Nursing diagnosis: risk for Urinary Retention
Risk factors may include
Pain and swelling in operative area
Need for remaining flat in bed
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Empty bladder in sufficient amounts.
Be free of bladder distention, with residuals after voiding within normal limits (WNL).
Nursing intervention with rationale:
1. Observe and record amount and time of voiding.
Rationale: Determines adequate voiding and bladder function.
2. Palpate for bladder distention.
Rationale: May indicate urinary retention.
3. Force fluids.
Rationale: Fluid intake helps maintain fluid balance and renal perfusion.
4. Stimulate bladder emptying by running water, pouring warm water over perineum, or having client put hand in warm water.
Rationale: These maneuvers relax the urinary sphincter thus stimulating urination.
5. Perform ultrasound bladder scan or catheterize for residual after voiding, when indicated. Insert and maintain indwelling catheter as needed.
Rationale: Helps determine the amount of urine in the bladder. Intermittent or continuous catheterization may be necessary for several days postoperatively until swelling is decreased.