Last updated on May 18th, 2022 at 10:54 am
Urinary Retention Nursing Care Plans Diagnosis and Interventions
Urinary Retention NCLEX Review and Nursing Care Plans
Urinary retention, also referred to as ischuria, can be defined as a medical condition in which the bladder does not drain completely after urination. Individuals who are sedentary, immobile, or strictly confined to bed rest may suffer from urinary retention and incontinence.
Additionally, people who have medical disorders such as BPH, hysterectomy, disk surgery, or those taking medications (e.g., high-blood-pressure drugs, anticholinergics, and antihistamines) may also be at risk of developing urinary retention and bladder distention since these medications may interfere with the nerve signals necessary to relax the sphincters.
Untreated urinary retention can lead to bladder injury and renal failure; hence, it is critical to address urinary retention as soon as possible to avoid further complications.
Signs and Symptoms of Urinary Retention
- Bladder distention
- 2 hours of decreased or non-existent urination
- Frequent urination
- Urine Incontinence
- The feeling of bladder fullness and urgency
- Presence of residual urine
- Inability to empty the bladder
- Discomfort in the abdomen
Causes of Urinary Retention
A variety of factors can cause urinary retention. Primarily, these may include:
- Urinary incontinence
- Presence of infections
- Presence of swelling or edema
- Disruption in the urinary and nervous system communication due to nerve problems.
- Medications that are taken for other existing ailments
- Surgery-related complications and side effects of the prescribed post-operative medications.
Other causes:
- Medications. Certain drugs might also induce urinary retention, such as:
- Antihistamines
- Anticholinergics
- Antipsychotics
- Blood pressure-lowering drugs
- Muscle relaxant drugs
- Drugs for hormones
- Obstruction. Urinary retention occurs when the bladder and urethra are obstructed, preventing urine from flowing freely. The urethra can get obstructed in men if the prostate gland grows to the point where it is pressing on the urethra; hence, chronic urine retention in men is almost often the result of this condition. For women, a sagging bladder (medically known as cystocele) is one of the contributing factors in developing urinary retention. Another possible cause is a disorder known as rectocele, in which the rectum settles into the back wall of the vagina.
- Surgery. Spine surgery, hip replacement, joint replacement, et.c may cause ischuria since pre-and post-operative sedatives may cause urine retention.
- Nerve damage. Urination occurs when the bladder contracts as a response to the brain’s commands, thereby facilitating urinary elimination. Shortly, relaxation of the urethra’s sphincter muscles follows. This mechanism allows the urine to be expelled by the body following normal flow. Hence, anything that blocks the passage and communication from the brain to the urethra and bladder is a potential source of urinary retention, and nerve damage or injury is one of the potentiating causes. Nerve problems can be caused by various conditions, including stroke, MS, pelvis and spine injuries, and diabetes.
Risk Factors of Urinary Retention
- Infections of the urinary tract (UTI)
- Use of medications (e.g., anticholinergics, antihistamines)
- Presence of neurodegeneration and neurodegenerative diseases such as diabetes
- Weakened bladder muscles owing to aging, sedentary behavior, or trauma
Diagnosis of Urinary Retention
- Physical Examination. Assessment and diagnosis of urine retention begin with recognizing symptoms that may suggest the existence of urinary retention. Usually, this process includes an examination of the genitalia and the rectum.
- Blood tests
- Urine examination
- Computed tomography (CT) – may aid in locating stones or obstructions impeding urine flow.
- Results from urodynamic testing that determines the volume of urine remaining in the bladder
- Ultrasound – can be used to determine how much urine remains in the bladder after urination.
- Post-Void Residual Test – to check for the remaining urine in the bladder after the patient has urinated/ voided
- Cystoscopy – is a procedure in which a camera-equipped tube is inserted into the urethra. This allows visualization of the bladder and urethral lining. The presence of tumor, urethral stricture, inflamed prostate, and blockage due to a stone may be detected by this test.
Treatment for Urinary Retention
In cases of acute urinary retention, prompt treatment with a catheter is often necessary. Meanwhile, chronic or long-term urinary retention may necessitate more extensive treatment. Acute or chronic urine retention might have several treatment options, depending on the underlying reason and severity of symptoms.
- Catheterization. For cases of acute urinary retention, a catheter is likely to be implanted to expedite the process of urination. And to minimize discomfort or pain of catheterization, the instrumentation is numbed with local anesthetics. Likewise, a physician may place a suprapubic catheter to facilitate urine drainage as an alternative to using a catheter. However, it is important to note that consistent usage of these devices can lead to infections from pathogens entering the body via the catheter or drainage tubes.
- Medications. Urinary retention can be alleviated with the use of medications such as treatment with the use of antibiotics for urinary tract infections, use of prostate and sphincter relaxants to aid in the passage of urine, and prescription drugs to shrink the prostate (most particularly for patients with BPH).
- Stent insertion and placement of urethral dilation. By placing small tubes into the urethra, it is possible to safely enlarge the urethral stricture. The physician may progressively raise the diameter of the tube inserted into the urethra until it is large enough to allow urine to flow. Alternatively, a balloon can be inserted into the urethra and progressively inflated to relieve stricture. Insertion of a stent allows more urine to pass through, thereby preventing urinary restriction.
