Nursing care plan/Urinary Retention

  1. 0
    I have a pt who has BPH and is can't void by himself at all. He gets daily bladder scans and caths to empty his bladder. He is in acute renal failure and is scheduled for a TURP next week. I have (obviously) decided on urinary retention as the primary nursing dx. I am having trouble coming up with goals for this patient other than preventing UTI's. All of the diagnosis books' goals/outcomes seem geared at helping the pt to void or preventing the retention in the first place. It seems pointless to put goals such as "pt will demonstrate consistent ability to urinate" etc as he is physiologically unable to do so. On our nursing care plans in says "GOALS - how would you know this is no longer a problem?" So I thought putting something like "Pt will undergo surgery successfully". If he did that, it would def. solve the problem and then I could do interventions like teaching about the surgery, assessing the things that may need to be changed (meds etc) to enter surgery. etc. But then I thought - that's probably a whole other nursing dx altogether. Any thoughts are appreciated.
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  3. 12 Comments so far...

  4. 0
    Ho may not be able to void without assistance from a catheter- but does he need assistance from someone else? What would you do to enable him to be able to empty his bladder independently?

    I think the statement "How do you know this is no longer a problem" is more of a guiding statement to help you think of goals. Remember that fixing a problem doesn't mean that you fix the condition. It could mean that you provide education and information in order to enable the patient to manage their diagnosis on their own.

    What goals and interventions can you come up with that would illustrate that the patient understand the diagnosis and can manage it independently?
  5. 0
    what psychological issue would be patient suffer as a result (embarrassement, fear)? Lack of knowledge or skill? Can he do the caths independently? What does his blood pressure do if he is "full"? What might his BP do if he is cathed too quickly? Any pain associated and, if not, what is danger of bladder rupture?
  6. 1
    How about sonething like=

    The patient will be free of signs and symptoms of urinary retention AEB absence of bladder distention and pain, UOP of > or = to 30ml/hr or 0.5ml/kg/hr, ETC....

    Intervention may include:

    Monitor uop
    Assess abdomen q×hrs
    Perform bladder scan
    I/O cath q×hrs per order
    Assist to void q2hrs
    ETC
    Esme12 likes this.
  7. 1
    Acute renal failure is also a priority. .puts pt at risk for or has FVE
    Esme12 likes this.
  8. 2
    Here we have another example of trying to fit a nursing diagnosis into the medical one. You are absolutely correct that his impaired urinary elimination/retention isn't something that nursing can do anything about from a nursing standpoint-- at this point for this patient, it's a surgical problem and will have to be treated surgically. Acute renal failure and presence of infection are also medical diagnoses. Not nursing, though risk of infection and risk of trauma are very real and perfectly useful to look at. This is why your "obvious(ly)" choice is not actually the best one. Classic rookie error--- but I'm a nurse, I can help.

    You're right. There is that "whole 'nother nursing diagnosis altogether" thang. Hold that thought. Of course he has other nursing diagnoses. How has having this condition affected his life? Has it disrupted his ability to care for himself? Engage in normal social/community activities? Is it painful? Embarrassing? Is he and/or his partner concerned about his sex life after surgery (hint: the answer is "yes")? Is all this affecting his sleep? His dignity? Is being in the hospital affecting his family relationships? How is he coping with all this? Is he worried that he has cancer-- then what? How's he doing for stress? Resilience? Spiritual distress?

    See, nursing diagnoses for all these are in the NANDA-I 2012-2014. I'll bet you dollars to doughnuts that many bona fide nursing diagnoses include defining characteristics that you have already assessed in this unfortunate man. You need to address them from a nuring standpoint, not a medicine-adjunct standpoint. $29 and free two-day delivery for students from Amazon, $24 for your Kindle. If you don't have this book you are cheating yourself. Get it now and surprise the heck out of your faculty on how fast you start really thinking like a nurse.
    man-nurse2b and pmabraham like this.
  9. 0
    I had a pt with this condition in my clinical recently and the goal "pt will demonstrate consistent ability to urinate" is not realistic since he has a physiological problem. you need to use a nursing diagnosis book to figure this one out. one example in my diagnosis book is the pt will maintain fluid balance, intake equal to output. That is something you can actually measure by giving something to drink and measuring output in cath bag. Another is pt will avoid bladder distension. this is achieved with use of catheter.
  10. 0
    Quote from man-nurse2b
    I had a pt with this condition in my clinical recently and the goal "pt will demonstrate consistent ability to urinate" is not realistic since he has a physiological problem. you need to use a nursing diagnosis book to figure this one out. one example in my diagnosis book is the pt will maintain fluid balance, intake equal to output. That is something you can actually measure by giving something to drink and measuring output in cath bag. Another is pt will avoid bladder distension. this is achieved with use of catheter.

    No evidence that there is a fluid imbalance or risk of one, so that won't fly.
    Inserting a Foley catheter is not part of a nursing plan of care, has to be prescribed by a physician.
    Nursing, here, nursing. NANDA-I is the way to go.
  11. 0
    Our nursing care plans include collaborative care so I guess it depends on what your specific program asks you

    We can also use PC's(collaborative problem or potential complication: used either way) which allows us to utilize medical diagnosis such as Hemorrage if its a higher priority then a nursing diagnosis

    Urinary retention or risk for wouldnt cause fluid imbalance?
  12. 0
    Per Saunders, Elsevier 2012:

    NURSING DIAGNOSIS: Urinary retention
    NANDA: The state in which an individual experiences incomplete emptying of the bladder



    related to:stasis of urine in the kidney and bladder associated with prolonged horizontal positioning;difficulty urinating associated with anxiety regarding use of bedpan or urinal;incomplete bladder emptying associated with:horizontal positioning (the gravity needed for complete bladder emptying is lost)decreased bladder muscle tone resulting from the generalized loss of muscle tone that occurs with prolonged immobility.

    Desired OutcomeThe client will not experience urinary retention as evidenced by:voiding at normal intervalsno reports of bladder fullness and suprapubic discomfortabsence of bladder distention and dribbling of urinebalanced intake and output

    .Nursing Actions and*Selected Purposes/Rationales
    Assess for signs and symptoms of urinary retention:frequent voiding of small amounts (25 - 60 ml) of urinereports of bladder fullness or suprapubic discomfortbladder distentiondribbling of urineoutput less than intake.Catheterize client if ordered*to
    determine the amount of residual urine.Implement measures*to prevent urinary retention:instruct client to urinate when the urge is first feltperform actions*to promote relaxation during voiding attempts*(e.g. provide privacy, hold a warm blanket against abdomen, encourage client to read)perform actions that may help trigger the micturition reflex and promote a sense of relaxation during voiding attempts (e.g. run water, place client's hands in warm water, pour warm water over perineum)allow client to assume a normal position for voiding unless contraindicatedinstruct and/or assist client to lean upper body forward and/or gently press
    downward on lower abdomen during voiding attempts unless contraindicated*in order to put pressure on the bladder (pressure helps create a sensation of bladder fullness, which stimulates the micturition reflex)
    administer parasympathomimetic (cholinergic) drugs (e.g. bethanechol) if ordered*to stimulate bladder contraction.Consult physician about intermittent catheterization or insertion of an indwelling catheter if above actions fail to alleviate urinary retention.


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