and
spend everything
that it needs.”

O: Observed good
parental guidance
and relationship;
observed intimacy in
the family.
 59

9. Sexuality S: “In terms of sexual Not a problem Not a problem Low This is considered as
Reproductive and reproduction, not a problem
Pattern there are no because the patient
problems since my has no any sexula
son is still young, concerns, history
who is 6 years old.” and problems since
as verbalized by the he was still a child.
mother of the patient.

10. Coping S:” Sometimes he Risk for Risk for situational Mod 1 This pattern is rated
Stress feels uncomfortable situational low low self-esteem as since the patient
Tolerance while talking to self-esteem related to negative expresses fluctuating
Pattern strangers and he ask feelings as feelings such as
me to accompany manifested by irritability and
him” as verbalized by irritability, emotional emotional outburst
the patient’s mother outburst and shame. while doing the
assessment being
provided by the
O: Nodding is noted , nurse. Children with
shows irritability ADHD tend to be

during the emotional and feel

 60

assessment, things very deeply.

emotional outburst is This problem can
observed. lead the patient to
embarrassment or
shame.

11. Values S: “After he wakes Not a Problem Not a Problem Low This pattern is rated
Belief Pattern up in the morning as not a problem
and before going to since the patient
be at night he does has good values and
prayer asking the belief patterns and is
Lord for guidance .” able to gain strength
as verbalize by the and guidance in God
patient’s mother through prayers
along with his
O: The patient prays
significant others.
every morning and
night to gain strength
and guidance in
God.
 61

Problem List

Problem (PES) Date Identified Time Date Resolved

November 22, 2021 8:00 AM Ongoing

Total Urinary Incontinence

r/t urethral obstruction amb

day time bedwetting;

bilateral mild

hydronephrosis and

trabeculated bladder with

inappropriate voluntary

contraction of urinary

sphincter

November 22, 2021 9:00 AM Ongoing

Fear related to perceived

inability to control events as

evidenced by reports of
 62

feelings of worry,

nervousness and

fearfulness, fidgeting,

restlessness and irritability.

November 22, 2021 4:00 PM Ongoing

Disturbed sleep pattern

related to urge incontinence

as manifested by fear of

wetting bed

November 22, 2021 1:00 PM Ongoing

Risk for situational low self-

esteem related to negative

feelings as manifested by

irritability, emotional

outburst and shame

November 22, 2021 10:00 AM Ongoing

Self-care deficit: toileting
 63

related to cognitive

impairment as manifested

by inability to get to the toilet

and day time bed wetting

November 22, 2021 8:30 AM Ongoing

Disturbed thought process

related to mental illness

secondary to ADHD as

manifested by altered

attention span and

inappropriate behavior

November 22, 2021 8:00 AM Ongoing

Ineffective adherence r/t

client- provider relationship

amb avoidance of

assistance from healthcare

 64

providers and shy attitude

towards unfamiliar

individuals

November 22, 2021 3:00 PM Ongoing

Readiness for enhanced

family coping
 65

Prioritization of Problems

PROBLEM Priority Rationale

Total Urinary Incontinence r/t urethral This pattern is given a high 1 because
High 1 the patient cues shows that his
obstruction amb day time bedwetting;
urinary incontinence affects his daily
bilateral mild hydronephrosis and
lifestyle and his own self confidence.
trabeculated bladder with In addition, it can be seen that the
cause of the urinary incontinence is
inappropriate voluntary contraction of
due to the constant urethral
urinary sphincter
obstruction, a urethral obstruction can
cause a serious complication such as
putting the individual's kidney at risk
of infection and can be deadly for the
patient. The urinary incontinence can
also cause different complications
such as skin problems because
constant wet skin may cause rashes,
sores and skin infection and can even
lead to urinary tract infections. If not
 66

given immediate attention and

management the urinary incontinence
can affect the different patterns and
will put patients' life in a constant
problem that will alter his comfort.

Fear related to perceived inability to This is rated as high 2 because a

High 2
control events as evidenced by reports child’s fear may linger and continue

of feelings of worry, nervousness and as he grows. If so, the patient who is

fearfulness, fidgeting, restlessness just six years old may develop further

and irritability anxiety and problems which may

affect his perspectives about himself

which will then lead to inability to cope

up with situations and problems that

arise because of powerlessness and

hopelessness. This needs a thorough

assessment and intervention to

 67

provide an early management of fear

because in this case, the patient’s

positive self perception and

management is much needed in order

to adhere to needed treatment of the

case. Thus, leading to a good and

better health outcome.

