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. Show
Signs and SymptomsThe 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
Chronic Urinary Retention
It is also important to note that some individuals with chronic urinary retention may not display any signs or symptoms. CausesUrinary retention can be the result of a number of factors including:
ComplicationsIf left untreated, urinary retention can lead to other complications for the individual. Some of these possible complications include:
Expected Outcomes
Nursing Assessment for Urinary Retention1. Assess patient’s individual risk of urinary retention 2. Assess patient’s voiding pattern/intake and output 3. Perform abdominal assessment 4. Assess urine characteristics 5. Assess post-void residuals 6. Assess/review medication list Nursing Interventions for Urinary Retention1. Provide patient with routine voiding measures including privacy, normal voiding positions, sound of running water, etc. 2. Encourage/provide appropriate perineal cleansing 3. Provide appropriate catheter care when catheter is present 4. Catheterize patient when indicated 5. Maintain patency of any indwelling catheter 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 7. Perform bladder scan as needed 8. Administer medications as ordered for urinary retention if chronic in nature References and Sources
Open Resources for Nursing (Open RN) The gastrointestinal (GI) system is responsible for the ingestion of food and the absorption of nutrients. Additionally, the GI and genitourinary (GU) systems are responsible for the elimination of waste products. Therefore, during assessment of these systems, the nurse collects subjective and objective data regarding the underlying structures of the abdomen, as well as the normal functioning of the GI and GU systems. Subjective AssessmentA focused gastrointestinal and genitourinary subjective assessment collects data about the signs and symptoms of GI and GU diseases, including any digestive or nutritional issues, relevant medical or family history of GI and GU disease, and any current treatment for related issues. Table 12.3a outlines interview questions used to explore medical and surgical history, symptoms related to the gastrointestinal and genitourinary systems, and associated medications. Information gained from the interview process is used to tailor the subsequent physical assessment and create a plan for patient care and education. Table 12.3a Interview Questions for Subjective Assessment of GI and GU Systems
GastrointestinalPain is the most common complaint related to abdominal problems and can be attributed to multiple underlying etiologies. Because of the potential variability of contributing factors, a careful and thorough assessment of this chief complaint should occur. Additional associated questions include asking if bloody stools (); dark, tarry stools ( ); bloating (abdominal distention); or vomiting of blood () are occurring. Nausea, vomiting, diarrhea, and constipation are common issues experienced by hospitalized patients due to adverse effects of medications or medical procedures. Read more details about commonly occurring gastrointestinal conditions in the “Elimination” chapter in Open RN Nursing Fundamentals. It is important to ask a hospitalized patient daily about the date of their last bowel movement and flatus so that a bowel management program can be initiated if necessary. If a patient is experiencing diarrhea, it is important to assess and monitor for signs of dehydration or electrolyte imbalances. Dehydration can be indicated by dry skin, dry mucous membranes, or sunken eyes. These symptoms may require contacting the health care provider for further treatment. Read additional information about fluid and electrolyte imbalances in the “Fluids and Electrolytes” chapter in Open RN Nursing Fundamentals. Additional specialized assessments of GI system function can include examination of the oropharynx and esophagus. For example, patients who have experienced a cerebrovascular accident (CVA), also called a “stroke,” may experience difficulty swallowing (). The nurse is often the first to notice these difficulties when swallowing pills, liquid, or food and can advocate for treatment to prevent complications, such as unintended weight loss or aspiration pneumonia. GenitourinaryThe nursing assessment of the genitourinary system generally focuses on bladder function. Ask about urinary symptoms, including , , or . Dysuria is any discomfort associated with urination and often signifies a urinary tract infection. Patients with dysuria commonly experience burning, stinging, or itching sensation. In elderly patients, changes in mental status may be the presenting symptom of a urinary tract infection. In women with dysuria, asking whether the discomfort is internal or external is important because vaginal inflammation can also cause dysuria as urine passes by the inflamed labia. Abnormally frequent urination (e.g., every hour or two) is termed urinary frequency. In older adults, urinary frequency often occurs at night and is termed nocturia. Frequency of normal urination varies considerably from individual to individual depending on personality traits, bladder capacity, or drinking habits. It can also be a symptom of a urinary tract infection, pregnancy in females, or prostate enlargement in males. Urinary urgency is an abrupt, strong, and often overwhelming need to urinate. Urgency often causes , a leakage of urine. When patients experience urinary urgency, the desire to urinate may be constant with only a few milliliters of urine eliminated with each voiding. Read additional information about commonly occurring genitourinary system alterations in the “Elimination” chapter in Open RN Nursing Fundamentals. Life Span ConsiderationsInfantsEating and elimination patterns of infants require special consideration based on the stage of development.
