Urinary retention is a condition that develops when an individual cannot fully empty his or her bladder of urine. It can be either an acute change or caused by a chronic condition.
In this article:
- Causes (Related to)
- Signs and Symptoms (As evidenced by)
- Complications
- Expected Outcomes
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- References
Causes (Related to)
Urinary retention can be the result of several factors including:
- Blockage or narrowing of the urethra
- Medications (i.e. antihistamines, opiates, antispasmodics)
- Nerve diseases/conditions (i.e. stroke, diabetes, multiple sclerosis, trauma to spine or pelvis)
- Infections
- Surgery
- Weak bladder muscles
- Constipation
Signs and Symptoms (As evidenced by)
The signs and symptoms of urinary retention can vary depending on whether the urinary retention is acute or chronic in nature. The signs and symptoms for both types are listed below.
Acute Urinary Retention
- Inability to urinate
- Lower abdominal pain (usually severe)
- Urgent need to urinate
- Swelling of the lower abdominal area
Chronic Urinary Retention
- Inability to completely empty the bladder while urinating
- Frequent, small amounts of urination
- Hesitancy (difficulty initiating urination)
- Slow urine stream
- Urge to urinate with little success
- Feeling the need to urinate immediately after having urinated
- Lower abdominal discomfort
It is also important to note that some individuals with chronic urinary retention may not display any signs or symptoms.
Complications
If left untreated, urinary retention can lead to other complications for the individual. Some of these possible complications include:
- Increased risk of urinary tract infections
- Bladder damage
- Renal damage
- Urinary incontinence
Expected Outcomes
The following are common nursing care planning goals and expected outcomes for urinary retention:
- Patient will be able to void sufficient amounts of urine.
- Patient will be free of any palpable bladder distention.
- Patient will be free of any post-void residuals greater than 100mL.
- Patient will be free of any abdominal discomfort related to urinary retention.
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 urinary retention.
1. Assess patient’s individual risk of urinary retention.
Reviewing a patient’s chart and medical history will help the nurse identify if the patient is at risk of urinary retention based on other medical conditions, history of recent surgery, or medications.
2. Assess the patient’s voiding pattern/intake and output.
If a patient is voiding frequent, small amounts of urine, it could be an indication of urinary retention.
3. Perform abdominal assessment.
Palpating the bladder may assist the nurse in determining if there is abdominal tenderness or if there is bladder distention.
4. Assess urine characteristics.
Noting urine color, clarity, and odor can assist in determining the presence of possible infection, which could cause urinary retention.
5. Assess post-void residuals.
Patients may feel the need to empty their bladder frequently if they are not completely emptying it while urinating. Assessing the volume of urine remaining in the bladder after voiding will indicate to the nurse if urinary retention is present and potentially how severe it is. Post-void residuals are assessed using a bladder scanner.
6. Assess/review medication list.
Some medications can cause urinary retention. If the patient is experiencing urinary retention due to medications, it will be beneficial to discuss the medication regimen with the primary healthcare provider.
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 urinary retention.
1. Provide the patient with routine voiding measures including privacy, normal voiding positions or the sound of running water.
These measures can assist with the relaxation of the perineal muscles, which can further help promote appropriate, effective voiding.
2. Encourage/provide appropriate perineal cleansing.
Appropriate cleansing will decrease the risk of infections, which can further contribute to urinary retention.
3. Provide appropriate catheter care when a catheter is present.
Appropriate catheter care will decrease the risk for potential infection, which can further contribute to urinary retention.
4. Catheterize patient when indicated.
If a patient is retaining a significant amount of urine, catheterization may be necessary. When necessary, ensure catheterization occurs per the healthcare provider’s orders.
5. Maintain patency of any indwelling catheter.
If kinks exist in the tubing, it can prevent the catheter from working appropriately and the bladder from draining effectively. Monitor for kinks and ensure catheter tubing is in a position to allow for appropriate drainage of urine.
6. Educate patients (and family members) on catheter care and the importance of catheter care if s/he will be discharged home with the catheter in place.
Providing appropriate education regarding catheters that the patient will go home with is important so the patient can be independent in their care at home and to prevent further complications associated with the catheter.
7. Perform bladder scan as needed.
If there is a concern for bladder retention (i.e. several hours since last void), perform a bladder scan to determine if the patient is retaining urine. Also, it can be useful to perform a bladder scan following a patient’s void to determine what, if any, post-void residual there is.
8. Administer medications as ordered for urinary retention if chronic in nature.
Some individuals experiencing chronic urinary retention may have scheduled medications to manage this retention. Ensure all medications for the treatment of urinary retention are given on the appropriate schedule to maintain appropriate bladder function.
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 urinary retention.
Care Plan #1
Diagnostic statement:
Urinary retention related to decreased bladder capacity secondary to a malignant tumor of the urethra as evidenced by urgency and nocturia.
