{ "name": "Urinary Retention & Catheter Care", "slug": "urinary-retention", "url": "https://nursingplex.com/care-plans/urinary-retention", "category": "Urinary & Renal", "summary": "Incomplete bladder emptying; bladder scanning, catheter care and CAUTI prevention.", "nursing_diagnoses": [ "Impaired urinary elimination", "Risk for infection", "Acute pain" ], "overview": [ "Urinary retention is the inability to completely empty the bladder. Acute retention is a sudden, painful inability to void at all and is a urologic emergency. Chronic retention develops gradually with a persistently elevated post-void residual, is often painless, and presents with overflow dribbling, frequency, nocturia and recurrent infection. Causes are obstructive — benign prostatic hyperplasia, stricture, stones, constipation — or neurogenic and pharmacologic, especially anticholinergics, opioids, antihistamines and anesthesia.", "Bladder scanning has largely replaced guessing: a portable ultrasound gives a post-void residual noninvasively and prevents unnecessary catheterization. When catheterization is required, drainage should be steady rather than rapid; historic practice of clamping after 500 mL has largely been abandoned, but rapid decompression of a massively distended bladder can still cause hematuria and hypotension, so it warrants monitoring. The larger nursing principle is that every indwelling catheter is a daily infection risk, so intermittent catheterization is preferred and removal should be pursued relentlessly." ], "key_facts": [ { "label": "Post-void residual", "text": "Scan within 10–15 minutes of voiding; more than about 100–150 mL suggests incomplete emptying and repeated high values need intervention." }, { "label": "Acute retention", "text": "Sudden inability to void with suprapubic pain and a palpable distended bladder — decompress urgently." }, { "label": "Chronic retention", "text": "Often painless with overflow dribbling; suspect it in recurrent UTI and nocturia." }, { "label": "Drug causes", "text": "Anticholinergics, antihistamines, opioids, tricyclics, alpha agonists and anesthesia — review the list first." }, { "label": "Catheter rule", "text": "Prefer intermittent over indwelling; assess necessity daily and remove at the earliest opportunity." } ], "nursing_priorities": [ "Relieve acute retention and the associated pain promptly.", "Determine and treat the underlying cause, including reversible drug effects and constipation.", "Protect renal function from back pressure and hydronephrosis.", "Prevent catheter-associated urinary tract infection.", "Restore normal voiding and remove catheters as early as possible.", "Teach intermittent self-catheterization and home catheter care where needed." ], "assessment": { "subjective": [ "Inability to void despite a strong urge, with suprapubic pain and restlessness", "Sensation of incomplete emptying, straining to start, weak or interrupted stream", "Frequency, urgency, nocturia and post-void dribbling", "Lower abdominal fullness, pressure or discomfort", "Anxiety and distress; in older adults, new confusion or agitation", "History of prostate disease, pelvic surgery, neurologic disease or new medications" ], "objective": [ "Palpable, percussable, distended bladder above the symphysis pubis", "Bladder scan post-void residual volume", "Absent or minimal urine output despite adequate intake", "Hypertension, tachycardia, diaphoresis and restlessness from bladder distention pain", "Overflow dribbling with a continuously wet perineum in chronic retention", "Rising BUN and creatinine, hydronephrosis on imaging", "Urinalysis and culture results indicating infection", "Enlarged prostate on examination; perineal sensation and anal tone in suspected neurologic cause", "New confusion or agitation in older adults as the presenting sign" ], "related_factors": [ "Bladder outlet obstruction from prostatic hyperplasia, stricture, stone or tumor", "Neurogenic bladder from spinal cord injury, multiple sclerosis, diabetes or stroke", "Medications with anticholinergic or opioid effects, and anesthesia", "Post-operative state, immobility and inability to void in a supine position", "Fecal impaction compressing the urethra", "Detrusor underactivity from chronic overdistention" ] }, "goals": [ "The client will void voluntarily with a post-void residual below the established threshold.", "The client will report relief of suprapubic pain and pressure.", "The client will maintain adequate urine output with stable renal function.", "The client will remain free of catheter-associated urinary tract infection.", "The client will demonstrate clean intermittent self-catheterization technique if required.", "The client will state the medications and habits that contribute to retention and how to avoid them." ], "interventions": [ { "title": "1. Assessment and detection", "points": [ "Palpate and percuss the suprapubic area for distention and correlate with reported urge and intake.", "Perform a bladder scan for post-void residual within 10–15 minutes of voiding rather than catheterizing to find out.", "Track intake and output meticulously, including voided volumes rather than only the number of