- Surgery. Surgery may be an option if medication and lifestyle modifications fail to alleviate urinary retention. For males, it is possible to remove clogs/blockages in the penis by inserting an instrument into the urethra. The use of specific tools or lasers may also remove the obstruction. The following are a few surgical options for treating urinary retention:
- Excision of prostate tissue that may be limiting the urethra or TURP
- Removal of the prostate
- Urethrotomy
Prevention of Urinary Retention
Lifestyle modifications are at the core of preventing urinary retention. These include:
- Control urination by drinking fluids at predetermined intervals.
- Improve control of the urinary sphincters by employing pelvic floor exercises
- Build the muscles that govern the bladder by doing exercises that target those areas.
Urinary Retention Nursing Diagnosis
Nursing Care Plan for Urinary Retention 1
Nursing Diagnosis: Urinary Retention related to mechanical blockage due to enlarged prostate, secondary to benign prostatic hyperplasia (BPH), as evidenced by dribbling of urine, incontinence, frequent urination and hesitation, incomplete bladder emptying, and presence of residual urine
Desired Outcomes:
- The patient demonstrates no perceptible bladder distention and is able to urinate sufficiently.
- The patient will demonstrate improved urinary elimination, as evidenced by fewer than 50 mL postvoid residuals (PVR), absence of overflow, and dribbling of urine.
| Nursing Interventions for Urinary Retention | Rationale |
| Instruct the patient to empty his/her bladder in a timely manner, such as every two to four hours or whenever the urge arises. | To prevent excessive bladder distention and urine retention |
| Ascertain whether the patient experiences stress incontinence when shifting, moving, coughing, sneezing, laughing, or carrying heavy objects, among other activities. | Increased urethral pressure can prevent voiding until the abdomen pressure rises sufficiently to cause involuntary urine discharge. |
| Assess for abdominal tenderness (for the presence of abdominal distention) by the use of percussion and palpitation of the suprapubic region. | For the purpose of diagnosis, determining the existence of overfilling or distention in the bladder aids in the rapid implementation of treatment options for those who have BPH. |
| Promote daily oral fluid intake of up to 3000 mL (3L) only to the extent that cardiac tolerance allows. | When the amount of fluid in the body is increased, it keeps the kidneys well-perfused and flushes out any remaining debris and bacteria from the urinary tract and bladder. Similarly, restricting fluid consumption will help the bladder to empty and fill itself at regular intervals. This may help prevent bladder distention until adequate urine flow is restored. |
| Suggest the use of a sitz bath. | Men with an enlarged prostate may suffer from signs of a lower urinary tract obstruction, such as urinary retention. Because of this, patients with BPH symptoms may find relief from the bladder and urethral problems by taking a sitz bath, a common hydrotherapy procedure. |
Nursing Care Plan for Urinary Retention 2
Nursing Diagnosis: Urinary Retention related to lack of motor control, secondary to Guillain Barre syndrome (GBS), as evidenced by ascending paralysis and bladder dysfunction
Desired Outcome: The patient will demonstrate regular patterns of urine elimination.
| Nursing Interventions for Urinary Retention | Rationale |
| Determine the extent or progression of paralysis and the impact on urination. | One possible cause of ineffective bladder contraction is neurological dysfunction. Transient paralysis may occur in patients with Guillain-Barré syndrome. As a result, patients may be unable to exercise their initiative to urinate, leading to decreased urine output (e.g., residual urine). |
| Inform parents of available resources, relevant services, and programs that can aid in the patient’s recovery to normal urine function. | To restore urinary function and ensure a more consistent urine pattern. Another benefit is that it prevents urinary retention or infection from occurring, both of which are undesired results. |
| Educate the patient and their families about the need to maintain a healthy fluid intake and to track fluid excretion. Monitor the output-to-intake ratio. | This ensures a healthy balance between the fluid intake-to-excretion ratio. Additionally, sufficient hydration encourages urination. |
| Develop a treatment plan for urine elimination with the patient or encourage him/her to follow through with a program for urinary elimination. In case Crede’s technique is warranted, proceed cautiously with gentle handling. | It aims to expedite the elimination of urine and the resumption of a regular cycle. |
| Inform the patient to call the nurse if he/she notices any absence in urinary elimination or lack thereof. | It reduces the possibility of neuromuscular dysfunction and its consequences on the bladder and urethra’s functionality. |
Nursing Care Plan for Urinary Retention 3
Nursing Diagnosis: Urinary Retention related to mechanical trauma, secondary to Hysterectomy or TAHBSO, as evidenced by urine production that is little, frequent, and/or non-existent, bladder distention, overflow incontinence, and feeling of bladder fullness.
