Impaired urinary elimination can occur as a result of a physical abnormality, a sensory impairment, or as a secondary cause of a disorder or disease. Symptoms can vary widely from bladder distention to painful urination to a complete lack of bladder control. Treatment depends on the cause and can range from noninvasive interventions such as bladder training to surgical options.
Impaired urinary elimination can be embarrassing and frustrating and have a significant impact on the patient’s quality of life. Nurses can guide patients in understanding the causes of their symptoms and how to prevent and manage them.
In this article:
- Causes (Related to)
- Signs and Symptoms (As evidenced by)
- Expected Outcomes
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- References
Causes (Related to)
The following are common causes of impaired urinary elimination:
- Sensory-motor impairment
- Anatomical abnormalities (obstruction)
- Urinary tract infections
- Renal diseases
- Congenital disorders
- Weakened bladder muscles (older age, pregnancy)
- Medications
- Neurological conditions
Signs and Symptoms (As evidenced by)
The following are common signs and symptoms of impaired urinary elimination. They are categorized into subjective and objective data based on patient reports and assessment by the nurse.
Subjective: (Patient reports)
- Urgency
- Hesitancy
- Dysuria
- Nocturia
Objective: (Nurse assesses)
- Bladder distention
- Retention as detected through bladder scanning
- Incontinence
- Use of catheterization
- Frequency
Expected Outcomes
The following are common nursing care planning goals and expected outcomes for impaired urinary elimination:
- Patient will verbalize techniques to prevent urinary infection and retention.
- Patient will demonstrate how to properly self-catheterize/clean indwelling catheter.
- Patient will achieve a normal elimination pattern free from frequency and urgency.
- Patient will verbalize diet changes to incorporate to improve urinary elimination.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In the following section, we will cover subjective and objective data related to impaired urinary elimination.
1. Identify causes of impaired urinary elimination.
UTIs, cystitis, multiple sclerosis, paralysis, dementia, an enlarged prostate, stroke, urologic surgeries, and chronic kidney disease are a few examples that contribute to impaired urinary elimination.
2. Assess voiding pattern and symptoms.
Assess the symptoms the patient is experiencing to lead to a diagnosis. Dribbling and incomplete urination may signal a prostate issue. Frequency and burning are common with UTIs. Back/flank pain can signal kidney problems. It may be useful to ask the patient to keep a diary of their voiding pattern.
3. Monitor labwork and urinalysis.
A urinalysis and culture can diagnose or rule out an infection. Kidney function should be assessed for acute or chronic renal disease. A prostate-specific antigen (PSA) blood test can detect inflammation levels of the prostate.
4. Review medications.
Certain medications have anticholinergic effects, which make voiding difficult. These can include antipsychotics, tricyclic antidepressants, and antiparkinson drugs.
5. Compare intake and output.
Compare intake amount and type (caffeine, water, soda) to the amount of urine output as well as the color (clear, amber, concentrated) to determine hydration levels.
6. Assess for issues with catheterization.
Some patients rely on intermittent self-catheterization or permanent suprapubic catheters due to bladder dysfunction. Ensure they are performing their catheterizations correctly and not introducing bacteria due to poor techniques. Also, assess if patients with indwelling catheters still require them. Prolonged or unnecessary catheterization increases the risk of infection.
7. Review diagnostic tests.
Urodynamic testing, cystoscopy, and imaging of the kidneys/ureters/bladder (KUB) can identify structural issues, diseases, and cancer that may be causing problems.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with impaired urinary elimination.
1. Educate on bladder training.
Patients with incontinence or an overactive bladder can teach their bladders to increase the amount of urine to hold. This starts by keeping a log of when urine leakage occurs and how many hours the patient waits before urinating. Based on this, they choose an interval and gradually add 15 minutes to it over the course of weeks or months. The patient should go to the bathroom at each set time, even if they don’t feel an urge, and if they feel an urge before the set time, remind themselves the bladder isn’t full yet.
2. Encourage water intake.
If not contraindicated, encourage the patient to drink plenty of water. This may seem counterintuitive if the patient has incontinence or an overactive bladder, but too little water will have worse effects. Proper hydration promotes urinary elimination by maintaining renal function and flushing bacteria and waste products.
3. Limit other fluids.
Patients should limit their intake of coffee and caffeine, carbonated beverages, and alcohol as these can be irritating to the bladder and cause increased frequency and urgency. Soda and sweet tea are huge culprits for kidney stones.