voids.", "Suspect retention in any post-operative patient who has not voided within 6–8 hours, and in older adults with new confusion.", "Review the medication list for anticholinergics, opioids, antihistamines and decongestants and discuss alternatives with the provider.", "Assess for and relieve fecal impaction, a common and readily fixable cause." ] }, { "title": "2. Promoting spontaneous voiding", "points": [ "Provide privacy, uninterrupted time and a normal position — standing for men, sitting upright for women.", "Use sensory and reflex triggers: running water, warm water over the perineum, a warm sitz bath, or placing hands in warm water.", "Encourage voiding on a schedule every 3–4 hours rather than waiting for a strong urge, and teach double voiding — void, wait a minute, then try again.", "Teach relaxed voiding without straining, and pelvic floor relaxation rather than pushing.", "Ambulate the patient and control pain, since immobility and post-operative pain both inhibit voiding.", "Apply gentle warmth to the lower abdomen; avoid the outdated practice of forceful Credé maneuver unless specifically prescribed." ] }, { "title": "3. Catheterization and decompression", "points": [ "Use intermittent straight catheterization in preference to an indwelling catheter whenever the problem is likely to be short-lived.", "Insert with strict sterile technique in the hospital, using the smallest effective size, and secure to prevent traction.", "Drain steadily and monitor the patient during decompression of a very large volume for hematuria, hypotension and post-obstructive diuresis.", "Monitor urine output closely after relief of chronic obstruction; post-obstructive diuresis can cause profound fluid and electrolyte loss requiring replacement.", "Document the volume drained, urine character and the patient's response.", "Assess the ongoing need for the catheter every single day and advocate for removal; conduct a trial of void with post-void residual measurement after removal." ] }, { "title": "4. Preventing infection and complications", "points": [ "Maintain a closed drainage system with the bag below bladder level and off the floor, and keep tubing free of dependent loops.", "Perform daily perineal hygiene with soap and water; avoid antiseptics and routine irrigation, which do not prevent infection.", "Encourage 2–3 liters of fluid daily unless restricted, to flush the system and dilute urine.", "Monitor for infection signs including fever, cloudy foul urine, suprapubic pain and, in older adults, new confusion.", "Monitor BUN, creatinine and imaging for hydronephrosis and renal impairment from prolonged back pressure.", "For patients with spinal cord injury above T6, recognize autonomic dysreflexia — sudden severe headache, hypertension, bradycardia, flushing above the lesion — as a bladder distention emergency requiring immediate drainage." ] }, { "title": "5. Pharmacologic and surgical management", "points": [ "Give alpha blockers such as tamsulosin as prescribed to relax the bladder neck, and warn about orthostatic hypotension, dizziness and retrograde ejaculation.", "Give 5-alpha reductase inhibitors as prescribed for prostatic enlargement and explain that benefit takes months and PSA values will change.", "Prepare the patient for urodynamic testing, cystoscopy or surgical relief such as transurethral resection when indicated.", "Provide post-operative care after prostate surgery including continuous bladder irrigation, monitoring outflow color and clot retention, and never occluding the irrigation flow.", "Teach avoidance of over-the-counter antihistamines and decongestants, which commonly precipitate acute retention in men with prostatic enlargement." ] }, { "title": "6. Self-catheterization and home teaching", "points": [ "Teach clean intermittent self-catheterization step by step with return demonstration, emphasizing hand washing, catheter handling, and a consistent schedule every 4–6 hours.", "Explain that clean rather than sterile technique is acceptable at home and reduces infection risk far more than an indwelling catheter would.", "Teach recognition of infection and when to call, and how to obtain supplies and dispose of or clean catheters.", "Involve caregivers when the patient lacks dexterity or vision, and arrange home health support.", "Address embarrassment and body-image concerns directly and reinforce that self-catheterization preserves independence and kidney function." ] } ], "patient_teaching": [ "Try to urinate every 3 to 4 hours rather than waiting for a strong urge, and use double voiding.", "Avoid over-the-counter antihistamines and decongestants — they can stop you from urinating entirely.", "Go to the emergency department if you cannot urinate at all and your lower abdomen is painful and swollen.", "Drink 2 to 3 liters of fluid daily unless your provider has restricted it.", "Treat constipation; a full bowel presses on the bladder outlet.", "If you self-catheterize, keep to the schedule, wash your hands carefully, and report cloudy foul urine, fever or blood.", "Ask every day whether an indwelling catheter is still needed — early removal is the best protection against infection." ] }