- 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: –
Date:-
CLICK HERE for Free NCLEX –RN & CGFNS Practice Questions
- 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. |
CLICK HERE for more Free Nursing Care Plan
___________________________________
Patient/Significant other signature
___________________________________
