Nursing diagnosis: urinary retention related to mechanical obstruction, enlarged prostate, decompensation of detrusor musculature, inability of bladder to contract adequately
Possibly evidenced by
Frequency, hesitancy, inability to empty bladder completely, incontinence and dribbling
Bladder distention, residual urine
Desired Outcomes/Evaluation Criteria—Client Will
Void in sufficient amounts with no palpable bladder distention.
Demonstrate postvoid residuals of less than 50 mL, with absence of dribbling or overflow.
Nursing intervention with rationale:
1. Encourage client to void every 2 to 4 hours and when urge is noted.
Rationale: May minimize urinary retention and overdistention of the bladder.
2. Ask client about stress incontinence when moving, sneezing, coughing, laughing, or lifting objects.
Rationale: High urethral pressure inhibits bladder emptying or can inhibit voiding until abdominal pressure increases enough for urine to be involuntarily lost.
3. Observe urinary stream, noting size and force.
Rationale: Useful in evaluating degree of obstruction and choice of intervention.
4. Have client document time and amount of each voiding. Note diminished urinary output. Measure specific gravity, as indicated.
Rationale: Urinary retention increases pressure within the ureters and kidneys, which may cause renal insufficiency. Any deficit in blood flow to the kidney impairs its ability to filter and concentrate substances.
5. Percuss and palpate suprapubic area.
Rationale: A distended bladder can be felt in the suprapubic area.
6. Encourage oral fluids up to 3,000 mL daily, within cardiac tolerance, if indicated.
Rationale: Increased circulating fluid maintains renal perfusion and flushes kidneys, bladder, and ureters of sediment and bacteria. Note: Fluids may be restricted to prevent bladder distention if severe obstruction is present or until adequate urinary flow is reestablished.
7. Monitor vital signs closely. Observe for hypertension, peripheral or dependent edema, and changes in mentation. Weigh daily. Maintain accurate intake and output (I&O).
Rationale: Loss of kidney function results in decreased fluid elimination and accumulation of toxic wastes; may progress to complete renal shutdown.
8. Provide and encourage meticulous catheter and perineal care.
Rationale: Reduces risk of ascending infection.
9. Recommend sitz bath, as indicated.
Rationale: Promotes muscle relaxation, decreases edema, and may enhance voiding effort.
10. Catheterize for residual urine and leave indwelling catheter, as indicated.
Rationale: Relieves and prevents urinary retention and rules out presence of ureteral stricture. Coudé catheter may be required because the curved tip eases passage of the tube around the enlarged prostate. Note: Bladder decompression should be done with caution to observe for signs of adverse reaction, such as hematuria due to rupture of blood vessels in the mucosa of the overdistended bladder and syncope due to excessive autonomic stimulation.