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NURSING DIAGNOSIS: Urinary Elimination, impaired/Urinary Retention [acute]
May be related to
- Mechanical trauma, surgical manipulation, presence of local tissue edema, hematoma
- Sensory/motor impairment: nerve paralysis
Possibly evidenced by
- Sensation of bladder fullness, urgency
- Small, frequent voiding or absence of urinary output
- Overflow incontinence
- Bladder distension
Desired Outcomes
Urinary Elimination (NOC)
- Empty bladder regularly and completely.
6 Hysterectomy Nursing Care Plan (NCP)
- Low Self-Esteem — Hysterectomy Nursing Care Plan (NCP)
- Impaired Urinary Elimination — Hysterectomy Nursing Care Plan (NCP)
- Constipation/Diarrhea — Hysterectomy Nursing Care Plan (NCP)
- Ineffective Tissue Perfusion — Hysterectomy Nursing Care Plan (NCP)
- Sexual Dysfunction — Hysterectomy Nursing Care Plan (NCP)
- Knowledge Deficit — Hysterectomy Nursing Care Plan (NCP)
Impaired Urinary Elimination — Hysterectomy Nursing Care Plan (NCP): Nursing Interventions & Rationale
| Nursing Interventions | Rationale |
| Note voiding pattern and monitor urinary output. | May indicate urinary retention if voiding frequently in small/insufficient amounts |
| Palpate bladder. Investigate reports of discomfort, fullness, inability to void. | Perception of bladder fullness, distension of bladder above symphysis pubis indicates urinary retention. |
| Provide routine voiding measures, e.g., privacy, normal position, running water in sink, pouring warm water over perineum. | Promotes relaxation of perineal muscles and may facilitate voiding efforts. |
| Provide/encourage good perianal cleansing and catheter care (when present). | Promotes cleanliness, reducing risk of ascending urinary tract infection (UTI). |
| Assess urine characteristics, noting color, clarity, odor. | Urinary retention, vaginal drainage, and possible presence of intermittent/indwelling catheter increase risk of infection,especially if patient has perineal sutures. |
| Catheterize when indicated/per protocol if patient is unable to void or is uncomfortable. | Edema or interference with nerve supply may cause bladder atony/urinary retention requiring decompression of the bladder.Note: Indwelling urethral or suprapubic catheter may be inserted intraoperatively if complications are anticipated. |
| Decompress bladder slowly. | When large amount of urine has accumulated, rapid bladderdecompression releases pressure on pelvic arteries, promoting venous pooling. |
| Maintain patency of indwelling catheter; keep drainage tubing free of kinks. | Promotes free drainage of urine, reducing risk of urinary stasis/retention and infection. |
| Check residual urine volume after voiding as indicated. | May not be emptying bladder completely; retention of urine increases possibility for infection and is uncomfortable/painful. |
Found through:
knowledge deficit nursing care plan, ncp for acute pain related to tahbso, body image care plan, impaired tissue perfusion ncp, ncp altered urinary elimination related to urinary drainage, ncp infection due to hysterectomy, nursing diagnosis for agn
