Urinary retention, the inability to completely empty the bladder, is a common and potentially serious condition encountered in various healthcare settings. Effective nursing care hinges on accurate diagnosis and targeted interventions. This article delves into the Nanda Nursing Diagnosis For Urinary Retention, providing a comprehensive guide for nurses to enhance patient care.
Understanding Urinary Retention: Causes and Contributing Factors
Urinary retention arises when the bladder cannot effectively expel urine. This can be an acute, sudden onset problem or a chronic, ongoing issue. Identifying the underlying causes is crucial for effective management. Several factors can contribute to urinary retention, including:
- Mechanical Obstruction: Blockage of the urethra due to conditions like benign prostatic hyperplasia (BPH), urethral strictures, or tumors.
- Medications: Certain medications, such as antihistamines, anticholinergics, opioids, and tricyclic antidepressants, can interfere with bladder muscle function or nerve signaling.
- Neurological Conditions: Nerve damage from conditions like stroke, diabetes, multiple sclerosis, Parkinson’s disease, or spinal cord injuries can disrupt bladder control.
- Postoperative Complications: Surgery, especially pelvic or spinal procedures, can temporarily impair bladder function due to anesthesia or nerve manipulation.
- Infections and Inflammation: Urinary tract infections (UTIs), prostatitis, or bladder inflammation can lead to irritation and retention.
- Weak Bladder Muscles: Age-related muscle weakness or conditions affecting muscle tone can hinder effective bladder emptying.
- Constipation and Fecal Impaction: A full bowel can press on the bladder and urethra, obstructing urine flow.
Recognizing the Signs and Symptoms of Urinary Retention
The presentation of urinary retention varies depending on whether it is acute or chronic. Recognizing these signs and symptoms is vital for prompt nursing intervention.
Acute Urinary Retention:
- Sudden Inability to Urinate: Complete inability to pass urine despite a strong urge.
- Severe Lower Abdominal Pain: Often described as sharp and intense, resulting from bladder distention.
- Urgent Need to Urinate: Intense sensation of needing to void, even though no urine is expelled.
- Lower Abdominal Swelling: Visible distention of the lower abdomen due to a full bladder.
Chronic Urinary Retention:
- Incomplete Bladder Emptying: Sensation of not fully emptying the bladder after urination.
- Frequent Urination of Small Amounts: Voiding small volumes frequently throughout the day and night.
- Urinary Hesitancy: Difficulty initiating the urine stream, with a delay after attempting to void.
- Weak Urine Stream: Slow and weak flow of urine during urination.
- Urge to Urinate with Little Output: Feeling the need to void but passing only a small amount or nothing at all.
- Post-Void Urgency: Feeling the need to urinate again immediately after voiding.
- Lower Abdominal Discomfort: A persistent dull ache or pressure in the lower abdomen.
- Asymptomatic Presentation: Crucially, some individuals, particularly with chronic retention, may experience minimal or no noticeable symptoms, making assessment even more important.
Potential Complications of Untreated Urinary Retention
If left unaddressed, urinary retention can lead to significant health complications:
- Urinary Tract Infections (UTIs): Stagnant urine in the bladder provides a breeding ground for bacteria, increasing UTI risk.
- Bladder Damage: Overdistention of the bladder can weaken the bladder muscle and impair its future function.
- Kidney Damage (Renal Damage): Backflow of urine into the kidneys (hydronephrosis) can cause kidney damage and even renal failure.
- Urinary Incontinence: Paradoxical overflow incontinence can occur as the bladder becomes overly full and leaks urine involuntarily.
NANDA Nursing Diagnosis: Urinary Retention
In nursing practice, the North American Nursing Diagnosis Association International (NANDA-I) provides a standardized language for describing patient health problems. Urinary Retention is a recognized NANDA-I nursing diagnosis, defined as: “Incomplete emptying of the bladder.” (00016)
This diagnosis is appropriate when a patient is experiencing or at risk of experiencing incomplete bladder emptying. It is crucial to differentiate this from other urinary elimination diagnoses such as “Impaired Urinary Elimination” (00016). While related, “Impaired Urinary Elimination” is a broader diagnosis encompassing various issues with urine excretion, whereas “Urinary Retention” specifically pinpoints the problem of incomplete bladder emptying.
