Urinary Retention

NANDA Definition
It is defined as incomplete emptying of the bladder.

Discussion of the Problem

An immobile person; a person with medical condition such as BPH, disk
surgery, or hysterectomy; or a person who experiencing side effect of medications,
including anesthetic agents, antihypertensives, antihistamines, antispasmodics, and
anticholinergics, may suffer form urinary retention, bladder distention, and
occasionally urinary incontinence. The decreased muscle tome of the urinary bladder
inhibits its ability to empty completely. In addition, the discomfort of using bedpan or
urinal, the embarrassment and lack of privacy associated with this function, and the
unnatural position of urination combine to make it difficult for the client to relax the
perineal muscles sufficiently to urinate while lying in bed. When urination is not
possible, the bladder gradually becomes distended with urine. The bladder may
stretch excessively, eventually inhibiting the urge to void. When bladder distention is
considerable, some involuntary urinary “dribbling” may occur (retention with
overflow). This does not relieve the urinary distention, because most of eh stagnant
urine remains in the bladder. The major nursing responsibility is to prevent the
occurrence of urinary retention, however, if already present, emptying of bladder
completely becomes the major responsibility.

Nursing Interventions Classification (NIC)

• Urinary Elimination Management
• Urinary Retention Care

Nursing Outcomes Classification (NOC)

• Infection Status
• Urinary Continence
• Urinary Elimination

Goal and Objectives

• Patient will have postvoid residuals of less than 50 mL, with no dribbling or
overflow.
• Patient will empty bladder totally.
• Patient will void in sufficient quantity with no palpable bladder distension.

Subjective and Objective Data

• Abdominal discomfort
• Bladder distension
• Decreased (less than 30 ml/hr) or absent urinary output for 2 consecutive
hours
• Frequency
• Hesitancy
• Inability to empty bladder completely
• Incontinence
• Residual urine
• Sensation of bladder fullness
• Urgency
Related Factors
• Decompensation of detrusor musculature
• General anesthesia, regional anesthesia
• High urethral pressures caused by disease, injury, edema and hematoma
• Inability of bladder to contract adequately
• Inadequate intake
• Infection
• Mechanical obstruction
• Enlarged prostate
• Pain, fear of pain
• Sensory/motor impairment, nerve paralysis
• Surgical manipulation

Assessment (Dx)
• Determine quantity, frequency, and character such as color, odor, and specific
gravity of urine. Urinary retention, vaginal discharge, and presence of
catheter predisposes patient to infection, especially if patient has perineal
sutures.

• Evaluate vital signs strictly. Check for alteration in mentation, hypertension,

and peripheral or dependent edema. Weigh daily. Maintain precise I&O record.
Kidney function deterioration results in reduced fluid excretion and builds up
of toxic wastes. It may develop to complete renal shutdown.

• Monitor time intervals between voiding and document the quantity voided.
Keeping an hourly record for 48 hours can aid in establishing a toileting
program and gives a clear picture of the patient’s voiding pattern.

FOLEY CATHETHER CARE

Any catheter which is inserted into the bladder and allowed to remain in the
bladder is called an indwelling catheter. A common type of indwelling catheter is a
Foley catheter. A Foley catheter has a balloon attachment at one end. After the
Foley catheter is inserted, the balloon is filled with sterile water. The filled balloon
prevents the catheter from leaving the bladder.

STAYING HEALTHY WITH A FOLEY CATHETER

DO

• Drink at least 4000cc (4 quarts) of liquid a day to keep urinary output over
two quarts. Check urine daily for color, odor, etc.
• Keep urine pH at 5.5 or under
• Check leg bag every 1-2 hours; if nothing is in it look for cause.
• Take medication regularly as prescribed
• Wash genital area twice daily, or more often if needed, especially around
the catheter
• Men: tape catheter on abdomen at night to prevent fistula
• Use only sterilized equipment for irrigation and drainage
• Use sterile technique for urinary procedures
• Irrigate only with prescribed solution
• Report signs of infection to your doctor
• Have urinary work-up every six months to one year as ordered. This
includes sonogram and cystogram, which are X-rays of urinary system
(also blood tests and urine tests). Entire work-up usually can be done in a
few hours as an outpatient.
• If your catheter plugs, change it immediately. Pinch catheter between
fingers daily to feel if there is grit inside. If there is, it is time to change the
catheter.
• Change catheter as often as recommended by your doctor (usually every
2-4 weeks) unless it plugs
• If you notice eggshell-like particles in catheter tip, or in urine let your doctor
know

DO NOT

• Touch with your bare hands anything that will go into the catheter or
directly into your bladder, i.e., tips of leg bag, irrigation syringe or solution.
• Allow the night drainage tubing to be higher than your bladder. The urine
drains back into bladder and can cause infection.
• Let your bladder get too full from a plugged catheter, too full bag, etc.
• Use a leg bag when in bed overnight.

