Nursing Care Plan for Urinary Retention
Urinary retention is the inability to empty the bladder completely during the process of urine. (Brunner and Suddarth. (2010). Text Book Of Medical Surgical Nursing 12th Edition. Thing in 1370).
Causes of urinary retention, among others, diabetes, enlarged prostate gland, urethral abnormalities (tumor, infection, calculus), trauma, childbirth or neurological disorders (stroke, spinal cord injury, multiple sclerosis and Parkinson's). Some medications can cause urinary retention either by inhibiting bladder contractions or increased resistance of the bladder. (Karch, 2008)
Signs and Symptoms
- Beginning with a slow flow of urine.
- Then there are the longer polyuria became worse because of inefficient bladder emptying.
- Abdominal distention occurs due to dilatation of the bladder.
- Feels no pressure, pain and sometimes feel the urge to urinate.
- In severe retention could reach 2000 -3000 cc.
The diagnostic checks that can be performed on urine retention is as follows:
- Examination of the urine specimen.
- Decision: sterile, random, midstream.
- General retrieval: pH, BJ, Culture, Protein, Glucose, hemoglobin, ketones and Nitrite.
- Cystoscopy (examination of the bladder).
- IVP (Intravenous pyelogram) / X-ray with contrast material.
Nursing Diagnosis for Urinary Retention : Acute Pain related to distension of the bladder.
Goal: pain problems can be resolved.
- Stating the pain is relieved / controlled.
- Shows relax, rest and increased activity appropriately.
1) Assess pain, note the location, intensity of pain.
R: Provides information to assist in determining interventions.
2) Plaster drainage hose on the thigh, and a catheter in the abdomen.
R: Preventing erosion withdrawal bladder and penile-scrotal meeting.
3) Maintain bed rest when indicated pain.
R: Bed rest may be necessary during the early phase of acute retention.
4) Provide comfort measures
R: Enhancing relaxation and coping mechanisms.