Urinary Retention Nursing Diagnosis & Care Plan

Urinary retention is a common yet potentially serious condition that affects many patients across various healthcare settings. As a nurse, understanding the intricacies of urinary retention is crucial for providing optimal care and improving patient outcomes.

What is Urinary Retention?

Urinary retention occurs when an individual is unable to empty their bladder completely. This condition can be acute (sudden onset) or chronic (long-term), and if left untreated, it can significantly impact a patient’s quality of life and overall health.

Causes of Urinary Retention

Urinary retention can result from various factors, including:

1. Obstruction of the urethra (enlarged prostate, urethral stricture)
2. Neurological disorders (multiple sclerosis, spinal cord injuries)
3. Medications (anticholinergics, opioids)
4. Weakened bladder muscles
5. Recent surgery, especially pelvic or abdominal procedures
6. Urinary tract infections
7. Constipation
8. Psychological factors (stress, anxiety)

Signs and Symptoms

The presentation of urinary retention can vary depending on whether it’s acute or chronic:

Acute Urinary Retention:

• Sudden inability to urinate
• Severe lower abdominal pain
• Bloating or swelling in the lower abdomen
• Urgent need to urinate with little or no results

Chronic Urinary Retention:

• Frequent urination in small amounts
• Weak urine stream
• Difficulty starting urination (hesitancy)
• The feeling of incomplete bladder emptying
• Nocturia (frequent nighttime urination)
• Mild lower abdominal discomfort

It’s important to note that some patients with chronic urinary retention may not exhibit obvious symptoms, making regular assessment crucial.

Complications

If left untreated, urinary retention can lead to severe complications:

• Urinary tract infections
• Bladder damage
• Kidney damage or failure
• Urinary incontinence
• Sepsis (in severe cases)

Nursing Assessment

A thorough nursing assessment is essential for diagnosing and managing urinary retention effectively:

1. Review the patient’s medical history, focusing on risk factors and potential causes.
2. Assess the patient’s voiding patterns, including frequency, volume, and difficulties.
3. Perform a focused physical examination, including abdominal palpation, to check for bladder distention.
4. Evaluate urine characteristics (color, odor, clarity) for signs of infection.
5. Measure post-void residual volume using ultrasound (bladder scanner) or catheterization.
6. Review the patient’s medication list for drugs that may contribute to urinary retention.
7. Assess for any neurological deficits that could affect bladder function.

Nursing Care Plans for Urinary Retention

Nursing Care Plan 1: BPH

Nursing Diagnosis: Urinary Retention related to prostatic hypertrophy as evidenced by inability to void, lower abdominal pain, and bladder distention.

Related Factors/Causes:

• Enlarged prostate gland
• Obstruction of urethra
• Weakened bladder muscles

Nursing Interventions and Rationales:

1. Bladder distention is assessed every 4 hours using palpation and a bladder scanner.
   Rationale: Regular assessment helps monitor the severity of retention and guides intervention timing.
2. Encourage the patient to void every 2-3 hours and use double-voiding technique.
   Rationale: Scheduled voiding and double-voiding can help improve bladder emptying.
3. Provide privacy and a calm environment during voiding attempts.
   Rationale: A relaxed environment promotes successful urination.
4. Implement bladder training techniques, such as timed voiding and pelvic floor exercises.
   Rationale: These techniques can improve bladder control and emptying over time.
5. Catheterize the patient as prescribed if unable to void or if residual volume exceeds 300 mL.
   Rationale: Catheterization relieves acute retention and prevents bladder overdistension.

Desired Outcomes:

• The patient will void spontaneously with minimal residual urine (< 100 mL) within 24 hours.
• The patient will report decreased lower abdominal discomfort within 4 hours of intervention.
• The patient will demonstrate proper use of the double-voiding technique by the end of the shift.

---

Nursing Care Plan 2: Impaired Urinary Elimination

Nursing Diagnosis: Impaired Urinary Elimination related to neurogenic bladder secondary to spinal cord injury as evidenced by the inability to initiate voiding and large post-void residual volumes.

Related Factors/Causes:

• Spinal cord injury affecting nerve pathways to the bladder
• Decreased bladder sensation
• Detrusor muscle weakness or overactivity

Nursing Interventions and Rationales:

1. Assess neurological status and level of spinal cord injury.
   Rationale: The level of injury determines the type of bladder dysfunction and guides management strategies.
2. Implement intermittent catheterization every 4-6 hours or as prescribed.
   Rationale: Regular catheterization prevents bladder overdistension and reduces the risk of urinary tract infections.
3. Teach the patient or caregiver a clean intermittent catheterization technique.
   Rationale: Proper technique minimizes the risk of introducing infections and promotes independence in bladder management.
4. Monitor fluid intake and output, aiming for a balanced intake of 1500-2000 mL daily.
   Rationale: Adequate hydration helps prevent urinary tract infections and maintains kidney function.
5. Assess for signs of autonomic dysreflexia during bladder care.
   Rationale: Autonomic dysreflexia can occur in patients with spinal cord injuries above T6 level and requires immediate intervention.

Desired Outcomes:

• The patient or caregiver will demonstrate proper clean intermittent catheterization technique within three days.
• The patient will maintain a urine output of 30-50 mL/hour with no signs of infection.
• The patient will report no episodes of autonomic dysreflexia related to bladder management.

---

Nursing Care Plan 3: Risk for Infection

Nursing Diagnosis: Risk for Infection related to urinary retention and use of intermittent catheterization.

