NURSING DIAGNOSIS: Urinary retention

related to:
  1. stasis of urine in the kidney and bladder associated with prolonged horizontal positioning;
  2. difficulty urinating associated with anxiety regarding use of bedpan or urinal;
  3. incomplete bladder emptying associated with:
    1. horizontal positioning (the gravity needed for complete bladder emptying is lost)
    2. decreased bladder muscle tone resulting from the generalized loss of muscle tone that occurs with prolonged immobility.
Desired Outcome
The client will not experience urinary retention as evidenced by:
  1. voiding at normal intervals
  2. no reports of bladder fullness and suprapubic discomfort
  3. absence of bladder distention and dribbling of urine
  4. balanced intake and output.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for signs and symptoms of urinary retention:
    1. frequent voiding of small amounts (25 - 60 ml) of urine
    2. reports of bladder fullness or suprapubic discomfort
    3. bladder distention
    4. dribbling of urine
    5. output less than intake.
  2. Catheterize client if ordered to determine the amount of residual urine.
  3. Implement measures to prevent urinary retention:
    1. instruct client to urinate when the urge is first felt
    2. perform actions to promote relaxation during voiding attempts (e.g. provide privacy, hold a warm blanket against abdomen, encourage client to read)
    3. perform actions that may help trigger the micturition reflex and promote a sense of relaxation during voiding attempts (e.g. run water, place client's hands in warm water, pour warm water over perineum)
    4. allow client to assume a normal position for voiding unless contraindicated
    5. instruct and/or assist client to lean upper body forward and/or gently press downward on lower abdomen during voiding attempts unless contraindicated in order to put pressure on the bladder (pressure helps create a sensation of bladder fullness, which stimulates the micturition reflex)
    6. administer parasympathomimetic (cholinergic) drugs (e.g. bethanechol) if ordered to stimulate bladder contraction.
  4. Consult physician about intermittent catheterization or insertion of an indwelling catheter if above actions fail to alleviate urinary retention.