U
Unilateral Neglect
NANDA-I
Impairment in sensory and motor response, mental representation, and spatial attention of the body and the corresponding environment characterized by inattention to one side and overattention to the opposite side; left-side neglect is more severe and persistent than right-side neglect
Related Factors (r/t)
Note: Because the right hemisphere plays a role in focusing attention while the left hemisphere specializes in global attention, unilateral neglect is more common if neurological pathology occurs in the right hemisphere of the brain, which results in left-sided neglect (Jepson, Despain & Keller, 2008).
NOC (Nursing Outcomes Classification)
Body Image, Body Positioning: Self-Initiated, Mobility, Self-Care: Activities of Daily Living (ADLs)
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Assess the client for signs of unilateral neglect (UN; e.g., not washing, shaving, or dressing one side of the body; sitting or lying inappropriately on affected arm or leg; failing to respond to environmental stimuli contralateral to the side of lesion; eating food on only one side of plate; or failing to look to one side of the body). Many tests for UN exist, but there is no consensus about which is the most valid. Joint assessments of UN that include both clinical observation and precise testing perform better than either used alone (Jepson, Despain, & Keller, 2008; Ting et al, 2011). EB: There is no difference in gender and UN in a sample of 155 women and 157 men with acute stroke (Kleinman et al, 2008). EB: UN was identified in 70 of 71 clients using NIHSS.
Collaborate with physician for referral to a rehabilitation team (including, but not limited to, rehabilitation clinical nurse specialist, physical medicine and rehabilitation physician, neuropsychologist, occupational therapist, physical therapist, and speech and language pathologist) for continued help in dealing with UN. EB: There is some evidence that rehabilitation for unilateral spatial neglect using tools such as visual scanning and prism adaptation improves performance, but its effect on disability is not clear. Further studies are needed (Ting et al, 2011).
• Use the principles of rehabilitation to progressively increase the client’s ability to compensate for UN by using assistive devices, feedback, and support. EB: Studies demonstrate that recovery from UN generally occurs in first 4 weeks after stroke with much more gradual recovery after that (Osawa & Maeshima, 2009).
• Set up the environment so that essential activity is on the unaffected side:
Place the client’s personal items within view and on the unaffected side.
Position the bed so that client is approached from the unaffected side.
Monitor and assist the client to achieve adequate food and fluid intake.
Helps in focusing attention and aids in maintenance of safety.
• Implement fall prevention interventions. Clients with right hemisphere brain damage are twice as likely to fall as those with left hemisphere damage (Jepson, Despain, & Keller, 2008).
• Position affected extremity in a safe and functional manner. EB: A study found that clients with UN had higher rates of shoulder-hand complications than those without UN (Wee & Hopman, 2008). EB: Clients with neglect had significantly lower FIM (functional independence measure) motor scores than those with aphasia (Gialanella & Ferlucci, 2010).
• Teach the client to be aware of the problem and modify behavior and environment. EB: Awareness of the environment decreases risk of injury. There is some evidence that use of scanning techniques may decrease visual neglect (Ting et al, 2011).
Home Care:
Client/Family Teaching and Discharge Planning:
• Engage discharge planning specialists for comprehensive assessment and planning early in the client’s stay. EB: A study demonstrated that clients with UN have longer length of stay and less likelihood of discharge to home than subjects without UN (Cumming et al, 2009).
• Encourage family participation in care and exercise. EB: UN improved in clients who participated in exercise training with their family members (Osawa & Maeshima, 2009).
• Explain pathology and symptoms of unilateral neglect to both the client and family.
• Teach the client how to scan regularly to check the position of body parts and to regularly turn head from side to side for safety when ambulating, using a wheelchair, or doing self-care tasks.
• Reinforce the client’s use of adaptive devices such as prisms prescribed by rehabilitation professionals (Shiraishi et al, 2008).
References
Cumming, T.B., et al. Hemispatial neglect and rehabilitation in acute stroke. Arch Phys Med Rehabil. 2009;90(11):1931–1936.
Gialanella, B., Ferlucci, C. Functional outcome after stroke in patients with aphasia and neglect: assessment by the Motor and Cognitive Functional Independence Measure Instrument. Cerebrovasc Dis. 2010;30(5):440–447.
Jepson, R., Despain, K., Keller, D.C. Unilateral neglect: assessment in nursing practice. J Neurosci Nurs. 2008;40(3):142–149.
Kleinman, J.T., et al. Gender differences in unilateral spatial neglect within 24 hours of ischemic stroke. Brain Cogn. 2008;68:49–52.
Osawa, A., Maeshima, S. Family participation can improve unilateral spatial neglect in patients with acute right hemispheric stroke. Eur Neurol. 2009;63:170–175.
Shiraishi, H., et al. Long-term effects of prism adaptation on chronic neglect after stroke. NeuroRehabilitation. 2008;23(2):137–151.
Ting, D.S.J., et al. Visual neglect following stroke: current concepts and future Focus. Surv Ophthalmol. 2011;56(2):114–134.
Wee, J.Y.M., Hopman, W.M. Comparing consequences of right and left unilateral neglect in a stroke rehabilitation population. Am J Phys Med Rehabil. 2008;87(11):910–920.