Related Factors (Risk Factors) for Urinary Retention (aligned with NANDA-I):
NANDA-I identifies factors that can contribute to urinary retention, which align with the causes previously discussed. These related factors help nurses pinpoint the etiology of the retention in each patient:
- Anesthesia
- Anticholinergic agents
- Autonomic dysreflexia
- Blockage
- Bladder outlet obstruction
- Childbirth
- Chronic kidney disease
- Constipation
- Diabetes mellitus
- Emotional distress
- Fluid overload
- Impaired detrusor contractility
- Impaired urethral sphincter control
- Infection
- Medications
- Multiple sclerosis
- Neurological conditions
- Postoperative state
- Prostatic hypertrophy
- Psychological factors
- Spinal cord injury
- Surgery
- Trauma
- Weak pelvic muscles
Defining Characteristics (Signs and Symptoms) for Urinary Retention (aligned with NANDA-I):
These are the observable and reportable manifestations that support the diagnosis of Urinary Retention:
- Absence of urine output
- Bladder distention
- Dysuria
- Frequent voiding
- Overflow incontinence
- Post-void dribbling
- Residual urine
- Sensation of bladder fullness
- Small voiding
- Urgency
Nursing Assessment for Urinary Retention: Gathering Subjective and Objective Data
A thorough nursing assessment is paramount for accurately diagnosing urinary retention and guiding appropriate interventions. This involves collecting both subjective and objective data.
1. Assess Individual Risk Factors: Review the patient’s medical history, medication list, and surgical history to identify predisposing factors for urinary retention. Pay close attention to conditions like diabetes, neurological disorders, BPH, and recent surgeries.
2. Evaluate Voiding Pattern and Intake/Output: Inquire about the patient’s usual voiding habits, including frequency, volume, and any changes. Monitor fluid intake and urine output to identify discrepancies. Frequent voiding of small amounts can be a key indicator.
3. Perform Abdominal Assessment: Palpate the lower abdomen to assess for bladder distention. A palpable, firm bladder above the symphysis pubis suggests retention. Note any tenderness upon palpation.
4. Analyze Urine Characteristics: Observe the color, clarity, and odor of urine. Cloudy or foul-smelling urine may indicate infection, a potential cause or complication of urinary retention.
5. Measure Post-Void Residual (PVR) Volume: This is a crucial assessment for confirming urinary retention. Use a bladder scanner or catheterization (if ordered) to measure the urine volume remaining in the bladder immediately after voiding. A PVR greater than 100mL is generally considered indicative of urinary retention.
6. Review Medication List: Identify medications the patient is taking that are known to cause or contribute to urinary retention.
Nursing Interventions for Urinary Retention: Promoting Bladder Emptying
Nursing interventions aim to facilitate bladder emptying, manage symptoms, and prevent complications.
1. Promote Normal Voiding Reflexes:
- Privacy: Ensure a private and comfortable environment for voiding.
- Positioning: Assist the patient to assume a normal voiding position (sitting upright for women, standing for men, if possible).
- Running Water: The sound of running water can sometimes stimulate the urge to urinate.
- Warm Water on Perineum: Pouring warm water over the perineum can promote relaxation and voiding.
2. Encourage Perineal Hygiene: Proper perineal cleansing reduces the risk of infection, which can exacerbate urinary retention.
3. Catheter Care (if applicable): For patients with indwelling catheters, meticulous catheter care is essential to prevent infection. Ensure patency of the catheter and drainage system.
4. Catheterization: Intermittent or indwelling catheterization may be necessary to drain retained urine and relieve bladder distention, especially in acute cases. Follow healthcare provider orders for catheterization.
5. Maintain Catheter Patency: Regularly check indwelling catheters for kinks, obstructions, or improper positioning that can impede drainage.
6. Patient and Family Education on Catheter Care: If the patient is discharged with a catheter, provide thorough education on proper catheter care to prevent complications at home.
7. Bladder Scanning: Use bladder scans regularly to monitor urine volume in the bladder, especially for patients at risk or those with suspected retention.
8. Medication Administration: For chronic urinary retention, administer medications as prescribed to manage underlying causes, such as alpha-blockers for BPH or cholinergic medications to improve bladder contractility.
Nursing Care Plan Examples: Addressing Urinary Retention
Nursing care plans provide structured frameworks for addressing patient needs. Here are examples incorporating the NANDA nursing diagnosis of Urinary Retention:
Care Plan #1: Urinary Retention related to Urethral Obstruction
NANDA Nursing Diagnosis: Urinary Retention related to mechanical obstruction secondary to urethral tumor as evidenced by urgency and nocturia.
Expected Outcomes:
- Patient will achieve a post-void residual volume of less than 100mL within 24 hours.
- Patient will report a decrease in urinary urgency and nocturia within 48 hours.
Nursing Interventions:
- Assess for bladder distention and overflow every 4 hours. (Rationale: Prevents bladder overdistention and overflow, reducing infection risk and autonomic hyperreflexia).
- Monitor for signs and symptoms of urinary tract infection (UTI) daily. (Rationale: Chronic obstruction increases UTI risk due to urinary stasis).
- Measure post-void residual urine volume after each void. (Rationale: Indicates the degree of urinary retention and detrusor muscle function).
