Nursing Diagnosis and Nursing Intervention

Acute Pain related to Urinary Retention

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.

Sample of Nursing Care Plan for Wandering

Wandering Definitions:

Moving from place to place without a fixed plan; roaming; rambling: wandering tourists.

Related factors:
  • Cognitive impairment (disorientation, difficulty remembering and memory).
  • Emotional (depression).
  • Excessive stimuli from the environment.
  • Lasts all day.

Objective data:
A woman, 62-year-old was found wandering, not be able to remember the people (neighbors, saleswoman) and the events that happened in the previous weeks.

Subjective data:
The patient reported that the stress because she was arguing with her husband. She said that she did not plan wandering. Only instinctively move from one place to another.


1. Safe Wandering
Definition: Safe, socially acceptable with no visible that cognitively impaired.

  • The patient is able to move without hurting themselves (1-5).
  • The Patient were able to demonstrate that the activity has a goal (1-5).
  • The patient wants to go home (1-5).

2. Acute confusion level
Definition: The severity of disturbances in consciousness and cognition that develops in a short period of time.

  • Patients did not experience disorientation place (1-5)
  • Patients did not experience disorientation people (1-5)
  • Patients experienced a decline in memory impairment (1-5)

3. Memory
The ability to restore cognitive function and reported previously stored information.

  • Given the close information accurately (1-5)
  • Given the information just accurately (1-5)
  • Given the information that the information is accurate (1-5)


1. Reality Orientation
Definition: introduce / increase patient awareness regarding personal identity, time and the environment.

  • Using a consistent approach when interacting with patients.
  • Inform patients about the people, places and times as needed.
  • Preventing patients frustrated by giving questions related to orientation can not afford missed.
  • Provide a physical environment that remains and planned daily routine.
  • Approach the patient with slowly and from the front.
  • Using a calm approach and not rush when interacting with patients.
  • Speak slowly, clearly and corresponding volume in patients.

2. Medication Management
Definition: Facilitation of safe and effective use of prescription and over the counter drugs.

  • Determine and regulate the drug is needed in accordance with the protocol.
  • Monitor the effectiveness of treatment modalities.
  • Monitor patient adherence to treatment regimens.

3. Family Involvement Promotion
Definition: Facilitating family participation in the emotional and physical care of patients.

  • Identification with family members about the patient's difficulty coping.
  • Inform family members about the factors that may increase the patient's condition.
  • Encourage family members to keep or maintain a good relationship with the family.

Nursing Diagnosis

Nursing Diagnosis


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