Impairments in urinary elimination can be due to urinary incontinence or urinary retention and all refer to the inability to pass urine effectively. Get to know the nursing care plan and management of patients with urinary elimination problems. Learn about the nursing assessment, nursing diagnosis, goals, and interventions for patients with urinary elimination and urinary retention.
Table of contents
- What is urinary incontinence?
- What is urinary retention?
- Signs and symptoms
- Goals and Outcomes
- Nursing interventions and rationales
- See also
What is urinary incontinence?
Urinary incontinence, also known as overactive bladder, is the involuntary loss of urine due to difficulties controlling the bladder, frequently seen in older individuals, particularly women. This condition often leads to feelings of embarrassment and a loss of independence, as issues such as wet clothing, urine odor, and the need for assistance with toileting can arise. Over time, the inability to control urination can negatively impact a person’s self-image and social interactions, as well as affect their work performance, resulting in feelings of shame and a diminished sense of self. There are different types of urinary incontinence, but the most common are:
Functional urinary incontinence
Functional urinary incontinence refers to difficulties in reaching or using the toilet when required, despite having normal neurological control mechanisms for urination and the ability to fill, store, and recognize the urge to void urine. Numerous factors may contribute to functional urinary incontinence, including environmental barriers and physical issues that inhibit swift movements to the bathroom or undressing for toilet use. Such physical issues can stem from musculoskeletal problems like back pain or arthritis, or neurological conditions such as Parkinson’s disease or multiple sclerosis.
Urge urinary incontinence
Urge urinary incontinence is characterized by unexpected bladder contractions, often strong enough to overpower the sphincter muscles that control urine flow from the bladder through the urethra. This “overactive” bladder condition can arise from spinal cord injuries, pelvic surgery, central nervous system disorders like Alzheimer’s, multiple sclerosis, and Parkinson’s disease, or due to conditions like interstitial cystitis, urinary tract infections, or pelvic radiation, and even excessive consumption of alcohol.
Reflex urinary incontinence
Reflex urinary incontinence occurs due to a disruption in the normal neurological mechanisms that control the contractions of the detrusor muscle and the relaxation of the sphincter. This condition is generally linked to issues with the central nervous system, resulting from factors such as stroke, Parkinson’s disease, brain tumors, spinal cord injuries, or multiple sclerosis. Individuals with reflex incontinence tend to urinate regularly without consciously recognizing the need to do so, with a consistent urine volume each time, both day and night. The amount of residual urine typically measures less than 50 mL. Urodynamic tests show that detrusor muscle contractions occur once the bladder reaches a specific volume.
Stress urinary incontinence
Stress urinary incontinence occurs when urine leaks when pressure is exerted on the bladder by coughing, sneezing, laughing, exercising or lifting something heavy.
Overflow urinary incontinence
Overflow urinary incontinence is the involuntary release of urine caused by an overfilled bladder, often in people who cannot fully empty their bladders.
Mixed urinary incontinence
Mixed urinary incontinence refers to the occurence of multiple types of incontinence – usually stress and urge incontinence.
What is urinary retention?
Urinary retention, or ischuria, is the inability to fully empty the bladder, and it may or may not coexist with urinary incontinence. It can be caused by factors such as immobility, medical conditions like BPH, disk surgery, or hysterectomy, and side effects of various medications including anesthetics, antihypertensives, and antihistamines. These medications may interfere with nerve signals crucial for relaxing the sphincters that enable urination, potentially leading to bladder distention and occasional incontinence. If left untreated, urinary retention can result in severe complications like bladder damage and chronic kidney failure, hence it needs prompt and appropriate management.
Signs and symptoms
Here are the common signs and symptoms for patients with problems with urinary elimination:
- Reports of urine leakage. Unintentional discharge or leakage of urine.
- Leakage of urine during physical activities. Incontinence that occurs during actions like coughing, sneezing, or exercising.
- Urgency to urinate that cannot be controlled. Strong and sudden urge to urinate that is difficult to postpone or control.
- Frequent urination. Need to urinate more often than usual.
- Dampness or wetness in the underwear or clothing. Presence of moisture or wet spots in the undergarments or clothing.
- Skin irritation or infection around the genital area. Redness, itching, or infection of the skin in the genital region.
- Difficulty initiating urination. Struggles to start the flow of urine.
- Weak or interrupted urine flow. Urine stream that is weak, intermittent, or stops and starts.
