Nursing diagnosis: impaired Urinary Elimination/Urinary Retention related to mechanical trauma, surgical manipulation, presence of local tissue edema, hematoma, sensory and motor impairment—nerve paralysis
Possibly evidenced by
Sensation of bladder fullness, urgency
Small, frequent voiding or absence of urinary output
Desired Outcomes/Evaluation Criteria—Client Will
Empty bladder regularly and completely.
Nursing intervention with rationale:
1. Note voiding pattern and monitor urinary output, once surgical catheter is removed.
Rationale: May indicate urinary retention if voiding frequently in small or insufficient amounts less than 100 mL.
2. Palpate bladder. Investigate reports of discomfort, fullness, and inability to void.
Rationale: Perception of bladder fullness and distention of bladder above symphysis pubis indicates urinary retention.
3. Provide routine voiding measures, such as privacy, normal position, running water in sink, and pouring warm water over perineum.
Rationale: Promotes relaxation of perineal muscles and may facilitate voiding efforts.
4. Provide and/or encourage good perineal cleansing and catheter care when present.
Rationale: Promotes cleanliness, reducing risk of ascending urinary tract infection (UTI).
5. Assess urine characteristics, noting color, clarity, and odor.
Rationale: Urinary retention, vaginal drainage, and possible presence of intermittent or indwelling catheter increase risk of infection, especially if client has perineal sutures.
6. Catheterize when indicated per protocol if client is unable to void or is uncomfortable.
Rationale: Edema or interference with nerve supply may cause bladder atony or urinary retention requiring decompression of the bladder. Note: Indwelling urethral or suprapubic catheter may be inserted intraoperatively if complications are anticipated.
7. Maintain patency of indwelling catheter; keep drainage tubing free of kinks.
Rationale: Promotes free drainage of urine, reducing risk of urinary stasis or retention and infection.
8. Check residual urine volume after voiding, as indicated.
Rationale: May not be emptying bladder completely; retention of urine increases possibility for infection and is uncomfortable, even painful.