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NCLEX & CGFNS Practice Questions
Urinary Retention
  • Actual
  • Risk for (Potential)

Related To: [Check those that apply]

  • General anesthesia
  • Regional anesthesia
  • High urethral pressures caused by disease, injury, or edema
  • Reflex arc inhibition
  • Pain, fear of pain
  • Infection
  • Inadequate intake
  • Urethral blockage

As evidenced by: [Check those that apply]

  • Decreased (less than 30 ml per hour) or absent urinary output for 2 consecutive hours
  • Frequency voiding
  • Hesitancy
  • Overflow incontinence
  • Urgency
  • Bladder distention
  • Abdominal discomfort
  • Dribbling of urine

Patient’s Diagnosis: –
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Objective/Expected Outcome;The patient will:

  • empties bladder completely.
  • Others

Note: you need to indicate time frame/target as objective must be measurable.

Nursing Interventions Scientific Rationale
Evaluate previous patterns of voiding. There is a wide range of normal" voiding frequency."
Visually inspect and palpate lower abdomen for distention. The bladder lies below the umbilicus.
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.
Monitor urinalysis, urine culture, and sensitivity. Urinary tract infection can cause retention, but is more likely to cause frequency.
Monitor blood urea nitrogen (BUN) and creatinine. To differentiate between urinary retention and renal failure.
Have patient listen to sound of running water, or place hands in warm water and/or pour warm water over perineum. To stimulate urination.
Perform Credé's 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.
Institute intermittent catheterization. Because many causes of urinary retention are self-limited, the decision to leave an indwelling catheter in should be avoided.
Teach patient or caregiver to perform meatal care twice daily with soap and water and dry thoroughly. To reduce the risk of infection.

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