- Sensation of incomplete bladder emptying. Feeling that the bladder is not fully emptied after urination.
- Increased frequency of urination. Need to urinate more frequently than usual.
- Urgency to urinate that cannot be relieved. Strong and immediate urge to urinate that cannot be alleviated.
- Lower abdominal discomfort or pain. Mild to moderate pain or discomfort in the lower abdomen.
- Distended or bloated lower abdomen. Swelling or bloating in the lower abdominal area.
- Urinary tract infection or recurrent urinary tract infections. Inflammation and infection of the urinary tract, often leading to repeated infections.
Goals and Outcomes
The following are the common goals and expected outcomes for impaired urinary elimination:
- The patient will demonstrate proper bladder emptying techniques, including double voiding and complete emptying of the bladder, to prevent urinary retention and reduce the risk of urinary tract infections, as evidenced by maintaining a post-void residual volume of less than 50 mL and reporting clear, odor-free urine.
- The patient will actively participate in the identification and management of factors contributing to urinary incontinence, including keeping a bladder diary, identifying triggers, and seeking appropriate treatment options, as evidenced by documenting potential causes and implementing interventions to manage incontinence.
- The patient will adhere to a prescribed fluid intake and voiding schedule, monitoring their input and output to maintain a balanced fluid balance, prevent bladder distension, and minimize urinary leakage, as evidenced by maintaining a voiding frequency of every 2-3 hours and reporting no episodes of urinary leakage or bladder distension.
- The patient will demonstrate understanding of the rationale behind prescribed treatments for incontinence and retention, including medications, exercises, and lifestyle modifications, by explaining the purpose and benefits of the recommended interventions to the healthcare provider.
- The patient will verbalize understanding of their condition, including the underlying causes and potential consequences of urinary incontinence and retention, as evidenced by accurately explaining the condition and its impact on their daily life during education and counseling sessions with healthcare providers.
Nursing interventions and rationales
Nursing interventions for managing impairments in urinary elimination focus on promoting optimal urinary function and addressing underlying causes. These interventions may include implementing a regular toileting schedule, providing privacy and comfort during toileting, encouraging adequate fluid intake, assisting with mobility and positioning, monitoring urinary output and bladder function, performing bladder scans or catheterizations as necessary, and educating the patient on proper hygiene and techniques to promote urinary elimination.
Establishing normal urinary elimination
1. Assess the voiding pattern (frequency and amount). Compare urine output with fluid intake. Note specific gravity.
Identifies characteristics of bladder function (effectiveness of bladder emptying, renal function, and fluid balance). Note: Urinary complications are a major cause of mortality.
2. Palpate for bladder distension and observe for overflow.
Bladder dysfunction is variable but may include loss of bladder contraction and inability to relax the urinary sphincter, resulting in urine retention and reflux incontinence. Note: Bladder distension can precipitate autonomic dysreflexia.
3. Note reports of urinary frequency, urgency, burning, incontinence, nocturia, and size or force of the urinary stream. Palpate bladder after voiding.
This provides information about the degree of interference with elimination or may indicate a bladder infection. Fullness over the bladder following void is indicative of inadequate emptying or retention and requires intervention.
4. Review drug regimen, including prescribed, over-the-counter (OTC), and street.
A number of medications such as some antispasmodics, antidepressants, and narcotic analgesics; OTC medications with anticholinergic or alpha agonist properties; or recreational drugs such as cannabis may interfere with bladder emptying.
5. Assess the availability of toileting facilities.
Patients may need a bedside commode if mobility limitations interfere with getting to the bathroom.
6. Assess the patient’s usual pattern of urination and occurrence of incontinence.
Many patients are incontinent only in the early morning when the bladder has stored a large urine volume during sleep.
7. Common Assessment Findings
- 7.1. Urgency
Strong desire to void may be caused by inflammation or infections in the bladder or urethra
- 7.2. Dysuria
Painful or difficult voiding
- 7.3. Frequency
Voiding that occurs more than usual when compared with the person’s regular pattern or the generally accepted norm of voiding once every 3 to 6 hours
- 7.4. Hesitancy
Undue delay and difficulty in initiating voiding
- 7.5. Polyuria
A large volume of urine or output voided at any given time
- 7.6. Oliguria
A small volume of urine or output between 100 to 500 mL/24 hr
- 7.7. Anuria
Lack of urine production
- 7.8. Nocturia
Excessive urination at night interrupts sleep
- 7.9. Hematuria
RBCs in the urine
8. Observe for cloudy or bloody urine, and foul odor. Dipstick urine as indicated.
Signs of the urinary tract or kidney infection that can potentiate sepsis. Multistrip dipsticks can provide a quick determination of pH, nitrite, and leukocyte esterase suggesting the presence of infection.