- Encourage patient to void when urge is felt or every 2-4 hours. (Rationale: Minimizes urinary retention and bladder overdistention).
- Educate on double voiding technique. (Rationale: Promotes more complete bladder emptying).
- Prepare patient for possible intermittent or indwelling catheterization as ordered. (Rationale: May be necessary to relieve retention and prevent complications).
Care Plan #2: Urinary Retention related to Postpartum Status
NANDA Nursing Diagnosis: Urinary Retention related to weak pelvic floor muscles secondary to postpartum status as evidenced by dribbling and hesitancy.
Expected Outcomes:
- Patient will demonstrate correct performance of pelvic floor muscle exercises (Kegel exercises) by discharge.
- Patient will report a decrease in urinary dribbling and hesitancy within one week.
Nursing Interventions:
- Assess intake and output, noting voiding amount and frequency every shift. (Rationale: Provides data on bladder emptying effectiveness).
- Assess changes in urinary elimination pattern daily. (Rationale: Monitors treatment response and identifies changes in symptoms).
- Teach patient how to perform timed voiding every 2-3 hours. (Rationale: Prevents bladder overdistention).
- Instruct patient on Kegel exercises, emphasizing proper technique and frequency. (Rationale: Strengthens pelvic floor muscles to improve bladder control).
- Encourage adequate oral fluid intake (1500-2000ml/day) unless contraindicated. (Rationale: Promotes renal perfusion and flushes out potential irritants).
- Suggest sitz baths as needed. (Rationale: Promotes muscle relaxation and may aid voiding).
Care Plan #3: Urinary Retention related to Benign Prostatic Hyperplasia (BPH)
NANDA Nursing Diagnosis: Urinary Retention related to blockage secondary to benign prostatic hypertrophy (BPH) as evidenced by reduced urine stream and bladder distention.
Expected Outcomes:
- Patient will verbalize strategies to minimize acute urinary retention risk factors by discharge.
- Patient will demonstrate consistent ability to void when urge is felt within 24 hours.
- Patient will exhibit absence of bladder distention upon palpation within 24 hours.
Nursing Interventions:
- Assess urinary elimination pattern, noting hesitancy, stream weakness, dribbling, and irritative symptoms every shift. (Rationale: BPH compresses urethra, causing these symptoms).
- Monitor laboratory studies (BUN, creatinine, electrolytes, urinalysis) as ordered. (Rationale: Detects potential kidney function impairment and UTIs).
- Advise patient to avoid over-the-counter cold remedies with decongestants or antihistamines. (Rationale: These can worsen urinary retention in BPH).
- Educate patient to limit alcohol intake. (Rationale: Alcohol can impair bladder control and lead to overdistention).
- Encourage voiding when urge is felt or every 2-4 hours. (Rationale: Prevents urinary retention and bladder overdistention).
- Administer medications (e.g., alpha-blockers, 5-alpha-reductase inhibitors) as prescribed and educate patient about their use. (Rationale: Medications can reduce prostate size and improve urine flow).
Conclusion
Accurate identification of urinary retention and its underlying causes is essential for effective nursing care. Utilizing the NANDA nursing diagnosis “Urinary Retention” provides a standardized framework for assessment, intervention, and outcome evaluation. By understanding the related factors and defining characteristics, nurses can develop individualized care plans to promote bladder emptying, prevent complications, and improve the quality of life for patients experiencing urinary retention.
References
- Ackley, B.J., Ladwig, G.B.,& Makic, M.B.F. (2017). Nursing diagnosis handbook: An evidence-based guide to planning care (11th ed.). Elsevier.
- Carpenito, L.J. (2013). Nursing diagnosis: Application to clinical practice (14th ed.). Lippincott Williams & Wilkins.
- Cleveland Clinic. (2021). Urinary retention. https://my.clevelandclinic.org/health/diseases/15427-urinary-retention
- Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2019). Nursing care plans: Guidelines for individualizing client care across the life span (10th edition). F.A. Davis Company.
- Gulanick, M. & Myers, J.L. (2014). Nursing care plans Diagnoses, interventions, and outcomes (8th ed.). Elsevier.
- Herdman, T. H., Kamitsuru, S., & Lopes, C. (Eds.). (2024). NANDA-I International Nursing Diagnoses: Definitions and Classification, 2024-2026. Thieme. 10.1055/b-000000928
- National Institute of Diabetes and Digestive and Kidney Diseases. (2019). Definition & Facts of urinary retention. https://www.niddk.nih.gov/health-information/urologic-diseases/urinary-retention/definition-facts
- National Institute of Diabetes and Digestive and Kidney Diseases. (2019). Symptoms & Causes of urinary retention. https://www.niddk.nih.gov/health-information/urologic-diseases/urinary-retention/symptoms-causes
