What would you have done? *urinary retention*

[Crux1024]

Pt with foley d/c'd (another shift) and due to void 6-8 hrs later. After 9 hours, was only able to piddle a scant amount (with ENORMOUS encouragement...). Bladder scan > 300. Called doc, Straight cath order obtained, pt refusing attempt. Pt states they are comfortable, (not distended or hardened as far as I could feel) I let them rest for a few hrs. BP rechecked and it is now 170 and wasnt before (basline about 130). Straight cath finally consented to, and ..swing and a miss.... (wasnt able to get straight cath on the first shot). Pt NOW adamantly refusing to be recathed and wants to sleep. Rechecked BP manually about 10 mins later and was 140's. Pt states no desire/urge to urinate. Is incontinent, but not enough on the brief to justify the > 300 mls on the scan.

I felt bad sending the pt on to the next shift with urinary issues, but I had no choice, Is there something else I could of done. Im not sure if the 170 BP was due to the retention issues, but I felt like it sure didnt help. I had asked the other nurses their thoughts but no one had any further than what I had already done. I charted as appropriate RE: refusals and attempts and etc.

*And for the record....I am the straight cath Queen...Last night though, I was dethroned...

[Sonjailana]

If they refuse, they refuse. Document and CYA. Make sure you let the doc know they are refusing. Make sure you educate them on risks, etc. You can't force a straight cath on anybody..

[CABG patch kid, BSN, RN]

I'd say you did all you could, the only thing I can think to add, when someone refuses a treatment that is very important, is to really explain the risks of refusal. I mean really tell them the risks, not to scare them into doing something, but just so that they can really make an informed refusal. I've had a few pts try to refuse meds like beta blockers, digoxin, lasix, things like that. Then after telling them what the med does, why they should take it and what could happen if they don't, they change their mind. Another trick I use is to say the DR wants such and such done. For some reason, pts are more receptive to what the DR wants done, lol.

I'm not saying you didn't do all this, just that it's the only thing I know to do when a pt refuses. Other than that, you charted, you covered your butt!

[Chaya, ASN, RN]

Just what you did, assuming you were not timid about stressing the importance of it. Just out of curiosity, do you know what did happen on the next shift? Did the pt end up voiding or consenting to be cathed? Sometimes I find pt's will consent to a procedure with one RN but not another (or else they just get plain worn down from two nurses nagging...)

[lifetimern]

I concur with CABG patch kid. I think your actions were correct and appropriate as long as the patient truly understood the ramifications of his decision.

BTW, I would have had another nurse (charge nurse, probably) encourage the patient to allow the I&0 cath. The second nurse should offer to perform the cath. herself.

If the patient started exhibiting symptoms of distress, I would have become adament that he allow someone else to perform the cath. -- this is when you make refusal more uncomfortable than allowing the procedure -- call the nursing supervisor to talk to the patient, call the doctor to the bedside, insist that the patient try different positions to urinate, etc. He can always continue to refuse, but sometimes people will give in just to shut you up. That is not very textbook, but sometimes I have had to do what I had to do for the patient's benefit.

[cherrybreeze, ADN, RN]

The point that this patient was at, I would have done the same things you did. I have my doubts that the blood pressure was due to retention, as a) it came back down, and b) 300ml isn't that much. If it were several hundred mls in the bladder, different story. The patient may just have been anxious thinking about needing to be cathed.

The patient refused. All you can do is document that as such, after you've explained the reason for doing it and the risks of not. If the other shift doesn't like it, what were supposed to do, hold him down and MAKE him be cathed? (I understand feeling bad about passing something on, but that's just the way it is sometimes)

We have a good number of surgeons that really aren't concerned about the length of time it takes a patient to void, some if the bladder isn't that full, some not at all. For the docs that have standing orders to cath, it's more often based on amount than time ("straight cath PRN for bladder scan >500ml").

As long as the amount in the bladder isn't too LOW, either (say, 150ml after 8 hours, meaning they may either be too dry or possibly have a renal issue), it's ok to wait a while longer. Should they be unable to void later with 800ml in their bladder, or have distention or discomfort, that's the point at which I'd call the physician. Chances are, however, that once they got to the point of feeling uncomfortable, or really feeling the urge to void and still can't, they'd consent to the cath. I've heard that there isn't much that is as uncomfortable as a blocked bladder.

[morte, LPN, LVN]

DTV of 6-8 hours is a little short.....8-10 is what i seem to remember....and 300 mls is BARELY to the point that he MIGHT feel the need to urinate.......double that amount and i might get a little pushier.....

[meadow85]

Educate the patient and maybe have another nurse try or use another catheter. I had a pt that required a special catheter w/ a curved tip and it was harder (Teman Catheter ?sp). Our NP was able to put it in for me.

But then again if he/she was refusing and not c/o any distention, pain or urge to void then you could encourage them to void by turning on the tap or reassess later?

[yiyayiya]

There is absolutely nothing you can do If the patient refuses. I have been in that position (as a patient on several occassions) and refuse any and all invasive procedures. At the end of the day the patient decides what is done to them, even if it means death, not the medical people and any force will result in a charge of battery and ending up in front of the Medical council.

[nursebubby]

300ml is minimal especially in the absence of discomfort or other relevant history. Normal bladder capacity varies tremendously. Do you know the patient's fluid balance? Why was catheter placed initially? Is there any other relevant history?

I would document refusal, inform doc, encourage fluids and ensure patient understands the importance of reporting even minimal discomfort. I would rescan in an hour or two or sooner if discomfort reported.

[pilotron57]

Tipically medical people thinking they own the patient . Patient refuses he or she refuses . Period . Nagging or forcing will not do anything. In my case I would get more ****** of. But then again nothing more arrogant then medical people .

[RNGriffin]

I would have walked the patient to the toilet or bedside commode, if this is an option for this patient, and palpated the bladder( lightly tapping on the bladder could induce the urge to void). I did this with many of my post spinal cord injury and spinal patients as a bladder training. It's not uncommon for patients to not void within the first 10hrs of de-cath.

Next time to make a sure hit, place the patient in trendelenburg and let the iodine highlight. You're less likely to miss. Also, having another personnel attempt possibly could make the patient more compliant with the in and out cath process.