9. Obtain periodic urinalysis and urine culture and sensitivity as indicated.
These tests monitor renal status. A colony count over 100,000 indicates the presence of infection requiring treatment.
10. Monitor BUN, creatinine, and white blood cell (WBC) counts.
These reflect renal function and identify complications.
11. Measure residual urine via postvoid catheterization or ultrasound.
Measuring residual urine via postvoid catheterization or ultrasound is helpful in detecting the presence of urinary retention and the effectiveness of a bladder training program. Note: The use of ultrasound is noninvasive, reducing the risk of colonization of the bladder.
12. Begin bladder retraining per protocol when appropriate (fluids between certain hours, digital stimulation of trigger area, contraction of abdominal muscles, Credé’s maneuver).
Timing and type of bladder program depend on the type of injury (upper or lower neuron involvement). Note: Credé’s maneuver should be used with caution because it may precipitate autonomic dysreflexia.
13. Encourage adequate fluid intake (2–4 L per day), avoiding caffeine and use of aspartame, and limiting intake during late evening and at bedtime. Recommend the use of cranberry juice/vitamin C.
Sufficient hydration promotes urinary output and aids in preventing infection. Note: When a patient is taking sulfa drugs, sufficient fluids are necessary to ensure adequate excretion of the drug, reducing the risk of cumulative effects. Note: Aspartame, a sugar substitute (e.g., Nutrasweet), may cause bladder irritation leading to bladder dysfunction.
14. Promote continued mobility, unless contraindicated.
Mobility decreases the risk of developing UTIs.
15. Cleanse the perineal area and keep it dry. Provide catheter care as appropriate.
Proper perineal hygiene decreases the risk of skin irritation or breakdown and the development of ascending infection.
16. Recommend good hand washing and proper perineal care.
Handwashing and perineal care reduce skin irritation and the risk of ascending infection.
17. Teach Kegel exercises.
These exercises improve pelvic floor muscle tone and urethrovesical junction sphincter tone.
18. Educate the patient about the importance of limiting the intake of alcohol and caffeine.
These chemicals are known to be bladder irritants. They can increase detrusor overactivity.
19. Catheterize as indicated.
Catheterization may be necessary as a treatment and for evaluation if the patient is unable to empty the bladder or retains urine.
20. Teach self-catheterization and instruct in the use and care of indwelling catheters.
This method helps patients maintain autonomy and encourages self-care. An indwelling catheter may be required, depending on the patient’s abilities and degree of urinary problem.
21. Keep the bladder deflated by means of an indwelling catheter initially. Begin intermittent catheterization program when appropriate.
An indwelling catheter is used during the acute phase for the prevention of urinary retention and for monitoring output. Intermittent catheterization may be implemented to reduce complications usually associated with the long-term use of indwelling catheters. A suprapubic catheter may also be inserted for long-term management.
22. Administer medications as indicated: Oxybutynin (Ditropan), propantheline (Pro-Banthine), hyoscyamine sulfate (Cytospaz-M), flavoxate hydrochloride (Urispas), tolterodine (Detrol).
These drugs reduce bladder spasticity and associated symptoms of frequency, urgency, incontinence, and nocturia.
23. Administer anti-infective agents as necessary: Nitrofurantoin macrocrystals. (Macrodantin); co-trimoxazole (Bactrim, Septra); ciprofloxacin (Cipro); norfloxacin (Noroxin).
Bacteriostatic agents inhibit bacterial growth and destroy susceptible bacteria. Prompt treatment of infection is necessary to prevent serious complications of sepsis/shock.
24. Refer for further evaluation for bladder and bowel stimulation.
Clinical research is being conducted on the technology of electronic bladder control. The implantable device sends electrical signals to the spinal nerves that control the bladder and bowel. Early results look promising.
25. Refer to a urinary continence specialist as indicated.
Collaboration with specialists is helpful for developing an individual plan of care to meet patients’ specific needs using the latest techniques, and continence products.