4. Educate on supplements.
Patients frequently affected by UTIs may benefit from cranberry supplements. Cranberry juice is acidic and may irritate the bladder like other fruit juices, and research has shown it may not be all that helpful. Cranberry in the form of a concentrated supplement, however, has been shown to be effective at preventing (not actively treating) UTIs, however this research is not conclusive.
5. Have the patient demonstrate catheterization techniques.
A patient with a chronic indwelling or suprapubic catheter or who self-catheterizes is at an increased risk for infection. Observe the patient perform their cath care to ensure they are using the proper techniques such as cleaning daily using water and mild soap and keeping the drainage bag below the level of the bladder.
6. Use bladder scanning.
If the patient is in the hospital, the nurse can use a bladder scanner to monitor for urinary retention. This non-invasive ultrasound can quickly assess the need for further intervention. A post-void residual (PVR) is done after a patient voids to assess how much urine is left in the bladder. This can provide information about the patient not effectively emptying their bladder.
7. Educate on proper hygiene.
Females are at an increased risk for UTIs due to a shorter urethra in close proximity to the anus. They should be instructed to wipe from front to back after using the bathroom, void immediately after sexual intercourse, wear cotton underwear and loose clothing, and change out of wet bathing suits as soon as possible.
8. Refer to urology.
Chronic urinary elimination problems need further assessment. A urologist can perform testing and provide treatments to ease pain, incontinence, and retention.
9. Educate on pelvic floor exercises.
Kegel exercises are helpful for both men and women in strengthening the pelvic floor muscles and preventing urine leakage. The patient should squeeze and hold the pelvic floor muscles for 3-5 seconds and repeat for 10 repetitions, 3 times daily.
10. Educate on medications.
If ordered by a physician, medications can help with retention and overactive bladder. Flomax helps relax bladder muscles relieving obstruction. Ditropan is an anticholinergic that prevents bladder contractions that cause the urge to urinate.
11. Use incontinence supplies.
Incontinent episodes and urgency can be embarrassing. Discreet incontinence pads and adult diapers can prevent uncomfortable situations when a bathroom isn’t available or the bladder cannot be held.
Nursing Care Plans
Nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for impaired urinary elimination.
Care Plan #1
Diagnostic statement:
Impaired urinary elimination related to bladder irritation secondary to infection as evidenced by urgency and frequency.
Expected outcomes:
- Patient will demonstrate voiding frequency at most every 2 hours.
- Patient will report an absence of urinary urgency.
- Patient will be free from urinary tract infection.
Assessment:
1. Assess for predisposing factors of the patient’s UTI.
Previous history of UTIs, instrumentation (such as a urinary catheter), sexual activity, sexually transmitted infections, pregnancy, surgeries of the genitourinary tract that may have resulted in scarring, or recent antibiotic therapy may all place the patient at an increased risk for developing UTI.
2. Monitor signs and symptoms of UTI.
Frequent urination, a sensation of urgency, and burning or pain with urination are classic signs of UTI. These are due to urethral or bladder inflammation. However, some patients may be asymptomatic, especially those with recurrent infections. Older patients who may not be cognitively capable of describing symptoms may develop a general change in behavior or decline overall functional ability as an early indication of UTI.
3. Review laboratory findings.
- Urinalysis: Red blood cells or white blood cells in the urine may indicate an infection-related inflammatory response.
- Bacteria in the urine: Bacterial counts greater than 105 are usually diagnostic for UTI.
- Urine culture and sensitivity: Identifying the causative organism is necessary for selecting the most effective antibiotic.
- White blood cell count: Leukocytosis is a systemic response to infection.
Interventions:
1. Encourage the patient to increase oral fluid intake.
Increased oral fluid intake by at least 2 to 3 liters per day promotes urination and flushes bacteria from the urinary tract.
2. Instruct the patient to empty the bladder every 2 to 3 hours.
Regular urination enhances bacterial clearance, reduces urine stasis, and prevents reinfection.
3. Recommend taking cranberry, prune juice, or vitamin C 500 to 1000 mg/day.
Bacteria thrive poorly in an acidic environment. Urine pH should be maintained at around 5. Cranberry or prune juice and Vitamin C can help acidify urine and prevent bacterial colonization.
4. Administer antibiotics as ordered.
Antibiotic therapy is the mainstay of managing UTI.
5. Teach the following measures to women to decrease the incidence of UTIs:
- Urinate at appropriate intervals. Do not ignore the need to void to prevent urine stasis.
- Drink plenty of water to help dilute the urine, allowing bacteria to be flushed from the urinary tract before an infection can begin.
- Wipe from front to back to prevent bacteria in the anus from spreading to the vagina and urethra.
- Wear cotton underwear. This allows air to circulate in the area and decreases moisture in the area, which predisposes to infection.
