1. URINARY RETENTION
ANALYSIS/
NURSING CARE PLAN/ EVALUATION/
PATHOPHYSIOLOGY ASSESSMENT NURSING DIAGNOSIS
IMPLEMENTATION OUTCOME CRITERIA
(in priority)
Assess for contributing
Immobility factors to urinary
Subjective Data: 1. Acute pain r/t Pt verbalizes
retention (pathological
bladder distention adequate relief of
Inability to void conditions, medications, pain and decrease
Suprapubic secondary to anxiety).
Discomfort of Unnatural position urinary retention in pain rating
discomfort Asses pain characteristics. scale to a
using bedpan for urination Abdominal pain 2. Urinary retention r/t Monitor I & O. tolerable level of
Restlessness decreased muscle 2/10 or less.
Embarrassment & lack of Dribbling tone of urinary Monitor urinary elimination
privacy in urination including consistency, Pt empties the
bladder and
odor, volume, color. bladder
abdominal muscle
Objective Data: completely with no
Provide enough time for
3. Risk for urge urinary palpable
Inability to relax Decreased Fluid intake larger bladder emptying.
incontinence distention,
perineal muscles muscle tone of than output Regulate liquid intake at experience no
risk factors: bladder
Firm, distended prescribed times. post void
distention,
bladder residuals, urine
decreased pelvic Respond immediately to
Small, frequent output >30mL/hr.
Urinary Abdominal Pelvic muscle tone complaints of pain.
voiding or absence
bladder muscle muscle of urine output Relieve pain by Pt will demonstrate
Urine output administering behavior changes
≤30mL/hr medications and to prevent urge
Overflow measures. urinary
URINARY RETENTION incontinence.
incontinence Promote pt mobility.
Bladder distention Implement intermittent
catheterization as
appropriate.
If indwelling catheter is in
Pain Urinary Dribbling
place, assess for
Incontinence patency and kinking.
(overflow)
Eliminate additional
stressors or sources of
discomfort when
possible.