STAYING HEALTH WITHOUT A FOLEY CATHETER

DO

• Drink amount of liquid necessary to keep urine clear or light in color

• Check urine daily for color, odor, and eggshell-like particles (call your
doctor if these are seen in your urine).
• Keep urine pH 5.5 or under
• Take medication regularly as prescribed
• Wash genital area twice daily or more often if needed. If you wear an
external catheter, wash when changing the catheter and leave it off at least
15 minutes.
• Empty bladder regularly, usually every 3-4 hours
• Do intermittent catheterization as often as needed so that more than 300cc
of urine do not accumulate. Catheterize for residual urine as often as
ordered.
• Use proper technique for urinary procedures. If you ever need to irrigate
following catheterization, use only sterile equipment.
• Have urinary work-up every six months to one year as ordered. This
includes sonogram and cystogram, which are X-rays of the urinary system,
as well as blood and urine tests, all of which can be done in a few hours as
an outpatient.
• If residual urine is ordered regularly, report any marked increase in amount
to your doctor (i.e. 60cc or more)
• Drink cranberry or prune juice to promote acidic urine and reduce the risk
of urinary tract infections.

DO NOT

• Let your bladder get too full of urine (not over 300cc). If your bladder is
 very small, the amount is less.
• Leave external catheters on so long that skin gets irritated
• Apply external catheters too tightly or sores will occur
• Use permanent rubber externals as skin breakdown can occur
• Apply external catheter over a sore
• Stretch tape or overlap tape when applying the external catheter or it will
act as a tourniquet and cause pressure sores

• Decrease fluid intake -You may become dehydrated, prone to stones, UTI's
(urinary tract infections), etc.

• Allow patient to keep a record amount and time of each voiding. Note down
decreased urinary output. Determine specific gravity as ordered. Retention of
urine increases pressure in the kidneys and ureters, which may lead to renal
insufficiency. Insufficiency of blood circulation to the kidney alters its
capability to filter and concentrate substances.

• Ask patient regarding stress incontinence when moving, sneezing, and

coughing, laughing, lifting objects. High urethral pressure can inhibit voiding
until abdominal pressure increases enough for urine to be involuntarily lost.
Also hinders bladder emptying.

• Check urinalysis, urine culture, and sensitivity. Urinary tract infection can
cause retention.

• Monitor blood urea nitrogen (BUN) and creatinine. This laboratory test will
differentiate between renal failure and urinary retention.

• Note residual urine volume after voiding as indicated. Urinary bladder may not
be emptying completely. Urinary retention increases likelihood for infection
and is uncomfortable and painful.

• Palpate and percuss suprapubic area. Explore verbalization of discomfort,

pain, fullness and difficulty of voiding. A distended bladder could be felt by
patient in the suprapubic area. Perception of bladder fullness, bladder
distention above symphysis pubis signifies urinary retention.

Therapeutic Interventions (Tx)

• Start the subsequent techniques:
 Allow patient to listen to sound of running water, or dip hands in warm
water or pour lukewarm water over perineum. This kindles urination.

 Offer thorough perineal and catheter care. Decreases the risk of

ascending infection.

 Perform Credé’s maneuver (pressing down over the bladder with the
hands). Credé’s method enhances urinary bladder pressure, and this
consequently induce relaxation of sphincter to allow voiding.
  Persuade everyday drinking of cranberry juice. Maintains acidity of
urine. This helps avert infection for the reason that cranberry juice
metabolizes to hippuric acid, which keeps acidic urine; acidic urine is
less likely to become infected.

 Place bedpan, urinal, or bedside commode within reach. Provide

privacy.

 Promote oral fluids up to 3000 mL daily, unless contraindicated.

Increased circulating fluid sustains renal perfusion and wash out
kidneys, bladder, and ureters of “sediment and bacteria.” Note: At
first, fluids may be controlled to avoid bladder distension until
sufficient urinary flow is reestablished.

• Decompress bladder gradually. Once huge amount of urine has accumulated,

fast urinary bladder decompression produces pressure on pelvic arteries, and
may cause venous pooling.

• Encourage patient to take bethanechol (Urecholine) as indicated. This

stimulates parasympathetic nervous system to release acetylcholine at nerve
endings and to enhance tone and amplitude of contractions of smooth
muscles of urinary bladder.

• If incomplete emptying is suspected, catheterize and measure residual urine.

Urinary retention predisposes the patient to urinary tract infection and may be
a sign of the need for an intermittent catheterization plan.

• Keep indwelling catheter patent; maintain drainage tubing kink-free. Provides

free drainage of urine, decreasing possibility of urinary stasis or retention and
infection.

• Secure the catheter of male patient to abdomen and to thigh for female. This
technique prevents urethral fistula and avoid inadvertent dislodgment.

Educative (Edx)
• Encourage patient or significant other to do perineal care twice daily with
soap and water and dry thoroughly. In addition, demonstrate proper perineal
care. This decreases the risk of infection.

• Inform patient and significant other to observe the different signs and
symptoms or bladder distention like reduced or lack of urine, urgency,
hesitancy, frequency, distention of lower abdomen, or discomfort).

• Inform patient or caregiver with regards to the significance of sufficient fluid

intake. For instance, drinking 8 to 10 glasses of fluids daily and as tolerated.

• Instruct patient to assume an upright position on bathroom if feasible. This is

the usual position for voiding, and uses the force of gravity.

• Persuade patient to void every 2–4 hour and as soon as urge is perceived.
May lessen urinary retention and bladder distention.
• Reinforce to patient or significant other on procedures to facilitate voiding.

• Suggest sitz bath as ordered. Supports muscle relaxation, reduces edema,

and may improve voiding attempt.