- Avoid potentially irritating feminine products. Using deodorant sprays, bubble baths, or other feminine products (e.g., douches and powders) in the genital area can irritate the urethra.
- Teach the sexually active woman about recurrent UTIs prevention measures, including
- Void after intercourse to flush bacteria out of the urethra and bladder.
- Use a lubricating agent during intercourse to protect the vagina from trauma and decrease the incidence of vaginitis.
- Watch for signs of vaginitis and seek treatment as needed.
- Avoid the use of diaphragms with spermicide.
Women are at higher risk of UTIs or bladder infections than men because of the former’s anatomic makeup. In women, the urethra is close to the anus, and the urethral opening is near the bladder, which provides easy access for the bacteria in the anus to enter the urethra and bladder.
Care Plan #2
Diagnostic statement:
Impaired urinary elimination related to diminished bladder cues secondary to enlarged prostate as evidenced by large residual urine volumes.
Expected outcomes:
- Patient reports an urge to void.
- Patient empties the bladder completely as evidenced by urine volume greater than or equal to 300 mL with each voiding and residual volume less than 100 mL.
Assessment:
1. Assess benign prostatic hyperplasia (BPH) symptom severity according to the American Urological Association Symptom Index (AUA-SI) for BPH.
AUA-SI is a 7-item self-report tool used to objectively assess the severity of urinary urgency, frequency, and voiding symptoms.
2. Asses for use of medications that may worsen urgency
Cold and allergy medicine, muscle relaxants and some anti-anxiety or antidepressants can worsen BPH.
3. Assess urinary elimination, Noting obstructive symptoms (e.g., urinary hesitancy, difficulty starting a stream, urinary dribbling, straining to void, a weak or narrow stream) and irritative symptoms (e.g., frequency, urgency, nocturia).
The prostate gland surrounds the male urethra. When the prostate gland is enlarged due to prostatic hyperplasia, the urethra is compressed. These symptoms are a result of the decreased caliber of the urethra. Irritative symptoms occur because of obstruction that causes hypersensitivity of the bladder.
4. Assess postvoid residual urine.
This will detect urinary stasis and impaired detrusor function. Postvoid catheterization, x-ray films, or ultrasound can assess postvoid residual urine.
5. Assess intake and output.
This will provide information on whether the bladder is emptied completely.
Interventions:
1. Advise the patient to void at least every 4 hours
Voiding at frequent intervals empties the bladder and reduces the risk of urinary retention.
2. Encourage oral fluids for adequate hydration, but do not push fluids or overhydrate.
Rapid filling of the bladder can precipitate complete urinary retention. Overhydration can aggravate the problem of residual urine and bladder distention. Coffee and other caffeinated beverages can increase the urine amount and urgency.
3. Encourage the patient to take medications as prescribed.
Several medications are available to reduce prostate size and improve urinary flow. These include 5-alpha-reductase inhibitors, alpha-blocking agents, and phosphodiesterase inhibitors.
4. Encourage therapeutic lifestyle modifications.
These modifications include limiting fluids before bed, reducing caffeine and alcohol intake, and double voiding before bed.
5. Encourage the patient to take antibiotics as prescribed.
Medication may be indicated to treat or prevent a UTI resulting from obstruction and stasis.
References
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- Carpenito, L.J. (2013). Nursing diagnosis: Application to clinical practice (14th ed.). Lippincott Williams & Wilkins.
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- Gulanick, M. & Myers, J.L. (2014). Nursing care plans Diagnoses, interventions, and outcomes (8th ed.). Elsevier.
- Harvard Health Publishing. (2010, April 20). Training your bladder. Harvard Health Publishing. https://www.health.harvard.edu/healthbeat/training-your-bladder
- Kubala, J. (2021, October 4). Does Cranberry Juice Help Treat UTIs? Myth vs. Science. Healthline. https://www.healthline.com/nutrition/cranberry-juice-uti
- Medline Plus. (2021, January 10). Kegel exercises – self-care. Medline Plus. https://medlineplus.gov/ency/patientinstructions/000141.htm
- Ng, M.& Baradhi, K.M. (2022). Benign prostatic hyperplasia. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK558920
- Nabili, S. N. (2020, March 24). Bladder Control Medications. Emedicine Health. https://www.emedicinehealth.com/understanding_bladder_control_medications/article_em.htm#facts_on_bladder_control_medications
- Wallace, R. (2017, September 28). 11 Foods to Avoid if You Have OAB. Healthline. https://www.healthline.com/health/11-foods-to-avoid-if-you-have-oab