Interventions for functional urinary incontinence
Nursing interventions for functional urinary incontinence focus on identifying and addressing the underlying factors contributing to the incontinence, such as cognitive or physical impairments. These interventions may include promoting a regular toileting schedule, providing assistance with toileting, offering mobility aids, and ensuring a safe and accessible environment. By addressing the functional limitations, nurses can help minimize the impact of incontinence and promote the patient’s independence and dignity.
1. Complete a focused record of the incontinence including duration, frequency, and severity of leakage episodes, and alleviating and aggravating factors.
This provides evidence of the causes, the severity of the condition, and its management.
2. Assess the patient’s recognition of the need to void.
Patients with functional urinary incontinence are incontinent because they are unable to get to an appropriate place to void. In some cases, functional incontinence may result from problems with thinking or communicating. A person with Alzheimer’s disease or other forms of dementia, for example, may not think clearly enough to plan trips to the restroom, recognize the need to use the restroom, or find the restroom. People with severe depression may lose all desire to care for themselves, including using the restroom.
3. Assess the patient for potentially reversible causes of acute/transient urinary incontinence (e.g., urinary tract infection [UTI], atrophic urethritis, constipation or impaction, sedatives or narcotics interfering with the ability to reach the toilet in a timely fashion, antidepressants or psychotropic medications interfering with efficient detrusor contractions, parasympatholytics, alpha-adrenergic antagonists, polyuria caused by uncontrolled diabetes mellitus, or insipidus).
Transient or acute incontinence can be reduced or eliminated by reversing the underlying cause.
4. Assess the availability of functional toileting facilities (working toilet, bedside commode).
A bedside commode is necessary for an immobile patient.
5. Assess the patient for established/chronic incontinence: stress urinary incontinence, urge urinary incontinence, reflex, or extra urethral (“total”) urinary incontinence. If present, begin treatment for these forms of urine loss.
Functional incontinence is often accompanied by another form of urinary leakage, particularly among the elderly.
6. Assess the patient’s ability to get to a toileting facility, both independently and with help.
This information allows the nurse to plan for assistance with transfer to a toilet or bedside commode. Functional continence requires the patient to be able to get to a toilet either independently or with assistance.
7. Evaluate the home, acute care, or long-term care environment for convenience to toileting facilities, giving special consideration to the following:
Functional continence demands access to the toilet; environmental barriers blocking this access can produce functional incontinence.
- Distance of toilet from bed, chair, living quarters
- Characteristics of the bed, including the presence of side rails and distance of the bed from the floor
- Characteristics of the pathway to the toilet, including barriers such as stairs, loose rugs on the floor, and inadequate lighting
- Characteristics of the bathroom, including patterns of use; lighting; the height of the toilet from the floor; the presence of handrails to assist transfers to the toilet; and breadth of the door and its accessibility for a wheelchair, walker, or other assistive devices
8. Assess the patient’s normal pattern of urination and an episode of incontinence.
This information is the source for an individualized toileting program. Many patients are incontinent only in the early morning when the bladder has collected a large urine volume during sleep.
9. Assess the patient’s need for physical assistive devices such as a cane, walker, or wheelchair.
Functional continence requires the ability to gain access to a toilet facility, either independently or with the assistance of devices to increase mobility.
10. Assess the patient for dexterity, including the strength to manage buttons, hooks, snaps, Velcro, and zippers needed to remove clothing. Consult physical or occupational therapists to promote optimal toilet access as indicated.
Functional continence requires the ability to remove clothing to urinate.
11. Assess cognitive status with a NEECHAM confusion scale (Neelan et al, 1992) for acute cognitive changes, a Folstein Mini-Mental Status Examination (Folstein, Folstein, McHugh, 1975), or other tools as designated.
Functional continence needs satisfactory mental acuity to respond to sensory input from a filling urinary bladder by locating the toilet, moving to it, and emptying the bladder.
12. Monitor elderly patients for dehydration in the long-term care facility, acute care facility, or home.
Dehydration can intensify urine loss, produce acute confusion, and increase the risk of morbidity and mortality, especially in frail elderly patients.
13. Set a toileting schedule.
A toileting schedule guarantees the patient of a designated time for voiding and reduces episodes of functional incontinence.
14. Eliminate environmental barriers to toileting in acute care, long-term care, or home setting. Help the patient remove loose rugs from the floor and improve lighting in hallways and bathrooms.
