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Nursing Care Plans: Nursing Diagnosis and Intervention, 5/e
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Urinary Retention
Doris M. McNear, RN, MSN

NANDA: The state in which an individual experiences incomplete emptying of the bladder

Urinary retention may occur in conjunction with or independent of urinary incontinence. Urinary retention, the inability to empty the bladder even though urine is present, may occur as a side effect of certain medications, including anesthetic agents, antihypertensives, antihistamines, antispasmodics, and anticholinergics. These drugs interfere with the nerve impulses necessary to cause relaxation of the sphincters, which allow urination. Obstruction of outflow is another cause of urinary retention. Most commonly, this type of obstruction in men is the result of benign prostatic hypertrophy.

Related Factors

Defining Characteristics

Expected Outcome

Patient empties bladder completely.

Ongoing Assessment

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(i) Evaluate previous patterns of voiding.
There is a wide range of "normal" voiding frequency.
(i) Visually inspect and palpate lower abdomen for distention.
The bladder lies below the umbilicus.
(i) Evaluate time intervals between voidings and record the amount voided each time.
Keeping an hourly log for 48 hours gives a clear picture of the patient's voiding pattern and amounts, and can help to establish a toileting schedule.
(c) Catheterize and measure residual urine if incomplete emptying is suspected.
Retention of urine in the bladder predisposes that patient to urinary tract infection and may indicate the need for an intermittent catheterization program.
(i) Assess amount, frequency, and character (color, odor, and specific gravity) of urine.
(i) Determine balance between intake and output. Intake greater than output may indicate retention.
(c) Monitor urinalysis, urine culture, and sensitivity.
Urinary tract infection can cause retention, but is more likely to cause frequency.
(i) If indwelling catheter is in place, assess for patency and kinking.
(c) Monitor blood urea nitrogen (BUN) and creatinine.
To differentiate between urinary retention and renal failure.

Therapeutic Interventions

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(i) Initiate the following methods
To facilitate voiding:
(c) Encourage patient to take bethanechol (Urecholine) as ordered
To stimulate parasympathetic nervous system to release acetylcholine at nerve endings and to increase tone and amplitude of contractions of smooth muscles of urinary bladder. Side effects are rare after oral administration of therapeutic dose. In small subcutaneous doses side effects may include abdominal cramps, sweating, and flushing. In larger doses they may include malaise, headache, diarrhea, nausea, vomiting, asthmatic attacks, bradycardia, lowered blood pressure (BP), atrioventricular block, and cardiac arrest.
(c) Institute intermittent catheterization.
Because many causes of urinary retention are self-limited, the decision to leave an indwelling catheter in should be avoided.
(c) Insert indwelling (Foley) catheter as ordered:

Education/Continuity of Care

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(i) Educate patient or caregiver about the importance of adequate intake, (e.g., 8 to 10 glasses of fluids daily).
(i) Instruct patient or caregiver on measures to help voiding (as described above).
(i) Instruct patient or caregiver on signs and symptoms of overdistended bladder (e.g., decreased or absent urine, frequency, hesitancy, urgency, lower abdominal distention, or discomfort).
(i) Instruct patient or caregiver on signs and symptoms of urinary tract infection (e.g., chills and fever, frequent urination or concentrated urine, and abdominal or back pain).
(i) Teach patient or caregiver to perform meatal care twice daily with soap and water and dry thoroughly.
To reduce the risk of infection.
(i) Teach patient to achieve an upright position on toilet if possible.
This is the natural position for voiding, and utilizes the force of gravity.

NIC

Urinary Retention Care

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