A patient is experiencing oliguria. which action should the nurse perform first?

Use this nursing diagnosis guide to help you create a Urinary Retention nursing care plan.

Inhaltsverzeichnis Show

Causes of Urinary Retention
Signs and Symptoms of Urinary Retention
Goals and Outcomes
Nursing Assessment for Urinary Retention
Nursing Interventions for Urinary Retention
Recommended Resources
What is the first line of action in urinary retention?
What are nursing interventions for impaired urinary elimination?
Which of the following is most effective nursing measure to relieve urinary retention?
What will the nurse expect to see in a patient with a urinary tract infection?

Urinary retention, also known as ischuria, is the body’s failure to effectively and completely empty the bladder. It may occur in conjunction with or independent of urinary incontinence. An immobile person; a person with a medical condition such as BPH, disk surgery, or hysterectomy; or a person who is experiencing the side effects of medications, including anesthetic agents, antihypertensives, antispasmodics, antihistamines, and anticholinergics, may experience urinary retention, bladder distention, and infrequently urinary incontinence. These drugs may meddle with the nerve impulses essential to cause relaxation of the sphincters, which enable urination.

Severe complications of untreated urinary retention include bladder damage and chronic kidney failure. Urinary retention is a disorder that needs to be managed immediately and correctly to prevent complications.

Causes of Urinary Retention
Signs and Symptoms of Urinary Retention
Goals and Outcomes
Nursing Assessment for Urinary Retention
Nursing Interventions for Urinary Retention

Recommended Resources
See also

Causes of Urinary Retention

Here are some factors that may be related to Urinary Retention:

Decompensation of detrusor musculature
Enlarged prostate
General anesthesia, regional anesthesia
High urethral pressures caused by disease, injury, edema, and hematoma
Inability of bladder to contract adequately
Inadequate intake
Infection
Mechanical obstruction
Pain, fear of pain
Sensory/motor impairment, nerve paralysis
Surgical manipulation
Urethral blockage

Signs and Symptoms of Urinary Retention

Urinary Retention is characterized by the following signs and symptoms:

Abdominal discomfort
Bladder distention
Decreased (less than 30 ml/hr) or absent urinary output for 2 consecutive hours
Frequency
Hesitancy
Inability to empty bladder completely
Incontinence
Residual urine
Sensation of bladder fullness
Urgency

Goals and Outcomes

The following are the common goals and expected outcomes for Urinary Retention:

Patient empties bladder completely.
Patient voids in sufficient quantity with no palpable bladder distension.
Patient has urine volume greater than or equal to 300 mL with each voiding and residual volume less than 100 mL.

Nursing Assessment for Urinary Retention

Assessment is required to determine potential problems that may have lead to Urinary Retention as well as manage any difficulty that may appear during nursing care.

Assessment	Rationales
Ascertain quantity, frequency, and character of urine, such as color, odor, and specific gravity.	Urinary retention, vaginal discharge, and presence of catheter predispose patient to infection, especially if patient has perineal sutures.
Review previous patterns of voiding.	There is a wide range of “normal” voiding frequency. Acute urinary retention requires immediate medical intervention. With chronic urinary retention, one is able to urinate but may have trouble starting the stream or emptying the bladder completely.
Allow patient to keep a record of the amount and time of each voiding. Take down decreased urinary output. Determine specific gravity as ordered.	Retention of urine increases pressure in the kidneys and ureters which may lead to renal insufficiency. Insufficiency of blood circulation to the kidney alters its capability to filter and concentrate substances.
Assess vital signs. Check for changes in mentation, hypertension, and peripheral or dependent edema. Weigh daily. Maintain precise I&O record.	Kidney failure results in reduced fluid excretion and builds up of toxic wastes. It may lead to complete renal shutdown.
Monitor time intervals between voiding and document the quantity voided.	Keeping an hourly record for 48 hours can help in establishing a toileting program and gives a clear picture of the patient’s voiding pattern.
Ask patient concerning stress incontinence when moving, sneezing, coughing, laughing, and lifting objects.	High urethral pressure can inhibit voiding until abdominal pressure increases enough for urine to be involuntarily lost. Also, hinders bladder emptying.
Palpate and percuss suprapubic area. Examine verbalization of discomfort, pain, fullness, and difficulty of voiding.	A distended bladder could be felt by the patient in the suprapubic area. Perception of bladder fullness, bladder distention above symphysis pubis implies urinary retention.
Monitor urinalysis, urine culture, and sensitivity.	Urinary tract infection can cause retention.
Monitor blood urea nitrogen (BUN) and creatinine.	This laboratory test will differentiate between renal failure and urinary retention.
Use a bladder scan (portable ultrasound instrument) or catheterize the patient to measure residual urine if incomplete emptying is presumed.	Retention of urine in the bladder predisposes the patient to urinary tract infection and may indicate the need for an intermittent catheterization program.
If an indwelling catheter is in place, assess for patency and kinking.	An occluded or kinked catheter may lead to urinary retention in the bladder.