Disturbed sleep pattern related to urge This is given a high 3 priority since the
High 3
incontinence as manifested by fear of patient is hesitant to sleep early

wetting bed because of the concern of wetting his

bed after peeing in the morning. This

problem will give stress to the patient

and also to the parent in which the

patient will no longer have the

confidence to have a nice and good

 68

sleep. Hence, sleep plays an

important role to children’s health

which helps in having improved

attention, behavior, learning, memory,

and overall mental and physical

health.

Moderate 1
Risk for situational low self-esteem This pattern is rated as since the

related to negative feelings as patient expresses fluctuating feelings

manifested by irritability, emotional such as irritability and emotional

outburst and shame outburst while doing the assessment

being provided by the nurse. Children

with ADHD tend to be emotional and

feel things very deeply. This problem

can lead the patient to

embarrassment or shame

Self-care deficit: toileting related to
cognitive impairment as manifested by
inability to get to the toilet and day
time bed wetting
Disturbed thought process related to
mental illness secondary to ADHD as
manifested by altered attention span
and inappropriate behavior
69
This is given a moderate 2 priority
Moderate 2
since the patient has been diagnosed
with ADHD/Hyperactivity which is a
cognitive disorder that causes the
patient to be unstable and lack focus.
The lack of focus and attention of the
patient causes him to have difficulties
in finishing simple tasks such as
toileting and getting to the toilet and
the patient becomes dependent on
the parents' assistance.
This is given a moderate 3 priority
Moderate 3
because of his altered attention span
and improper behavior, the patient is
unlikely to comply with the medical
 70

therapy provided by the nurses. A

person with ADHD has trouble with

attention span or lack of focus and

shows inappropriate behaviors such

as being irritable. These kinds of

behaviors are hindrance in terms of

the medical process of the patient

whereas the patient could be more

likely not to adhere or cooperate to

assessments and medical procedure.

Ineffective adherence r/t client- This pattern is given a rate of low

Low 1
provider relationship amb avoidance because the main cause of the

of assistance from healthcare patient's ineffective adherence is due

providers and shy attitude towards to his ADHD. Patients with ADHD are

unfamiliar individuals known to have short span attention,

 71

impulsive, and hyperactive that makes

them wary of unfamiliar surroundings

and individuals, this makes them also

to lose interest with the things that are

being done to them. In the end

despite the apprehension of the

patient, he was still able to do the

diagnostic test with the assistance of

his mother. The nurses believe that as

the patient adapts to the

surroundings, his ineffective

adherence will be diminished and will

be able to participate in the treatment

management with the help of his

mother and the other healthcare

providers.
 72

Readiness for enhanced family coping This is rated as low because in this
Low 2
case, a patient needs much family

support and guidance since the

patient is a child. It is important for the

family and the child to be willing and

be ready to have an enhanced health

and also, personal growth. Through

this, a patient's problem with self-

management and perception may be

highly affected because it reflects

potential for personal growth. Hence,

family plays an essential role in this

child’s health crisis which supports

and optimizes wellness.

 73

Nursing Care Plan

Nursing care plan for Total Urinary Incontinence

Health Desired Evaluation

Cues Diagnosis Intervention Rationale Evaluation
Pattern Outcome Modification

After 8 Independent: Goal Continuity of

S: “Mom, I peed Total
again in my pants, Eliminati hours of 1. Obtain a 1. The partially care is needed
Urinary
what do I do? It’s on nursing history of symptom met. Patient in order to
Incontinenc
all wet, the nurses
pattern intervention duration of and minimize the
will see it and I e r/t
think they will get , patient will and continuou significant embarrassment
urethral
mad because I be able to severity of s other was and anxiety of
obstruction
made a mess in
urine loss, incontine able to the child and
the bed. Im sorry amb day
mom, I wasn’t able General: previous nce may establish the frustration
time
to control it ● Esta method of be bladder experienced by
bedwetting;
because it just
blish manageme caused regimen the parents.
really went out and bilateral
 74

I feel like I was mild blad nt, and by extra with the Most children
gonna pee” as
hydronephr der aggravatin urethral help of with enuresis
verbalized by the
osis and regi g or leakage nursing feel very much
patient
trabeculate men alleviating or other intervention alone with their
O: Patient is a 6
year old male d bladder for features. types of s. Patient is problem.

