Urinary retention means the bladder does not empty completely or at all. It can be caused by an enlarged prostate, anesthesia, opioids, nerve problems, or a blocked catheter. Your priorities are finding and relieving the retention, preventing bladder damage and infection, and helping the client return to normal voiding.
Each care plan below follows the nursing process (ADPIE).
Urinary Retention
- Blockage such as an enlarged prostate
- Effects of anesthesia, opioids, or anticholinergic medications
- Nerve damage affecting bladder signals
- Pain or anxiety after surgery
- Not voiding for 6 to 8 hours or more
- Bladder distention felt above the pubic bone
- Bladder scan shows a large volume
- Frequent small voids or dribbling
- Lower abdominal discomfort
- Client voids within 6 to 8 hours after surgery or catheter removal, or per protocol
- Post-void residual is below the ordered limit
- Client empties the bladder completely and has no urinary tract infection
- Intake and output
- Time of last void
- Bladder scan for volume and post-void residual as ordered
- Lower abdomen for distention and tenderness
- Medications that can cause retention
| INTERVENTION | RATIONALE |
|---|---|
| Help the client into a normal voiding position, such as standing for males if safe | Natural positions use gravity and help the bladder empty. |
| Provide privacy and use cues like running water or warm water over the perineum | These help the client relax the muscles that control urine flow. |
| Perform a bladder scan and insert a straight or indwelling catheter as ordered if unable to void | Draining the bladder prevents overstretching and kidney damage. |
| Report medications that may be causing retention to the provider | Changing the medication may solve the problem. |
| Give medications such as alpha blockers as ordered for an enlarged prostate | These relax the muscle at the bladder neck so urine can flow. |
EVALUATION
- Client voids adequate amounts
- Post-void residual is within the ordered limit
- Bladder is not distended on exam
Risk for Infection
- Urine sitting in the bladder
- Indwelling or intermittent catheter use
- Client shows no signs of urinary tract infection during the hospital stay
- Client stays free of UTI after discharge
- Urine color, clarity, and odor
- Temperature
- Confusion in older adults
- Catheter need each day
| INTERVENTION | RATIONALE |
|---|---|
| Use sterile technique when inserting a catheter | This keeps bacteria out of the bladder. |
| Keep the drainage bag below the bladder and off the floor, and keep tubing free of kinks | This prevents backflow and keeps urine draining. |
| Give catheter and perineal care per policy | Clean skin lowers bacteria near the catheter. |
| Ask the provider each day whether the catheter is still needed | Removing it early is the best way to prevent catheter infections. |
EVALUATION
- Urine is clear and the client is afebrile
- Catheter is removed as soon as it is no longer needed
Practice this in Chart Review
Read the I&O and bladder scan results to decide when a client needs a catheter.
Play Chart ReviewQuick answers
What is the first thing a nurse should do when a post-op client has not voided in 8 hours?
Assess the bladder, by palpating and using a bladder scan as ordered, before inserting a catheter.
Which medications commonly cause urinary retention?
Opioids, anticholinergics, some antihistamines, and anesthesia can all cause the bladder to hold urine.
For learning only. Individualize every care plan to your client, and follow your program, current guidelines, provider orders, and facility policy.