Impaired Urinary Elimination
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Question the client regarding the following:
Presence of bothersome symptoms such as incontinence, dribbling, frequency, urgency, dysuria, and nocturia
Presence of pain in the area of the bladder
The pattern of urination, and approximate amount
Possible aggravating and alleviating factors for urinary problems
• Ask the client to keep a bladder diary/bladder log. EB: Use of a bladder diary may reduce client discrepancies in recall and is a valuable tool for assessment; short (24-hour) duration of the bladder diary may yield inadequate data, and excessive diary duration reduces compliance (Bright, Drake, & Abrams, 2011).
• For interventions on urinary incontinence, refer to the following nursing diagnosis care plans as appropriate: Stress Incontinence, Urge urinary Incontinence, Reflex Incontinence, Overflow Incontinence, or Functional Incontinence.
Perform a focused physical assessment including inspecting the perineal skin integrity, percussion, and palpation of the lower abdomen looking for obvious bladder distention or an enlarged kidney. A palpable kidney or bladder provides direct evidence of a dilated urinary collection system (Policastro et al, 2011). If signs of urinary obstruction are present, refer to a urologist. Unrelieved obstruction of urine can result in renal damage, and if severe, renal failure (Policastro et al, 2011). Refer to the nursing care plan for Urinary Retention if retention is present.
Check for costovertebral tenderness. Costovertebral tenderness is seen with pyelonephritis and kidney stones (Gupta & Trautner, 2011).
Review results of urinalysis for the presence of urinary infection: WBCs, RBCs, bacteria, positive nitrites. If urinalysis results are not available, request a midstream specimen of urine (urine obtained during voiding, discarding the first and last portions) for a urinalysis (Norrby, 2011).
Urinary Tract Infection
Consult the physician for a culture and sensitivity testing and antibiotic treatment in the individual with evidence of a symptomatic urinary tract infection. UTI is a transient, reversible condition that is usually associated with urgency or urge urinary incontinence (French et al, 2009; Norrby, 2011). Eradication of UTI will alleviate or reverse symptoms of suprapubic pressure and discomfort, urgency, daytime voiding frequency, and dysuria (French et al, 2009; Norrby, 2011).
Teach the client to recognize symptoms of UTI: dysuria that crescendos as the bladder nears complete evacuation; urgency to urinate followed by micturition of only a few drops; suprapubic aching discomfort; malaise; voiding frequency; sudden exacerbation of urinary incontinence with or without fever, chills, and flank pain. There are a variety of typical and unexpected symptoms in women with a history of recurring UTI (French et al, 2009).
Recognize that a cloudy or malodorous urine, in the absence of other lower urinary tract symptoms, may not indicate the presence of a urinary tract infection and that asymptomatic bacteriuria, in the elderly, does not justify a course of antibiotics. Asymptomatic bacteriuria may be associated with cloudy or malodorous urine, but these signs alone do not justify antimicrobial therapy when balanced against the potential adverse effects of treatment, including adverse side effects of the various antibiotics and encouragement of colonization of the urine with antibiotic-resistant bacterial strains (Ariathianto, 2011; Norrby, 2011).
Geriatric:
Perform urinalysis in all elderly persons who experience a sudden change in urine elimination patterns such as new-onset incontinence, lower abdominal discomfort, acute confusion, or a fever of unclear origin. Elderly persons often experience atypical symptoms with a UTI or pyelonephritis (Nazarko, 2009).
• Encourage elderly women to drink at least 10 oz of cranberry juice daily, regularly consume one to two servings of fresh blueberries, or supplement the diet with cranberry concentrate capsules as ordered. EBN: A systematic literature review reveals that consumption of 400 mg of cranberry tablets, 8 to 10 oz of cranberry juice, or an equivalent portion of foods containing whole cranberries or blueberries exerts a bacteriostatic effect on Escherichia coli, the most common pathogen associated with urinary infection among community-dwelling adult women (Masson et al, 2009).
Refer the elderly woman with recurrent urinary tract infections to her physician for possible use of topical estrogen creams for treatment of atrophic vaginal mucosa from decreased hormonal stimulation, which can predispose to UTIs (Buhr, Genao, & White, 2011; Norrby, 2011).
Recognize that UTIs in elderly men are typically associated with prostatic hyperplasia, or strictures of the urethra. Refer to a urologist (Norrby, 2011).
Client/Family Teaching and Discharge Planning:
• Teach the client/family methods to keep the urinary tract healthy. Refer to Client/Family Teaching in the care plan Readiness for enhanced Urinary Elimination.
• Teach the following measures to women to decrease the incidence of urinary tract infections:
Urinate at appropriate intervals. Do not ignore need to void, which can result in stasis of urine.
Drink plenty of liquids, especially water. Drinking water helps dilute the urine and ensures more frequent urination, allowing bacteria to be flushed from the urinary tract before an infection can begin. Note: Some references no longer recommend increased fluid intake (Norrby, 2011).
Avoid potentially irritating feminine products. Using deodorant sprays, bubble baths, or other feminine products, such as douches and powders, in the genital area can irritate the urethra. There are multiple commonsense measures that can be utilized to decrease the incidence of urinary tract infections (Gupta & Trautner, 2011; Mayo Clinic, 2012; Nazarko, 2009).
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