presented with day with indivi incontine in the Hence,

time urinating;
inappropriat dual nce that process of continuous
bowel movement
is 3x a week and e voluntary situat have maintaining adherence to

has a urine output contraction ion been normal the

of more than 2.5
of urinary with inadequa voiding interventions
liters; toilet trained
at the age of 3 sphincter the tely periods and would lead to

years but was help evaluated adheres to proper and

back in diapers at
of and/or further appropriate
the present; during
Backgroun care managed intervention elimination
assessment his
bowel movements d giver . The that could patterns with
were normal; The knowledge: and patient lead to the help of
initial evaluation
 75

was done and was man history regular containment

According
consisted of a
age will voiding devices and
urinalysis, urine to NANDA,
incon provide schedule other
culture, serum urinary
creatinine level, tinen clues to with normal techniques
incontinenc
and bladder
ce the urine provided. Once
ultrasound e is the
with etiology output. With continued, as
examination: inability of
the of the that, patient the child ages,
● Urine usually
studies= famil urinary has also management of
continent
normal; y or leakage. maintained the case will be
person to
● Serum
signif In this intact carried out
creatinine reach the
level= 1.0 icant case, perineal leading to
toilet in
mg/dL other participati skin and better health
time to
(elevated);
so on of the starts to outcome.
● Ultrasound avoid
examination that parents use a
unintention
revealed socia or containmen
al loss of
bilateral
l caregiver t device in
mild urine.
 76

hydronephr Whereas in functi may also clothing to

osis and a
this case, onin be used maintain
thickened
the patient g is to gather dignity.
bladder
wall; is main data.
● Cystoscopy
experiencin taine
revealed a
g daytime d or 2. Complete a 2. The
highly
trabeculated bedwetting. regai bladder log bladder
bladder, as
He ned. of urine log
is seen in
manifests elimination provides
either high-
grade enuresis patterns further
obstruction;
starting 3 Specific: and informati
● Urodynamic
years of ● Urine frequency on,
studies
revealed a age and loss and allowing
high-
cannot is severity of the nurse
pressure
control adeq urine loss to
bladder,
poor voiding at uatel with the differenti
emptying,
 77

and present age y help of the ate

inappropriat
- 6. cont patient’s extrauret
e voluntary
aine guardian. hral from
contraction
of the d, other
striated,
clothi forms of
urinary
ng urine loss
sphincter
during rema and
micturition.
ins providing

unsoi the basis

led, for further

and evaluatio

odor n and

is treatment

contr

olled 3. Urine

● Main 3. Assist the containm

 78

tains patient and ent

intact the products

perin caregiver include a

eal to select variety of

skin and apply absorptiv

● Main a urine e pads,

tains containme incontine

dignit nt devices nt briefs,

y, or devices. underpad

hides Review s for

urine types of bedding,

cont containme absorptiv

ainm nt products e inserts

ent with the that fit

devic patient and into

e in caregiver, specially
 79

clothi including designed

ng, advantage undergar

and s and ments,

mini potential and

mize complicatio condom

s ns catheters

bulk associated . Careful

and with each selection

noise type of of a

relat product. containm

ed to ent

the product

devic and

e education

concernin

g its use
 80

maximize

s its

effectiven

ess in

controllin

g urine

loss for a

particular

individual

4. Cleansin

g the

4. Cleanse patient’s

the skin perineal

with an area may

incontinenc help in

e cleansing preventin
 81

product g dryness

system or and

plain water avoids

when exacerba

changing ting

urinary alteration

containme s in skin

nt devices integrity.

or pads. Moisturiz

Use soap ers

and water promote

on the comfort

perineum and may

no more reduce

than once the risk of

daily or skin
 82

every other breakdow

day as n.

necessary.

Apply a

skin

moisturizer

following

cleansing.

Teach also

the

significant

other on

how to

perform the 5. A

cleansing. calendar

can help
 83

5. Educate determin

and e if there

encourage is a

the patient pattern to

and wetting

significant and what

others to may

keep a trigger

calendar of the

wet and incidents.

dry days.

6. Toilet

training

may help

6. Encourage the child

significant train their

 84

others to body to

continue void at

toilet appropria

training. te times.

Set a In spite of

toileting bedwettin

schedule g

and periods,

consider the body

the use of can still

enuresis adjust

alarms with the

while being help of

patient with supportin

the child. g

devices.
 85

Also,

alarms

may be

placed on

the bed

to alert or

wake the

child

when he

void.

1. The use

of

medicatio

Dependent: n help to
 86

1. Administer reduce

medication occurren

as ce of

prescribed incontine

by the nce

physician.

