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As evidenced by: [Check those that apply]
Patient’s Diagnosis: –
Date:-
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| 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. |