NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
* Urinary Continence
* Urinary Elimination
* Infection Status
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
* Urinary Retention Care
NANDA Definition: 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.
* Defining Characteristics: Decreased (<30 ml/hr) or absent urinary output for 2 consecutive hours
* Lower abdominal distention
* Abdominal discomfort
* Related Factors: General anesthesia
* Regional anesthesia
* High urethral pressures caused by disease, injury, or edema
* Pain, fear of pain
* Inadequate intake
* Urethral blockage
* Expected Outcomes Patient empties bladder completely.
* 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.
* 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.
* Assess amount, frequency, and character (e.g., color, odor, and specific gravity) of urine.
* Determine balance between intake and output. Intake greater than output may indicate retention.
* Monitor urinalysis, urine culture, and sensitivity. Urinary tract infection can cause retention but is more likely to cause frequency.
* If indwelling catheter is in place, assess for patency and kinking.
* Monitor blood urea nitrogen (BUN) and creatinine. This will differentiate between urinary retention and renal failure.
* Initiate the following methods:
o Encourage fluids. Unless medically contraindicated, fluid intake should be at least 1500 ml/24 hours.
o Encourage intake of cranberry juice daily. This keeps urine acidic. This helps prevent infection because cranberry juice metabolizes to hippuric acid, which maintains an acidic urine; acidic urine is less likely to become infected.
o Place bedpan, urinal, or bedside commode within reach.
o Provide privacy.
o Encourage patient to void at least every 4 hours.
o Have patient listen to sound of running water, or place hands in warm water and/or pour warm water over perineum. This stimulates urination.
o Offer fluids before voiding.
o Perform Credé’s method over bladder. Credé’s method (pressing down over the bladder with the hands) increases bladder pressure, and this in turn may stimulate relaxation of sphincter to allow voiding.
These facilitate voiding.
* Encourage patient to take bethanechol (Urecholine) as ordered. This stimulates 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), atrio-ventricular block, and cardiac arrest.
* Institute intermittent catheterization. Because many causes of urinary retention are self-limited, the decision to leave an indwelling catheter in should be avoided.
* Insert indwelling (Foley) catheter as ordered:
o Tape catheter to abdomen (male). This prevents urethral fistula.
o Tape catheter to thigh (female). This prevents inadvertent displacement.
Education/Continuity of Care
* Educate patient or caregiver about the importance of adequate intake, (e.g., 8 to 10 glasses of fluids daily).
* Instruct patient or caregiver on measures to help voiding (as described above).
* 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).
* 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).
* Teach patient or caregiver to perform meatal care twice daily with soap and water and dry thoroughly. This reduces the risk of infection.
* Teach patient to achieve an upright position on toilet if possible. This is the natural position for voiding, and utilizes the force of gravity.