Nursing Diagnosis: Urinary Retention

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

• Urinary Continence

• Urinary Elimination

• Infection Status
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels

• Urinary Retention Care

NANDA Definition: Incomplete emptying of the bladder
Urinary retention may occur in conjunction with or independent of urinary incontinence. Urinary
retention, the inability to empty the bladder even though urine is present, may occur as a side
effect of certain medications, including anesthetic agents, antihypertensives, antihistamines,
antispasmodics, and anticholinergics. These drugs interfere with the nerve impulses necessary to
cause relaxation of the sphincters, which allow urination. Obstruction of outflow is another cause
of urinary retention. Most commonly, this type of obstruction in men is the result of benign
prostatic hypertrophy.
Defining Characteristics:
• Decreased (<30 ml/hr) or absent urinary output for 2 consecutive hours
• Frequency
• Hesitancy
• Urgency
• Lower abdominal distention
• Abdominal discomfort
• Dribbling
Related Factors:
• General anesthesia
• Regional anesthesia
• High urethral pressures caused by disease, injury, or edema
• Pain, fear of pain
• Infection
• Inadequate intake
 • Urethral blockage
Expected Outcomes
• Patient empties bladder completely.

Ongoing Assessment

• Evaluate time intervals between voidings and record the amount voided each time.
Keeping an hourly log for 48 hours gives a clear picture of the patient’s voiding pattern
and amounts, and can help to establish a toileting schedule.

• Catheterize and measure residual urine if incomplete emptying is suspected.

Retention of urine in the bladder predisposes that patient to urinary tract infection and
may indicate the need for an intermittent catheterization program.

• Assess amount, frequency, and character (e.g., color, odor, and specific gravity) of
urine.

• Determine balance between intake and output. Intake greater than output may
indicate retention.

• Monitor urinalysis, urine culture, and sensitivity. Urinary tract infection can cause
retention but is more likely to cause frequency.

• If indwelling catheter is in place, assess for patency and kinking.

• Monitor blood urea nitrogen (BUN) and creatinine. This will differentiate between
urinary retention and renal failure.
Therapeutic Interventions

• Initiate the following methods:

○ Encourage fluids. Unless medically contraindicated, fluid intake should be at
least 1500 ml/24 hours.
○ Encourage intake of cranberry juice daily. This keeps urine acidic. This helps
prevent infection because cranberry juice metabolizes to hippuric acid, which
maintains an acidic urine; acidic urine is less likely to become infected.
○ Place bedpan, urinal, or bedside commode within reach.
○ Provide privacy.
○ Encourage patient to void at least every 4 hours.
 ○ Have patient listen to sound of running water, or place hands in warm water
and/or pour warm water over perineum. This stimulates urination.
○ Offer fluids before voiding.
○ Perform Credé’s method over bladder. Credé’s method (pressing down over the
bladder with the hands) increases bladder pressure, and this in turn may
stimulate relaxation of sphincter to allow voiding.
These facilitate voiding.

• Encourage patient to take bethanechol (Urecholine) as ordered. This stimulates

parasympathetic nervous system to release acetylcholine at nerve endings and to
increase tone and amplitude of contractions of smooth muscles of urinary bladder. Side
effects are rare after oral administration of therapeutic dose. In small subcutaneous
doses, side effects may include abdominal cramps, sweating, and flushing. In larger
doses they may include malaise, headache, diarrhea, nausea, vomiting, asthmatic
attacks, bradycardia, lowered blood pressure (BP), atrio-ventricular block, and cardiac
arrest.

• Institute intermittent catheterization. Because many causes of urinary retention are

self-limited, the decision to leave an indwelling catheter in should be avoided.

• Insert indwelling (Foley) catheter as ordered:

○ Tape catheter to abdomen (male). This prevents urethral fistula.
○ Tape catheter to thigh (female). This prevents inadvertent displacement.
Education/Continuity of Care

• Educate patient or caregiver about the importance of adequate intake, (e.g., 8 to 10

glasses of fluids daily).

• Instruct patient or caregiver on measures to help voiding (as described above).

• Instruct patient or caregiver on signs and symptoms of overdistended bladder (e.g.,

decreased or absent urine, frequency, hesitancy, urgency, lower abdominal distention, or
discomfort).

• Instruct patient or caregiver on signs and symptoms of urinary tract infection (e.g.,
chills and fever, frequent urination or concentrated urine, and abdominal or back pain).

• Teach patient or caregiver to perform meatal care twice daily with soap and water
and dry thoroughly. This reduces the risk of infection.
• Teach patient to achieve an upright position on toilet if possible. This is the natural
position for voiding, and utilizes the force of gravity.