ChildrenThe expected abdominal contour of a child is protuberant until about the age of 4. Children often cannot provide more information than “my stomach hurts”; they may have symptoms of decreased school attendance due to abdominal discomfort. Older AdultsConstipation may be more common in older adults due to decreased physical mobility and oral intake. Urinary urgency, urinary frequency, urinary retention, nocturia, and urinary incontinence are also common concerns for older adults. Objective AssessmentPhysical examination of the abdomen includes inspection, auscultation, palpation, and percussion. Note that the order of physical assessment differs for the abdominal system compared to other systems. Palpation should occur after the auscultation of bowel sounds so that accurate, undisturbed bowel sounds can be assessed. The abdomen is roughly divided into four quadrants: right upper, right lower, left upper, and left lower (see Figure 12.3). When assessing the abdomen, consider the organs located in the quadrant you are examining. Figure 12.3 Four Quadrants of the AbdomenIn preparation for the physical assessment, the nurse should create an environment in which the patient will be comfortable. Encourage the patient to empty their bladder prior to the assessment. Warm the room and stethoscope to decrease tensing during assessment. InspectionThe abdomen is inspected by positioning the patient supine on an examining table or bed. The head and knees should be supported with small pillows or folded sheets for comfort and to relax the abdominal wall musculature. The patient’s arms should be at their side and not folded behind the head, as this tenses the abdominal wall. Ensure the patient is covered adequately to maintain privacy, while still exposing the abdomen as needed for a thorough assessment. Visually examine the abdomen for overall shape, masses, skin abnormalities, and any abnormal movements.
AuscultationAuscultation, or the listening, of the abdomen, follows inspection for more accurate assessment of bowel sounds. Use a warmed stethoscope to assess the frequency and characteristics of the patient’s bowel sounds, which are also referred to as peristaltic murmurs. Begin your assessment by gently placing the diaphragm of your stethoscope on the skin in the right lower quadrant (RLQ), as bowel sounds are consistently heard in that area. Bowel sounds are generally high-pitched, gurgling sounds that are heard irregularly. Move your stethoscope to the next quadrant in a clockwise motion around the abdominal wall. It is not recommended to count abdominal sounds because the activity of normal bowel sounds may cycle with peak-to-peak periods as long as 50 to 60 minutes. The majority of peristaltic murmurs are produced by the stomach, with the remainder from the large intestine and a small contribution from the small intestine. Because the conduction of peristaltic murmur is heard throughout all parts of the abdomen, the source of peristaltic murmur is not always at the site where it is heard. If the conduction of peristaltic sounds is good, auscultation at a single location is considered adequate. may indicate bowel obstruction or gastroenteritis. Sometimes you may be able to hear a patient’s bowel sounds without a stethoscope, often described as “stomach growling” or . This is a common example of hyperactive sounds. may be present with constipation, after abdominal surgery, peritonitis, or paralytic ileus. As you auscultate the abdomen, you should not hear vascular sounds. If heard, this finding should be reported to the health care provider., PalpationPalpation, or touching, of the abdomen involves using the flat of the hand and fingers (not the fingertips) to detect palpable organs, abnormal masses, or tenderness (see Figure 12.4 ). When palpating the abdomen of a patient reporting abdominal pain, the nurse should palpate that area last. Light palpation is primarily used by bedside nurses to assess for musculature, abnormal masses, and tenderness. Deep palpation is a technique used by advanced practice clinicians to assess for enlarged organs. Lightly palpate the abdomen by pressing into the skin about 1 centimeter beginning in the RLQ. Continue to move around the abdomen in a clockwise manner. Palpate the bladder for distention. Note the patient response to palpation, such as pain, guarding, rigidity, or rebound tenderness. refers to voluntary contraction of the abdominal wall musculature, usually the result of fear, anxiety, or the touch of cold hands. refers to involuntary contraction of the abdominal musculature in response to peritoneal inflammation, a reflex the patient cannot control. is another sign of peritoneal inflammation or peritonitis. To elicit rebound tenderness, the clinician maintains pressure over an area of tenderness and then withdraws the hand abruptly. If the patient winces with pain upon withdrawal of the hand, the test is positive.,, Note: If the patient has a Foley catheter in place, additional assessments are included in the “Facilitation of Elimination” chapter. Figure 12.4 Light Palpation of the AbdomenPercussionYou may observe advanced practice nurses and other health care providers percussing the abdomen to obtain additional data. Percussing can be used to assess the liver and spleen or to determine if costovertebral angle (CVA) tenderness is present, which is related to inflammation of the kidney.
See Table 12.3b for a comparison of expected versus unexpected findings when assessing the abdomen. Table 12.3b Expected Versus Unexpected Gastrointestinal and Genitourinary Assessment Findings
Stool dark in color and tarry in consistency. Urination every hour or two. An intense urge to urinate that can lead to urinary incontinence. Involuntary leakage of urine. Convex or bulging appearance. An expansion of the abdomen caused by the accumulation of air or fluid. Patients often report “feeling bloated”. White or silver markings from stretching of the skin. Increased peristaltic activity; may be related to diarrhea, obstruction, or digestion of a meal. Hyperperistalsis, often referred to as “stomach growling”. Decreased peristaltic activity; may be related to constipation, following abdominal surgery, or with an ileus. Voluntary contraction of abdominal wall musculature; may be related to fear, anxiety or presence of cold hands. Involuntary contraction of the abdominal musculature in response to peritoneal inflammation. Pain when hand is withdrawn during palpation. |