Friday, November 26, 2010

Urinary Retention

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.

            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.
  • 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
  • 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.

  • 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.

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

Ø  Offer thorough perineal and catheter care. Decreases the risk of ascending infection.

Ø  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.

Ø  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.

Ø  Place bedpan, urinal, or bedside commode within reach. Provide privacy.

Ø  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.

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