Loose rugs and inadequate lighting can be a barrier to functional continence.
15. Place an appropriate, safe urinary receptacle such as a 3-in-1 commode, female or male hand-held urinal, no-spill urinal, or containment device when toileting access is limited by immobility or environmental barriers. Provide privacy.
The patient must take this alternative toileting facility. Some people may be ashamed when using a toilet in a more open area.
16. Assist the person to change their clothing to maximize toileting access. Select loose-fitting clothing with stretch waistbands rather than buttoned or zippered waist; minimize buttons, snaps, and multilayered clothing; and substitute Velcro or other easily loosened systems for buttons, hooks, and zippers in existing clothing.
Clothing can be a barrier to functional continence if it takes time to remove before voiding. Women may find skirts or dresses easier to wear while implementing a toileting program. Pants with elastic waistbands may be easier for men and women to remove for toileting.
17. Start a prompted voiding program or patterned urge response toileting program for the elderly patient with functional incontinence and dementia in the home or long-term care facility:
Prompted voiding or patterned urge response toileting has been revealed to considerably lessen or eliminate functional incontinence in selected patients in the long-term care facility and in the community setting.
- Ascertain the frequency of current urination using an alarm system or check and change the device.
- Note urinary elimination and incontinent patterns on a bladder log to use as a baseline for assessment and evaluation of treatment efficacy
- Start a prompted toileting program based on the results of this program; toileting frequency may vary from every 1.5 to 2 hours, to every 4 hours
- Praise the patient when toileting occurs with prompting
- Refrain from any socialization when incontinent episodes occur; change the patient and make her or him comfortable
18. Tell the patient to limit fluid intake 2 to 3 hours before bedtime and to void just before bedtime.
Restricting fluid intake and voiding before bedtime reduces the need to disrupt sleep for voiding.
19. Manage any existing perineal skin excoriation with a vitamin-enriched cream, followed by a moisture barrier.
Moisture barrier ointments are beneficial in protecting perineal skin from urine.
20. Explain to the patient and caregiver the rationale behind and implementation of a toileting program.
Successful functional continence requires consistency in the use of a toileting program.
21. Educate caregivers and family members about the importance of responding immediately to the patient’s request for assistance with voiding.
Functional continence is promoted when caregivers respond promptly to the patient’s request for help with voiding.
22. Advise the patient about the benefits of using disposable or reusable insert pads, pad-pant systems, or replacement briefs specifically designed for urinary incontinence (or double urinary and fecal incontinence) as indicated.
Most absorptive products utilized by community-dwelling elders are not designed to absorb urine, prevent odor, and protect the perineal skin. Substitution of disposable or reuse
Interventions for urge urinary incontinence
Nursing interventions for urge urinary incontinence aim to manage and reduce the frequency and intensity of sudden urges to urinate. These interventions may include implementing bladder training techniques, such as scheduled voiding and pelvic floor muscle exercises, providing education on healthy bladder habits, offering guidance on fluid intake management, and collaborating with the healthcare team to explore medication options if necessary.
1. Determine the patient’s episodes of incontinence.
Urge incontinence happens when the bladder muscle abruptly contracts. The patient may report feeling the need suddenly to urinate but being unable to get to the bathroom in time.
2. Tell the patient to keep a daily diary indicating voiding frequency and patterns.
This information enables the nurse to recognize patterns in voiding. This information will allow for an individualized treatment plan. The patient may be voiding as often as every 2 hours.
3. Take a specimen of urine for culture.
A bladder infection can result in a strong urge to urinate; successful management of a urinary tract infection may reduce or improve incontinence.
4. Observe the results of cystometry.
Diagnostic testing is used to measure bladder pressures and fluid volume during filling, storage, and urination. The results of this test may show the underlying problem leading to urge incontinence.
5. Promote access to toilet facilities, and instruct patient to make scheduled trips to the bathroom.
Scheduled voiding allows for frequent bladder emptying.
6. Give or encourage the use of medications as ordered:
- 6.1. Anticholinergics. Anticholinergics lessen or block detrusor contractions, thereby reducing the occurrence of incontinence.
- 6.2. Tricyclic antidepressants. The tricyclics increase serotonin or norepinephrine, which results in the relaxation of the bladder wall and increased bladder capacity.
7. Educate the patient about the effects of extreme alcohol and caffeine intake.
These chemicals are known to be bladder irritants. they can increase detrusor overactivity.