Expected outcomes:
- Patient will have a urinary residual volume of <250 mL.
- Patient will not experience urinary urgency and nocturia.
Assessment:
1. Assess for bladder distention and observe for overflow.
Preventing bladder distention and urinary overflow reduces the risk of infection and autonomic hyperreflexia.
2. Assess the history of urinary tract infections.
Chronic urinary tract obstruction causes urinary stasis and infection.
3. Assess postvoid residual urine.
Postvoid residual urine indicates urinary stasis and impaired detrusor function.
Interventions:
1. Encourage the patient to urinate when the urge is felt or void every 2 to 4 hours.
This may minimize urinary retention and overdistention of the bladder.
2. Assist with developing toileting routines (e.g., timed voiding, bladder training, prompted voiding, habit retraining).
For adults who are cognitively intact and physically capable of self-toileting, bladder training, timed voiding, and habit retraining may be beneficial, particularly if there is reduced bladder capacity.
3. Educate about double voiding by urinating, resting in the bathroom for 3 to 5 minutes, and then trying again to urinate.
Double voiding promotes more efficient urination by allowing the detrusor to contract initially and then rest and contract again.
4. Insert a urinary catheter to drain residual urine and leave as indicated.
Urinary catheterization prevents and relieves urinary retention and rules out ureteral stricture. A Coudé catheter with a curved tip would ease tube insertion around the enlarged prostate. However, catheters should be avoided when possible as they increase the risk of urinary tract infections.
Care Plan #2
Diagnostic statement:
Urinary retention related to weak pelvic floor muscles secondary to postpartum status, as evidenced by dribbling and hesitancy.
Expected outcomes:
- Patient will demonstrate strategies to strengthen pelvic floor muscles.
- Patient will not experience urinary dribbling and hesitancy.
Assessment:
1. Assess the intake and output, noting the amount and frequency of voids.
These data give information on the completion of bladder emptying.
2. Assess changes in urinary elimination pattern.
Note reports of problems (e.g., frequency, urgency, painful urination, leaking or incontinence, changes in size and force of urinary stream, problems emptying bladder, nocturia or enuresis). Having baseline information on the urinary elimination pattern may help to monitor treatment response and assess changes in manifestations to determine disease severity.
3. Review results of diagnostic studies
Diagnostic studies aid in identifying the presence and type of elimination problems. Review results of diagnostic studies including:
- Uroflowmetry
- Cystometrogram
- Post void residual ultrasound (bladder scan)
- Pressure flow and leak point pressure measurement
- Video urodynamics
- Electromyography
- Kidney, ureter, and bladder [KUB] imaging
Interventions:
1. Teach the patient how to urinate by the clock.
Timed or scheduled voiding may reduce urinary retention by preventing bladder overdistention.
2. Teach kegel exercises.
Kegel exercises strengthen the pelvic floor muscles which may reduce dribbling.
3. Encourage oral fluids.
Increased circulating volume promotes better renal perfusion and facilitates the flushing of sediments and bacteria in the kidneys, bladder, and ureters.
4. Encourage sitz bath.
Sitz baths promote muscle relaxation, decrease edema, and may enhance the voiding effort.
5. Teach abdominal strain and Valsalva maneuver; instruct client to:
- Lean forward on their thighs.
- Contract abdominal muscles, if possible, and strain or “bear down”; hold breath while straining (Valsalva maneuver).
- Hold strain or breath until urine flow stops; wait 1 minute, and strain again as long as possible.
- Continue until no more urine is expelled.
These are methods to assist in emptying the bladder. Valsalva maneuver contracts the abdominal muscles, which manually compresses the bladder.
References
- Ackley, B.J., Ladwig, G.B.,& Makic, M.B.F. (2017). Nursing diagnosis handbook: An evidence-based guide to planning care (11th ed.). Elsevier.
- Carpenito, L.J. (2013). Nursing diagnosis: Application to clinical practice (14th ed.). Lippincott Williams & Wilkins.
- Cleveland Clinic. (2021). Urinary retention. https://my.clevelandclinic.org/health/diseases/15427-urinary-retention
- Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2019). Nursing care plans: Guidelines for individualizing client care across the life span (10th edition). F.A. Davis Company.
- Gulanick, M. & Myers, J.L. (2014). Nursing care plans Diagnoses, interventions, and outcomes (8th ed.). Elsevier.
- National Institute of Diabetes and Digestive and Kidney Diseases. (2019). Definition & Facts of urinary retention. https://www.niddk.nih.gov/health-information/urologic-diseases/urinary-retention/definition-facts
- National Institute of Diabetes and Digestive and Kidney Diseases. (2019). Symptoms & Causes of urinary retention. https://www.niddk.nih.gov/health-information/urologic-diseases/urinary-retention/symptoms-causes
