Assessment

Subjective:
I am having difficulty in
initiating urination. Even
though I have the urge to
expel urine, only a few
drops come out when I
check it. , as verbalized
by the patient
Objective:
Dysuria
Sitting to void
Distended abdomen
upon palpation
Urine output of 20 mL
in 8 hours
Vital Signs:
Temperature: 37.4
Pulse: 110bpm
Respiration: 21bpm
Blood
Pressure:130/90mmHg

Diagnosis
Acute urinary
retention
related to
mechanical
obstruction of
an enlarged
prostate as
evidenced by
bladder
distension

Planning
Goal:
After 3 days of
nursing
intervention, the
patient will be
able to achieve
a regular
voiding pattern.
Objective:
After 8 hours of
nursing
intervention, the
patient will be
able to void in
sufficient
amounts with
no palpable
bladder
distension.

Intervention
Independent
1. Monitor vital
signs and input
and output.
2. Weigh daily.
3. Encourage
patient to void
every 2-4
hours when
urge is noted.

4. Provide
perineal care.
5. Percuss and
palpate
suprapubic
area.
6. Encourage to
increase oral
fluid intake up
to 2-3 L per
day, within
cardiac
tolerance, if
indicated.

Rationale
Observe for
hypertension
and fever.
Increase in
weight may
indicate
decreased
fluid
elimination.
May minimize
urinary
retention/ove
r distension of
the bladder.
Reduces risk
of ascending
infection.
A distended
bladder can
be felt in the
suprapubic
area.
Increased
circulating
fluid
maintains
renal
perfusion and
flushes the
kidneys,
bladder, and
ureters of
sediment
and
bacteria.

Evaluation
After 3 days of
nursing
intervention, the
patient was
able to achieve
a regular
voiding pattern.
After 8 hours of
nursing
intervention, the
patients urine
output was
250mL in 8 hours
with no
palpable
bladder
distention.

Collaborative
1. Catheterize for
residual urine and
leave indwelling
catheter as
indicated.
2. Administer
medications as
indicated.

Relieves or
prevents
urinary
retention and
rules out
presence of
urinary
stricture.
Androgen
inhibitors
reduce the
size of the
prostate and
decreases
symptoms if
taken longterm.
Antibiotics
are given to
combat
infection.