Desired Outcome: The patient will empty his/her bladder on a regular and thorough basis.
| Nursing Interventions for Urinary Retention | Rationale |
| Monitor the patient’s voiding pattern and the volume of his/her urination. | If the patient regularly urinates in small and insufficient volumes, urinary retention may be suspected. |
| Assist the patient in relieving bladder discomfort by following a set of regular voiding procedures provided, such as:Maintaining a comfortable positionGiven private settingWarm water is poured over the perineumThere is water running in the sink | Allows for easier urination by relaxing the perineal muscles. |
| Assist the patient in the proper management of catheters. Provide him/her with as much information about perianal hygiene as feasible. | Maintaining personal hygiene and post-operative care lowers the risk of a urinary tract infection (UTI). This is critical because a urinary tract infection can cause urethral enlargement (i.e., swelling) or bladder weakening, both of which can result in urine retention. |
| Determine the volume of residual urine that remains in the patient’s bladder after urination. | Urinary retention is a complication that can occur following hysterectomies. As a result, evaluating the residual urine to determine the ability of the bladder to empty fully aids in the identification of the risk of infection. |
| Ensure that the indwelling catheter remains intact and free of kinks and obstructions. | Using a catheter inserted into the bladder helps expel urine. Likewise, maintaining its patency reduces the likelihood of urinary stasis, infection, and retention by encouraging unrestricted urine flow. |
Nursing Care Plan for Urinary Retention 4
Nursing Diagnosis: Urinary Retention related to swelling and inflammation in the location of the surgical procedure, secondary to laminectomy, as evidenced by verbalization of pain in the surgical area, bladder problems, discomfort, numbness near the legs or groin, and bladder distention.
Desired Outcomes:
- The patient will be able to empty his/her bladders to their satisfaction.
- The postvoid residuals of the patient will be within typical ranges.
| Nursing Interventions for Urinary Retention | Rationale |
| Examine the functions of the patient’s bowel and bladder. | This assessment aims to determine if the bowels and bladder are functioning appropriately. |
| Check for bladder distension by inspecting and palpating the abdomen. | A distended bladder could be a sign of urinary retention. |
| Monitor the patient’s voiding patterns and document the frequency, time, and duration of voiding. | Analyzes if the bladder is emptying normally and, if it is, whether medical intervention is necessary. |
| Ensure that the patient is well-hydrated. | Preserves the patient’s kidney function and minimizes the likelihood of developing renal stasis. |
| Assist the patient in relieving bladder discomfort and voiding by: Using running water to stimulate bladder emptying Drenching the lower abdomen (peritoneal area) in warm water Allowing the patient to dip his/her hand in warm water to relieve his/her discomfort | It helps to relax the urinary sphincter, which encourages urination. |
| After voiding, catheterize the patient’s bladder to check for residual urine. Whenever necessary, administer and maintain an indwelling catheter in the bladder. | Intermittent or prolonged catheterization may be necessary until the post-operative swelling subsides. |
| In cases where a patient is confined to a bed, have his/her waste (e.g., urine) removed with the help of a fracture pan. | Increases comfort and helps to alleviate muscle tension |
Nursing Care Plan for Urinary Retention 5
Nursing Diagnosis: Urinary Retention related to a defective neuromuscular system, secondary to spina bifida as evidenced by urine retention, increased or reduced tone in the neurogenic bladder, and failure to recognize bladder fullness
Desired Outcome: The patient will demonstrate regular patterns of urine elimination.
| Nursing Interventions for Urinary Retention | Rationale |
| Observe the patient’s urinary elimination, including color, volume, turbidity, and urine odor. | Urine that is characterized by a dark, red, or bloody color with cloudy turbidity may indicate bladder infection possibly caused by urinary retention. Bacteria can infect the urinary system if there is an irregular flow of urine at the entrance of the urethra; hence, urinary retention is a risk factor for infection. |
| Determine if the patient has a neurogenic bladder, including the following factors:The extent of urinary incontinenceAgeRehabilitation potential | Describes the problem and provides information on implementing a regular urine elimination schedule. |
| Provide the patient with instructions to clean his/her genital and anal areas following urinary elimination, especially if the patient is incontinent. | To avoid the entry of bacteria into the urinary system (e.g., urethra, bladder) and facilitate their spread, it is important to maintain adequate hygiene for each urinary elimination activity. This reduces the likelihood of contracting an infection. |
| Advise patients to consume at least one fl. oz./lb of fluids each day. Include acidic beverages and acid-rich meals in the recommended daily intake. | Aids in the prevention of infection by increasing the flow of renal blood and increasing the acidity of urine. |
| If the patient is above the age of three years old, recommend that parents use a pad or a water-resistant undergarment rather than relying on diapers. | It prevents the child from feeling humiliated or embarrassed. |
| Provide parents with information about other therapeutic interventions for incontinence, such as -Placement of artificial urinary sphincter (AUS) -Insertion of artificial reservoir instrumentation -Creation of a channel for urine to pass through (i.e., urinary diversion) | Other modalities of treatment are discussed if intermittent catheterization is not possible. |
| Inform the patient and parents/guardians in identifying changes in the properties of urine, including urinary symptoms that could indicate a bladder infection. Educate them on the preventive measures to take to avoid this problem. | Infection and renal problems can be controlled early on with prompt interventions. |
Nursing References
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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