2. Helps the

caregiver

s to

ensure

that the

2. Monitor patient

Input and has

Output proper

Daily intake of

fluid and
 87

to

determin

e the

output of

urine.

3. Schedule

voiding

allows for

frequent

bladder

3. Promote emptying.

access to

toilet

facilities

and
 88

instruct the

significant

others to 4. Helps the

make patient to

scheduled improve

trips to the bowel

bathroom. moveme

nt and

4. Promote successf

toilet ully

training voiding.

such as

bladder

training,

pelvic floor

exercise
 89

1. Physical

Collaborative: therapy

.1. Refer the helps

patient to physical reduce

therapist the

symptom

s and

incidence

of

incontine

nce by

strengthe

ning the

pelvic

floor
 90

muscles.
 91

Nursing care plan for Fear

Health Desired
Cues Diagnosis Intervention Rationale Evaluation
Pattern Outcome

Self After 8hrs of Independent: Goal partially

S: “Uhm, I think I Fear
am different from perceptua Nursing 1.Open up about your 1.This approach met. After
related to
other children and l- Self Intervention awareness of the validates the 8hrs of
perceived
my friends because
perceptio the patient will patient’s fear; feelings the patient nursing
I am not like them. I inability to
am different n pattern be able to: is holding and intervention
control
because I always ● Be demonstrates the patient is
events as
get wet on my bed
confide recognition of those seen to be
and I can’t control evidenced
it. I always get nt and feelings; more open to
by reports
annoyed when I open his thoughts,
of feelings
don’t notice that I
with his 2.Tell patient that fear he was also
already pee. I said of worry,
to mommy that I conditio is a normal and 2.This action places able to
nervousnes
am really disgusted n to his appropriate response fear within the field understand
s and
and frustrated with
friends to circumstances in of normal human his condition
this happening. I
 92

am worried, fearful fearfulness, and which loss of control experiences; and enabled
and nervous that
fidgeting, close is anticipated or felt; the nurses to
my friends and
restlessnes loved be closer to
playmates will find
out that I am like s and ones; 3.Discuss the him, but the
this and I might get
irritability ● Have a situation and the 3.To enable patient nurses can
embarrassed.” as
close happenings to the to understand the still notice that
verbalized by the Backgroun
patient. interacti patient in a easy and situation and adjust the patient is
d
O: Observed on with calm manner; to the environment; still have
Knowledge:
nervousness the constant
through small Fear is a nurses; 4.Stay with the thoughts of
movements of the
distressing ● Verbali patient to make them 4.Because the worries about
hands (fidgeting)
and observed emotion ze feel safe especially patient feels lost his bed
restlessness and caused by underst during frightening with the problem he wetting and
irritability.
impending anding procedures; may also feel that the thoughts
danger or with the he is not safe letting of his friends
pain conditio people inspect him, and other
 93

whether the n; by being on his side loved ones.

threat is ● Display he will have a

real or actions sense of familiarity

imagined. that 5.Maintain a quiet to the people that

The shows environment whether are inspecting him;

individual perseve at home or in a

experiencin rance hospital setting. Drop 5.Patient’s fear is

g fear can on any unnecessary stuff not reduced and

recognize followin around the patient resolved if the

the person, g health when trying to
environment is
place, or treatme communicate with
unsafe;
thing nt and them;

precipitatin manag

g this ement Collaborative:

1.Cognitive
feeling. In 1.Refer patient for a
behavioral therapy
the patient cognitive behavioral
 94

case, he is therapy enables to

a 6 year old manage fears by

child helping the way a
diagnosed
think. It's based
with ADHD
on the
and given
interconnectednes
the patient
s of thoughts,
mental
beliefs, feelings,
health
and behaviors
status it

also plays

on the

factor why

the patient

is

experiencin
 95

g fear

especially

that he was

in a

unfamiliar

place and

he was not

able to

understand

the problem

in his body.
 96

Nursing care plan for Disturbed Sleep Pattern

Health Desired Evaluation

Cues Diagnosis Intervention Rationale Evaluation
Pattern Outcome Modification

Sleep/Rest Independent: Patient Goal Partially

S: “My mother Disturbed After 8 hrs
wants me to Pattern sleep pattern of nursing 1. Determine 1. Each was able met.
intervention,
sleep early, but related to patterns of individual has to obtain
the patient
I’m kind of urge will be able
sleep in the different amounts -Continuity of
hesitant incontinence to:
1. Patient past in a patterns of of sleep as care
because if I as
sleep then when manifested obtains normal sleep. evidence -Continues to
I wake up, my by fear of optimal environment: Information d by encourage the
bed is full of wetting bed
amounts of amount, about this patient follow
pee. I’ll be too rested
shy to tell my sleep. bedtime topic the treatment
appearan
mom that I wet 2. To see routines, provides -The patient is
my bed and I ce,
improveme depth, length, baseline data still adjusting
am afraid that
verbalizati
she will get nts in the positions, for evaluating in peeing
angry at me.” as on of
sleep/rest aids, and means to before going
verbalized by
 97

