Nursing diagnosis: impaired Urinary Elimination related to mechanical obstruction—blood clots, edema, trauma, surgical procedure, pressure and irritation of catheter and balloon, loss of bladder tone due to preoperative overdistention or continued decompression
Possibly evidenced by
Frequency, urgency, hesitancy, dysuria, incontinence, retention
Bladder fullness, suprapubic discomfort
Desired Outcomes/Evaluation Criteria—Client Will
Void normal amounts without retention.
Demonstrate behaviors to regain bladder and urinary control.
Nursing intervention with rationale:
1. Assess urine output and catheter drainage system, especially during bladder irrigation.
Rationale: Retention can occur because of edema of the surgical area, blood clots, and bladder spasms.
2. Assist client to assume normal position to void; for example, stand and walk to bathroom at frequent intervals after catheter is removed.
Rationale: Encourages passage of urine and promotes sense of normality.
3. Record time, amount of voiding, and size of stream after catheter is removed. Note reports of bladder fullness inability to void, and urgency.
Rationale: The catheter is usually removed 2 to 5 days after surgery, but voiding may continue to be a problem for some time because of urethral edema and loss of bladder tone.
4. Encourage client to void when urge is noted but not more than every 2 to 4 hours per protocol.
Rationale: Voiding with urge prevents urinary retention. Limiting voids to every 4 hours, if tolerated, increases bladder tone and aids in bladder retraining.
5. Encourage fluid intake to 2,000 to 2,500 mL as tolerated. Limit fluids in the evening once catheter is removed.
Rationale: Maintains adequate hydration and renal perfusion for urinary flow. “Scheduling” fluid intake reduces need to void during the night.
6. Instruct client in perineal exercises, such as tightening buttocks and stopping and starting urine stream.
Rationale: Helps regain bladder sphincter control, minimizing incontinence.
7. Advise client that “dribbling” is to be expected after catheter is removed and should resolve as recuperation progresses. Provide and instruct in use of continence pads when indicated.
Rationale: Information helps client deal with the problem. Postoperative incontinence is usually temporary, but stress incontinence— leaking urine when coughing, laughing, and lifting—can persist indefinitely.
8. Measure residual volumes via suprapubic catheter, if present, or with Doppler ultrasound.
Rationale: Monitors effectiveness of bladder emptying. Residuals of more than 50 mL suggest need for continuation of catheter until bladder tone improves.
9. Maintain continuous bladder irrigation (CBI), as indicated, in early postoperative period.
Rationale: Flushes bladder of blood clots and debris to maintain patency of the catheter and urinary flow.