Nursing Interventions for Urinary Retention

The following are the therapeutic nursing interventions for Urinary Retention:

Interventions	Rationales
Start the following techniques to facilitate voiding:
Promote fluids, if not contraindicated.	Unless medically restricted, fluid intake should be at least 1500 mL/24 hr.
Encourage regular intake of cranberry juice.	Cranberry juice keeps the acidity of urine. This aids in preventing infection.
Place the patient in an upright position to facilitate successful voiding.	An upright position on a commode or in bed on a bedpan increases the patient’s voiding success through force of gravity.
Provide privacy	Privacy aids in the relaxation of urinary sphincters.
Encourage the patient to void at least every 4 hours.	Voiding at frequent intervals empties the bladder and reduces risk of urinary retention.
Allow the patient to listen to the sound of running water, or dip hands in warm water/pour lukewarm water over perineum.	These actions promote urination.
Offer fluids before voiding.	Sufficient urine volume is necessary to stimulate the voiding reflex.
Perform Credé’s maneuver.	Credé’s method (pressing down over the bladder with the hands) enhances urinary bladder pressure, and this consequently induces relaxation of sphincter to allow voiding.
Decompress bladder moderately.	Once huge amount of urine has accumulated, fast urinary bladder decompression produces pressure on pelvic arteries, and may cause venous pooling.
Encourage patient to take bethanechol (Urecholine) as indicated.	Bethanechol stimulates parasympathetic nervous system to release acetylcholine at nerve endings and to enhance tone and amplitude of contractions of smooth muscles of the urinary bladder.
If incomplete emptying is presumed, catheterize and measure residual urine.	Urinary retention predisposes the patient to urinary tract infection and may be a sign of the need for an intermittent catheterization program.
Keep indwelling catheter patent; maintain drainage tubing kink-free.	These provide free drainage of urine, decreasing the possibility of urinary stasis or retention and infection.
Secure the catheter of male patient to the abdomen and thigh for female.	This technique prevents urethral fistula and avoids accidental dislodgment.
Educate the patient on the importance of meatal care. This should be done twice daily with soap and water and dry thoroughly.	Meatal care reduces the risk for infection.
Discuss the importance of adequate fluid intake.	Increased fluid stimulates voiding and decreases the risk of urinary tract infections.
Inform the patient and significant other to observe the different signs and symptoms of bladder distention like reduced or lack of urine, urgency, hesitancy, frequency, distention of lower abdomen, or discomfort.	Knowledge of the signs and symptoms allows the patient, significant other, or caregiver to recognize them and seek treatment.
Instruct the patient and significant other to observe the different signs and symptoms of urinary tract infection like chills and fever, frequent urination or concentrated urine, and abdominal or back pain.	Knowledge of the signs and symptoms allows the patient, significant other, or caregiver to recognize them and seek treatment.
Teach the patient to achieve an upright position on the toilet in possible.	An upright position is the natural position for voiding and uses the force of gravity.
Teach the patient about possible surgical treatment as needed.	If prostate enlargement is involved, surgery may be required. Women may need surgery to lift a fallen bladder or rectum. A urethral stent may be required to treat a urethral stricture.
Suggest sitz bath as ordered.	A sitz bath supports muscle relaxation, reduces edema, and may improve voiding attempt.

Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

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Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
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NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
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