This nursing care plan is for patients who are experiencing urinary retention. Patients can experience urinary retention for numerous reasons. Some of these reasons include: strictures, prostate enlargement, drug side effects, diabetic neuropathy, uteterocele, just to name a few.
Urinary retention is where patients are unable to completely empty their bladder of urine. Patients will most commonly tell the nurse they feel like they still have urine in their bladder and feel the need to void even though they already have. Urinary retention causes the patient to feel uncomfortable. Some patients tend to be embarrassed by this and may not share this problem with the nurse. The nurse must assess the patient urinary habits and make sure the patient is completely emptying their bladder.
Below is a case scenario that may be encountered as a nursing student or nurse in a hospital setting.
What are nursing care plans? How do you develop a nursing care plan? What nursing care plan book do you recommend helping you develop a nursing care plan?
This care plan is listed to give an example of how a Nurse (LPN or RN) may plan to treat a patient with those conditions.
Important Disclosure: Please keep in mind that these care plans are listed for Example/Educational purposes only, and some of these treatments may change over time. Do not treat a patient based on this care plan.
Care Plans are often developed in different formats. The formatting isn’t always important, and care plan formatting may vary among different nursing schools or medical jobs. Some hospitals may have the information displayed in digital format, or use pre-made templates. The most important part of the care plan is the content, as that is the foundation on which you will base your care.
Nursing Care Plan for: Urinary Retention
If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below. Otherwise, scroll down to view this completed care plan.
Scenario: |
A 74 year old woman was admitted to your floor with COPD excaberation and is almost fully recovered. The patient is complaining of incomplete bladder emptying after voiding. She states this has never happened to her before until she came into the hospital. The patient thinks it may be the new medications she was started on because she states “that is the only thing I am doing different”. The patient was started on Theophylline to help with her breathing. During your assessment you have the patient empty her bladder and then you bladder scan her. You find 283 cc of urine still in the bladder after the patient voided 100 cc of urine.
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Nursing Diagnosis: |
Urinary retention related to impaired afferent pathways secondary to theophylline as evidence by 283 cc of residual urine and patient states that it feels as though the bladder is not emptying after voiding.
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Subjective Data: |
The patient is complaining of incomplete bladder emptying after voiding. She states this has never happened to her before until she came into the hospital. The patient thinks it may be the new medications she was started on because she states “that is the only thing I am doing different”.
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Objective Data: |
A 74 year old woman was admitted to your floor with COPD excaberation and is almost fully recovered. The patient was started on Theophylline to help with her breathing. During your assessment you have the patient empty her bladder and then you bladder scan her. You find 283 cc of urine still in the bladder after the patient voided 100 cc of urine.
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Nursing Outcomes: |
-The patient will be able to empty her bladder completely within 24 hours.-The patient will verbalize feelings of satisfaction with bladder emptying within 24 hours.
-The patient will be able to use the Valsalva maneuver to help with bladder emptying of residual urine of less than 50 cc. |
Nursing Interventions: |
-The nurse will assess with the bladder scanner for urine residual after each patient void.-The nurse will assess the patients feelings of bladder emptying after each void.
-The nurse will teach the patient how to correctly perform the Valsalva maneuver while voiding. |