the patient. pattern. other improve the feeling to bed

interfering patient’s rested,

Specifically factors. sleep and
O: Patient is
1. Report
hesitant to sleep improvem
improveme
due to concern ent in
nt in 2. Encourage 2. .This will
of daytime sleep
sleep/rest the patient to prevent the
wetting; taking a pattern.
pattern. void or empty patient from
long time to
2. Identify the bladder waking up
sleep because
appropriate before going during bed
of worrying
intervention to sleep time hours

s to

promote

sleep 3. Discourage 3. Having full

3. Free from the patient to meals just

worry about eat heavy before

 98

daytime meals, drink bedtime may

wetting. fluids and produce

caffeine gastrointestin

before bed al upset and

time. hinder sleep

onset.

Caffeine

stimulates

the nervous

system . This

may interfere

with the

patient’s

ability to relax

and fall

asleep.
 99

4. Encourage 4. Stress may

daytime be reduced

physical by

activities therapeutic

activities and

may promote

sleep.

5. Remind the

patient to 5. This will

avoid taking a refrain the

large amount patient from

of fluids going to the

before bathroom in

bedtime. between

sleep.
 100

Health Teachings

1. The nurse must teach the patient and the family about the cause of the disease.

2. The nurse educates the patient and family about diurnal enuresis about how and

when to take prescribe medication

3. The nurse provides a verbal and written plan for the patient and family to take

home and use and about the actions and possible side effects of the medications

4. The nurse should explain to the patient and family the importance of frequent

follow-up check ups in order to check if there is an undetected disease that may

occur.

5. Advice the parents and encourage the patient to do frequent toilet training

6. Educate the patient and the family about the bad effects of holding the urine for

too long in the bladder and the importance of immediate toileting.

7. Encourage your child to use the toilet when you notice signs that he or she may

need to go, such as squatting, squirming, crossing the legs, or standing very still.

8. Offer more liquids to drink. Drinking more liquids will increase the amount of urine

in the bladder, causing your child to need to go to the bathroom more often.

9. Instruct the child to go to the bathroom every hour during the day.

10. Encourage your child to take extra time on the toilet so that he or she will be

more likely to empty the bladder.

11. Encourage your child to go to the bathroom whenever the urge happens.

12. Reward your child for being dry. You may use hugs, stickers, or special treats as

rewards.
 101

13. Don't make your child wear a diaper. Wearing a diaper may make him or her feel

babyish. Also, it may be hard for a child to get the diaper off when using the toilet.

Wearing disposable underwear, such as Pull-Ups, may be helpful. But it may

also make the problem last longer, because the child may have less motivation to

learn bladder control.

 102

Bibliography

Website

Cincinnati’s Children. (2018). Daytime Wetting (Diurnal Enuresis).

https://www.cincinnatichildrens.org/health/d/wetting

Drugs.com. (2020). Oxybutynin. https://www.drugs.com/oxybutynin.html

NURSING.com. (2021). Nursing Care Plan for Enuresis / Bedwetting.

https://nursing.com/lesson/nursing-care-plan-for-enuresis-bedwetting/

Editor, B. C. H. (2021). Enuresis (urinary incontinence): Diagnosis & treatments:

Boston Children's Hospital. Boston Childrens Hospital. Retrieved October 25, 2021,

from https://www.childrenshospital.org/conditions-and-

treatments/conditions/e/enuresis-urinary-incontinence/diagnosis-and-treatments.

Editor, J. H. M. (2020). Anatomy of the urinary system. Johns Hopkins Medicine.

Retrieved October 25, 2021, from

https://www.hopkinsmedicine.org/health/wellness-and-prevention/anatomy-of-the-

urinary-system.