Related Factors/Causes:

• Incomplete bladder emptying
• Frequent catheterization
• Altered immune system function

Nursing Interventions and Rationales:

1. Perform thorough hand hygiene and maintain aseptic technique during catheterization.
   Rationale: Proper hygiene and aseptic technique reduce the risk of introducing pathogens into the urinary tract.
2. Educate the patient on the importance of perineal hygiene and proper wiping technique (front to back).
   Rationale: Good perineal hygiene helps prevent the introduction of fecal bacteria into the urinary tract.
3. Monitor urine characteristics (color, odor, clarity) and report any changes immediately.
   Rationale: Changes in urine characteristics can indicate the onset of a urinary tract infection.
4. Encourage adequate fluid intake (1500-2000 mL/day) unless contraindicated.
   Rationale: Proper hydration helps flush out bacteria and maintains urinary tract health.
5. Administer prophylactic antibiotics as prescribed.
   Rationale: In some cases, prophylactic antibiotics may be necessary to prevent recurrent urinary tract infections.

Desired Outcomes:

• The patient will remain free from signs and symptoms of urinary tract infection.
• The patient will demonstrate proper perineal hygiene technique within 24 hours.
• The patient will maintain adequate hydration as evidenced by clear, pale yellow urine output.

---

Nursing Care Plan 4: Acute Pain

Nursing Diagnosis: Acute Pain related to bladder distention secondary to urinary retention as evidenced by verbal reports of discomfort and guarding behavior.

Related Factors/Causes:

• Increased bladder pressure due to urine accumulation
• Stretching of the bladder wall
• Possible inflammation or infection

Nursing Interventions and Rationales:

1. Assess pain characteristics using a standardized pain scale every 4 hours and as needed.
   Rationale: Regular pain assessment guides pain management strategies and evaluates intervention effectiveness.
2. Position the patient for comfort, often slightly forward, to relieve pressure on the bladder.
   Rationale: Proper positioning can help alleviate discomfort associated with bladder distention.
3. Apply a warm compress to the lower abdomen as tolerated.
   Rationale: Heat can help relax the pelvic muscles and provide comfort.
4. Administer prescribed pain medications as ordered, evaluating their effectiveness.
   Rationale: Pharmacological interventions can provide pain relief when non-pharmacological methods are insufficient.
5. Provide prompt intervention to relieve urinary retention (e.g., catheterization) as ordered.
   Rationale: Relieving the underlying cause of pain (bladder distention) is crucial for effective pain management.

Desired Outcomes:

• The patient will report pain reduction to a level of 3 or less on a 0-10 scale within 2 hours of intervention.
• The patient will demonstrate a relaxed posture and decreased guarding behavior within 4 hours.
• The patient will verbalize understanding of pain management strategies by the end of the shift.

---

Nursing Care Plan 5: Deficient Knowledge

Nursing Diagnosis: Deficient Knowledge related to urinary retention management as evidenced by verbalization of misconceptions and inappropriate bladder habits.

Related Factors/Causes:

• Lack of exposure to information about urinary retention
• Misinterpretation of health information
• Cognitive limitations

Nursing Interventions and Rationales:

1. Assess the patient’s current knowledge and understanding of urinary retention and its management.
   Rationale: Understanding the patient’s baseline knowledge helps tailor education to their needs.
2. Provide concise information about urinary retention, its causes, and management strategies.
   Rationale: Accurate information empowers the patient to actively participate in their care.
3. Demonstrate and teach proper techniques for double voiding and clean intermittent catheterization if applicable.
   Rationale: Hands-on instruction enhances learning and promotes proper technique.
4. Discuss lifestyle modifications that can help manage urinary retention (e.g., timed voiding, fluid management).
   Rationale: Lifestyle changes can significantly improve bladder function and reduce retention episodes.
5. Provide written materials and reputable online resources for the patient to review.
   Rationale: Multiple forms of information reinforce learning and provide references for future use.

Desired Outcomes:

• The patient will verbalize an understanding of urinary retention and its management by the end of the education session.
• The patient will demonstrate proper technique for relevant self-care measures (double voiding and catheterization) within 3 days.
• The patient will identify at least three lifestyle modifications to improve bladder function by discharge.

Conclusion

Urinary retention is a complex condition that requires thorough assessment and individualized care. By understanding the underlying causes, recognizing the signs and symptoms, and implementing appropriate nursing interventions, healthcare professionals can significantly improve patient outcomes and quality of life. Regular reassessment and adjustment of care plans are essential to ensure optimal management of urinary retention.

References

1. Abrams, P., Cardozo, L., Fall, M., Griffiths, D., Rosier, P., Ulmsten, U., … & Wein, A. (2002). The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourology and Urodynamics, 21(2), 167-178.
2. Chapple, C. R., Osman, N. I., Birder, L., van Koeveringe, G. A., Oelke, M., Nitti, V. W., … & Dmochowski, R. R. (2015). The underactive bladder: a new clinical concept?. European Urology, 68(3), 351-353.
3. Doughty, D. B., & Moore, K. N. (2019). Wound, Ostomy and Continence Nurses Society Core Curriculum: Continence Management. Wolters Kluwer Health.
4. Kampf, G., Löffler, H., & Gastmeier, P. (2009). Hand hygiene for the prevention of nosocomial infections. Deutsches Ärzteblatt International, 106(40), 649.
5. Newman, D. K., & Wein, A. J. (2018). Office-based behavioral therapy for management of incontinence and other pelvic disorders. Urologic Clinics, 45(4), 607-622.
6. Vahr, S., Cobussen-Boekhorst, H., Eikenboom, J., Geng, V., Holroyd, S., Lester, M., … & Vandewinkel, C. (2013). Evidence-based guidelines for best practice in urological health care. Catheterisation, urethral intermittent in adults. European Association of Urology Nurses (EAUN).