Nursing Diagnosis and Nursing Intervention

NANDA Urinary Retention Nursing Diagnosis

NANDA Definition: Incomplete emptying of the bladder

Defining Characteristics:

  • Measured urinary residual >150 to 200 ml or 25% of total bladder capacity; 
  • obstructive lower urinary tract symptoms (poor force of stream, intermittency of stream, hesitancy of urination, postvoiding dribbling, feelings of incomplete bladder emptying); 
  • irritative lower urinary tract symptoms (urgency to urinate, diurnal frequency of urination, nocturia); 
  • overflow incontinence (dribbling urine loss caused when intravesical pressure overwhelms the sphincter mechanism)

Related Factors:
  • Bladder outlet obstruction: benign prostatic hyperplasia, prostate cancer, prostatitis, urethral stricture, bladder neck dyssynergia, bladder neck contracture, detrusor striated sphincter dyssynergia, obstructing cystocele or urethral distortion, urethral tumor, urethral polyp, posterior urethral valves, postoperative complication
  • Deficient detrusor contraction strength: sacral level spinal lesions, cauda equina syndrome, peripheral polyneuropathies, herpes zoster or simplex affecting sacral nerve roots, injury or extensive surgery causing denervation of pelvic plexus, medication side effect, complication of illicit drug use, impaction of stool
NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
  • Urinary Elimination
  • Urinary Continence
Client Outcomes
  • Completely and regularly eliminates urine from the bladder; measured urinary residual volume is <150 to 200 ml or 25% of total bladder capacity (voided volume plus urinary residual volume) 
  • Correction or relief from obstructive symptoms 
  • Correction or alleviation of irritative symptoms
  • Client is free of upper urinary tract damage (renal function remains sufficient; absence of febrile urinary infections)
NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels
  • Urinary Catheterization
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