00023 Urinary Retention

Domain 3: elimination and exchange
Class 1: urinary function
Diagnostic Code: 00023
Nanda label: urinary retention
Diagnostic focus: retention
Approved 1986 • Revised 2017, 2020 • Level of evidence 3.1

NANDA Nursing Diagnosis Definition

Nanda’s nursing diagnosis « urinary retention » is defined as: incomplete emptying of the bladder

Definite characteristics

  • Absence of diuresis
  • Black distension
  • Dysuria
  • Increased diurnal urinary frequency
  • Minimum volume emptying
  • Incontinence for overflowing
  • Informs a sensation of bladder replacement
  • Informs urinary waste sensation
  • Water urine jet

Related factors

  • Limitations of the environment
  • Fecal impact
  • Incorrect posture in the toilet
  • Inadequate relaxation of pelvic soil muscles
  • Insufficient intimacy
  • prolapse of a pelvic organ
  • Weakened bladder musculature

Risk population

  • Puéperas women

Associated problems

  • Benign prostatic hyperplasia
  • Diabetes mellitus
  • Nervous system diseases
  • Pharmacological preparations
  • Urinary tract obstruction

Suggested alternative diagnostics

  • Urinary elimination, deterioration of the
  • Urinary effort incontinence
  • Urinary emergency incontinence
  • Functional urinary incontinence
  • Urinary incontinence for overflowing

NOC Results

  • Urinary elimination: accumulation and urine waste

Evaluation objectives and criteria

  • Demonstrates urinary continence, which is manifested by the following indicators (specify from 1 to 5: seriously, substantially, moderately, slightly or not compromised):
    • Elimination pattern
    • Total bladder emptying
  • Shows urinary continence, which is manifested by the following indicators (specify from 1 to 5: severe, substantial, moderate, light or none):
    • Urinary retention

Other examples

  • Residue after urination> 100-200 cc
  • Demonstrates bladder emptying with clean intermittent catheterization procedure
  • Describe the home care plan
  • Stay free from urinary tract infection
  • Report decreased bladder spasms
  • Manifest intake and elimination balance for 24 hours
  • empty the bladder completely

NIC Interventions

  • Medication administration: preparation, administration and evaluation of the effectiveness of prescribed and non -prescribed drugs
  • Urinary catheterization: Introduction of a probe in the bladder for temporal or permanent drainage of urine
  • Urinary catheterization: intermittent: regular periodic use of a probe to empty the bladder
  • Urinary retention care: Help to relieve the distension of the bladder
  • Urinary elimination management: maintenance of an optimal urinary excretion pattern
  • Medication management: Facilitate the safe and effective use of drugs with and without recipe
  • Liquid surveillance: Patient data collection and analysis to regulate water balance

Nursing Activities

  • See also nursing activities of urinary incontinence due to overflowing.

Valuations

  • Identify and document the emptying pattern of the patient’s bladder
  • (NIC) care of urinary retention ’.
    • Monitor the use of agents without prescription with anticholinergic or alpha agonist properties
    • Monitor the effects of prescribed drugs, such as calcium channel blockers and anticholinergics
    • Monitor intake and elimination
    • Monitor the degree of bladder distension through palpation and percussion

Patient and family education

  • Indicate the patient to report the signs and symptoms of a urinary tract infection (for example, fever, chills, side pain, hematuria, and changes in the consistency and smell of urine)
  • (NIC) Care of urinary retention: teach the patient and the family to register urinary elimination, as required

Collaboration activities

  • Channel with nursing personnel specialized in whole therapy to receive instruction about the cleaning of intermittent catheterization every four to six hours while it is awake
  • (NIC) Urinary retention care: channel with a urinary continence specialist, as required

Others

  • Establish a training program for urinary evacuation
  • Space the intake of liquids throughout the day to guarantee adequate intake without bladder overdistension
  • Motivate oral fluid intake: ___ my during the day; ___ my during the afternoon; __ mi during the night
  • (NIC) Care of urinary retention:
    • Provide privacy for elimination
    • Use the power of suggestion, opening the water jet or activating the toilet
    • Stimulate the bladder reflex applying cold in the abdomen, hitting the inside of the thigh or with the water jet
    • Provide enough time for the emptying of the bladder (10 minutes)
    • Use freshness atmosphere in urinals and wedges
    • Facilitate the Credé maneuver, when necessary
    • Use a waste probe, if necessary
    • Insert an urinary probe, if required