Foundation, U. C. (2021). Urodynamics. What is Urodynamics? - Urology Care

Foundation. Retrieved October 25, 2021, from

https://www.urologyhealth.org/urology-a-

z/u/urodynamics#:~:text=Urodynamic%20studies%20(UDS)%20test%20how,could

%20be%20leaks%20or%20blockages.
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Gabbey, A. E. (2017, September 30). Uroflowmetry: Purpose, procedure, and

results. Healthline. Retrieved October 25, 2021, from

https://www.healthline.com/health/uroflowmetry.

Health, M. M. (2021). Cystometry. MidMichigan Health. Retrieved October 25,

2021, from https://www.midmichigan.org/conditions-treatments/tests-

procedures/cystometry/.

Reference, P. D. (2021). Detrol. Detrol (tolterodine tartrate) dose, indications,

adverse effects, interactions... from PDR.net. Retrieved October 25, 2021, from

https://www.pdr.net/drug-summary/Detrol-tolterodine-tartrate-476.

Smith, K., Migala, J., Wessells, D. H., Rauf, D., Bellefonds, C. de, Phillips, Q.,

Dunleavy, B. P., & Patino, E. (2018). Urinalysis: How the test is done and what

results mean. EverydayHealth.com. Retrieved October 25, 2021, from

https://www.everydayhealth.com/urine/urinalysis-how-test-done-what-results-

mean/#:~:text=During%20a%20urinalysis%2C%20a%20clean,and%20measured

%20in%20a%20urinalysis.

Taylor, T. (2021). Urinary system: Anatomy and physiology with Interactive

Pictures. Innerbody. Retrieved October 25, 2021, from

https://www.innerbody.com/image/urinov.html#continued.

Team, C. C. (2021). Urodynamic testing: What is it, procedure & what to expectC.

Cleveland Clinic. Retrieved October 25, 2021, from

https://my.clevelandclinic.org/health/diagnostics/15684-urodynamic-testing.
 104

CURRICULUM VITAE

Renz Kamille M. Balaba

Bachelor of Science in Nursing

PERSONAL INFORMATION

Nickname: Milay

Address: Block 18, Lot 15 Sofia Subdivision, Nursery Road Lagao GSC

Age: 21

Birthdate: January 23, 2000

Birthplace: General Santos City

Citizenship: Filipino

Civil Status: Single

Gender: Female

Religion: Protestant

EDUCATIONAL BACKGROUND

ELEMENTARY General Santos City SPED Integrated School

Years attended: 2006-2012

SECONDARY General Santos City SPED Integrated School

Years attended: 2012-2018

TERTIARY Notre Dame of Dadiangas University

Years attended: 2018-Present

 105

CURRICULUM VITAE

Siparah Richaine T. Basangan

Bachelor of Science in Nursing

PERSONAL INFORMATION

Nickname: Shane

Address: Brgy. Bauyan Purok 2, 408, General Santos City

Age: 22

Birthdate: September 25, 1999

Birthplace: General Santos City

Citizenship: Filipino

Civil Status: Single

Gender: Female

Religion: Islam

EDUCATIONAL BACKGROUND

ELEMENTARY Stratford International School

Years attended: 2006-2012

SECONDARY Stratford International School

Years attended: 2012-2018

TERTIARY Notre Dame of Dadiangas University

Years attended: 2018-Present

 106

CURRICULUM VITAE

Diether John G. Acharon

Bachelor of Science in Nursing

PERSONAL INFORMATION

Nickname: Diet

Address: Brgy. Fatima Purok 18, Employees Village, General Santos City

Age: 22

Birthdate: January 28, 1999

Birthplace: General Santos City

Citizenship: Filipino

Civil Status: Single

Gender: Male

Religion: Roman Catholic

EDUCATIONAL BACKGROUND

ELEMENTARY Dadiangas West Central Elementary School

Years attended: 2006-2012

SECONDARY General Santos City National High School

Years attended: 2012-2018

TERTIARY Notre Dame of Dadiangas University

Years attended: 2018-Present

 107

CURRICULUM VITAE

Jude Michael Alex E. Arizala

Bachelor of Science in Nursing

PERSONAL INFORMATION

Nickname: Jude

Address: Purok 9 Paradise-Arizala Subdivision, Brgy Mabuhay

Age: 21

Birthdate: November 30, 1999

Birthplace: General Santos City

Citizenship: Filipino

Civil Status: Single

Gender: Male

Religion: Protestant

EDUCATIONAL BACKGROUND

ELEMENTARY Gensan Christlife Academy

Years attended: 2006-2012

SECONDARY The Heritage Academy of the Philippines

Years attended: 2012-2018

TERTIARY Notre Dame of Dadiangas University

Years attended: 2018-Present