A client has been admitted with incontinence. what should the nurse expect to assess in this client?

Urinary retention is a condition that develops when an individual is not able to empty his or her bladder of urine. It can be either an acute, a sudden change, or it can be a chronic condition in which the individual gradually over time is unable to completely empty his or her bladder.

Signs and Symptoms 

The signs and symptoms of urinary retention can vary a little bit depending on if 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 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.

Causes

Urinary retention can be the result of a number of 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

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 due to the bladder being stretched too far or for too long of periods  
• Renal damage  
• Urinary incontinence

Expected Outcomes

• 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 any of abdominal discomfort related to urinary retention

Nursing Assessment for Urinary Retention

1. Assess patient’s individual risk of urinary retention
Reviewing patient’s chart and medical history will help the nurse to identify if the patient is at risk of urinary retention based on other medical conditions, history of recent surgery, or medications.

2. Assess patient’s voiding pattern/intake and output
If 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 with 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.

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 alternative medications with the healthcare provider.

Nursing Interventions for Urinary Retention

1. Provide patient with routine voiding measures including privacy, normal voiding positions, sound of running water, etc.
These measures can assist with the relaxation of the perineal muscles which can further help to promote appropriate, effective voiding.

2. Encourage/provide appropriate perineal cleansing
Appropriate cleansing will decrease risk of infections which can further contribute to urinary retention.

3. Provide appropriate catheter care when catheter is present
Appropriate catheter care will decrease risk for potential infection which can further contribute to urinary retention.

4. Catheterize patient when indicated
If patient is retaining a significant amount of urine, catheterization may be necessary. When necessary ensure catheterization occurs per the healthcare provider 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 is able to 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 time schedule to maintain appropriate bladder function.

References and Sources

1. Cleveland Clinic. (2021). Urinary retention. https://my.clevelandclinic.org/health/diseases/15427-urinary-retention
2. 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.
3. 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
4. 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

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