8. Aid the patient with developing a bladder training program that includes voiding at scheduled intervals, and gradually increasing the time between voidings.
A bladder training program helps increase bladder capacity through the regulation of fluid intake, pelvic exercises, and scheduled voiding. A regular schedule of voiding helps decrease detrusor overactivity and increase bladder fluid volume capacity.
9. Educate patient about Kegel exercises.
Kegel exercises are done to strengthen the muscles of the pelvic floor and can be followed with a minimum of exertion. The repetitious tightening and relaxation of these muscles (10 repetitions four or five times per day) aid some patients regain continence.
Interventions for reflex urinary incontinence
Nursing interventions for reflex urinary incontinence focus on managing and addressing the involuntary bladder contractions that lead to urine leakage. These interventions may include implementing a timed voiding schedule to empty the bladder regularly, using assistive devices such as urinary catheters or continence products as needed, providing education on techniques to manage bladder spasms, monitoring fluid intake and promoting healthy hydration, and collaborating with the healthcare team to explore medications or interventions that can help regulate bladder function.
1. Ascertain the patient’s recognition of the need to urinate.
Patients with neurological impairments may have damaged sensory fibers, and may not have the sensation of the need to void.
2. Measure and record urine volume with each voiding.
Urine volumes are usually consistent with reflex incontinence.
3. Review the results of urodynamic studies.
A cystometrogram will measure bladder pressures and fluid volumes during filling, storage, and urination. Electromyography will record detrusor activity during voiding. Test results will indicate the point of coordination between detrusor muscle and sphincter activity.
4. Allow the patient to maintain a “bladder diary.”
Data about fluid intake and voiding patterns provide a basis for planning bladder management techniques.
5. Tell the patient to limit fluid intake 2 to 3 hours prior to bedtime and to void just before going to bed.
Restricting fluid intake and voiding before going to bed reduces the need to interrupt sleep for voiding.
6. Allow voiding at scheduled intervals before predictable urination.
Voiding at regular intervals, based on knowledge of the patient’s voiding pattern, lowers the possibility of uncontrolled incontinence.
7. For the male patient, acknowledge the application of an external catheter.
An external catheter attached to a gravity drainage device enables the patient to remain dry.
8. Catheterize the patient at regular intervals if spontaneous voiding is not possible.
Emptying the bladder at regular intervals will reduce incontinence episodes. The risk for infection is noteworthy with indwelling catheters.
9. Explain the importance of absorbent pads in social situations.
Absorbent pads will preserve clothing when the patient is in public. The patient needs to learn about replacing the pads at regular intervals to prevent skin irritation from exposure to urine and moisture.
10. Demonstrate to patient or caregiver intermittent catheterization.
This method drains the bladder at particular periods.
11. Work with the patient and family to establish a reasonable, manageable voiding program.
Participation in the plan of care promotes additional knowledge and appropriate management.
12. Ascertain the quantity, frequency, and character of urine, such as color, odor, and specific gravity.
Urinary retention, vaginal discharge, and the presence of a catheter predispose the patient to infection, especially if the patient has perineal sutures.
13. Review previous patterns of voiding.
There is a wide range of “normal” voiding frequency. Acute urinary retention requires immediate medical intervention. With chronic urinary retention, one is able to urinate but may have trouble starting the stream or emptying the bladder completely.
14. Allow the patient to keep a record of the amount and time of each voiding. Take 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.
15. Assess vital signs. Check for changes in mentation, hypertension, and peripheral or dependent edema. Weigh daily. Maintain precise I&O records.
Kidney failure results in reduced fluid excretion and builds up of toxic wastes. It may lead to a complete renal shutdown.
16. Monitor time intervals between voiding and document the quantity voided.
Keeping an hourly record for 48 hours can help in establishing a toileting program and gives a clear picture of the patient’s voiding pattern.
17. Ask patient about stress incontinence when moving, sneezing, coughing, laughing, and lifting objects.
High urethral pressure can inhibit voiding until abdominal pressure increases enough for urine to be involuntarily lost. Also, hinders bladder emptying.
18. Palpate and percuss suprapubic area. Examine verbalization of discomfort, pain, fullness, and difficulty of voiding.
A distended bladder could be felt by the patient in the suprapubic area. Perception of bladder fullness and bladder distention above the symphysis pubis implies urinary retention.
19. Monitor urinalysis, urine culture, and sensitivity.
Urinary tract infection can cause retention.
20. Monitor blood urea nitrogen (BUN) and creatinine.
This laboratory test will differentiate between renal failure and urinary retention.
21. Use a bladder scan (portable ultrasound instrument) or catheterize the patient to measure residual urine if incomplete emptying is presumed.
Retention of urine in the bladder predisposes the patient to urinary tract infection and may indicate the need for an intermittent catheterization program.
22. If an indwelling catheter is in place, assess for patency and kinking.
An occluded or kinked catheter may lead to urinary retention in the bladder.
Initiate interventions for urinary retention
Nursing interventions for urinary retention focus on promoting bladder emptying and relieving the obstruction or underlying causes. These interventions may include assisting the patient with toileting or providing bladder stimulation techniques, such as warm water sitz baths or applying a warm compress to the lower abdomen, encouraging increased fluid intake to promote urinary flow, monitoring the patient’s intake and output, collaborating with the healthcare team to explore medications or interventions that can help stimulate bladder contractions, and ensuring proper catheter care and management if necessary
1. Start the following techniques to facilitate voiding:
- 1.1. Promote fluids, if not contraindicated. Unless medically restricted, fluid intake should be at least 1500 mL/24 hr.
- 1.2. Encourage regular intake of cranberry juice. Cranberry juice keeps the acidity of urine. This aids in preventing infection.
- 1.3. Place the patient in an upright position to facilitate successful voiding. An upright position on a commode or in bed on a bedpan increases the patient’s voiding success through the force of gravity.
- 1.4. Provide privacy. Privacy aids in the relaxation of urinary sphincters.
- 1.5. Encourage the patient to void at least every 4 hours. Voiding at frequent intervals empties the bladder and reduces the risk of urinary retention.
- 1.6. Allow the patient to listen to the sound of running water, dip hands in warm water/pour lukewarm water over the perineum. These actions promote urination.
- 1.7. Offer fluids before voiding. Sufficient urine volume is necessary to stimulate the voiding reflex.
- 1.8. Perform Credé’s maneuver. Credé’s method (pressing down over the bladder with the hands) enhances urinary bladder pressure, and this consequently induces relaxation of the sphincter to allow voiding.
2. Decompress bladder moderately.
Once a huge amount of urine has accumulated, fast urinary bladder decompression produces pressure on pelvic arteries and may cause venous pooling.
3. Encourage patient to take bethanechol (Urecholine) as indicated.
Bethanechol stimulates parasympathetic nervous system to release acetylcholine at nerve endings and to enhance the tone and amplitude of contractions of smooth muscles of the urinary bladder.
4. If incomplete emptying is presumed, 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 program.
5. Keep indwelling catheter patent; maintain drainage tubing kink-free.
These provide free drainage of urine, decreasing the possibility of urinary stasis or retention and infection.
6. Secure the catheter of the male patient to the abdomen and thigh for the female.
This technique prevents urethral fistula and avoids accidental dislodgement.
7. Educate the patient on the importance of meatal care. This should be done twice daily with soap and water and dry thoroughly.
Meatal care reduces the risk for infection.
8. Discuss the importance of adequate fluid intake.
Increased fluid stimulates voiding and decreases the risk of urinary tract infections.
9. Inform the patient and significant other to observe the different signs and symptoms of bladder distention like reduced or lack of urine, urgency, hesitancy, frequency, distention of lower abdomen, or discomfort.
Knowledge of the signs and symptoms allows the patient, significant other, or caregiver to recognize them and seek treatment.
10. Instruct the patient and significant other to observe the different signs and symptoms of urinary tract infection like chills and fever, frequent urination or concentrated urine, and abdominal or back pain.
Knowledge of the signs and symptoms allows the patient, significant other, or caregiver to recognize them and seek treatment.
11. Teach the patient to achieve an upright position on the toilet if possible.
An upright position is the natural position for voiding and uses the force of gravity.
12. Teach the patient about possible surgical treatment as needed.
If prostate enlargement is involved, surgery may be required. Women may need surgery to lift a fallen bladder or rectum. A urethral stent may be required to treat a urethral stricture.
13. Suggest a sitz bath as ordered.
A sitz bath supports muscle relaxation, reduces edema, and may improve voiding attempts.
Recommended nursing diagnosis and nursing care plan books and resources.
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.