Nursing Diagnosis: Urinary retention Application of NANDA, NOC, NIC | Kumpulan Asuhan Keperawatan

Nursing Diagnosis: Urinary retention Application of NANDA, NOC, NIC

March 8th, 2012 0 Comments

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Nursing Diagnosis: Urinary retention
Mikel Gray

NANDA Definition:Incomplete emptying of the bladder

Defining Characteristics: Measured urinary residual >150 to 200 ml or 25% of total bladder capacity; obstructive lower urinary tract symptoms (poor force of stream, intermittency of stream, hesitancy of urination, postvoiding dribbling, feelings of incomplete bladder emptying); irritative lower urinary tract symptoms (urgency to urinate, diurnal frequency of urination, nocturia); overflow incontinence (dribbling urine loss caused when intravesical pressure overwhelms the sphincter mechanism)

Related Factors:

·         Bladder outlet obstruction: benign prostatic hyperplasia, prostate cancer, prostatitis, urethral stricture, bladder neck dyssynergia, bladder neck contracture, detrusor striated sphincter dyssynergia, obstructing cystocele or urethral distortion, urethral tumor, urethral polyp, posterior urethral valves, postoperative complication
·         Deficient detrusor contraction strength: sacral level spinal lesions, cauda equina syndrome, peripheral polyneuropathies, herpes zoster or simplex affecting sacral nerve roots, injury or extensive surgery causing denervation of pelvic plexus, medication side effect, complication of illicit drug use, impaction of stool
NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
·         Urinary Elimination
·         Urinary Continence
Client Outcomes
·         Completely and regularly eliminates urine from the bladder; measured urinary residual volume is <150 to 200 ml or 25% of total bladder capacity (voided volume plus urinary residual volume)
·         Correction or relief from obstructive symptoms
·         Correction or alleviation of irritative symptoms
·         Client is free of upper urinary tract damage (renal function remains sufficient; absence of febrile urinary infections)
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
·         Urinary Catheterization
Nursing Interventions and Rationales
·         Obtain focused urinary history emphasizing character and duration of lower urinary symptoms, remembering that the presence of obstructive or irritative voiding symptoms is not diagnostic of urinary retention. Query the patient about episodes of acute urinary retention (complete inability to void) or chronic rentention (documented elevated postvoid residual volumes). A focused nursing history provides clues to the likely etiology of retention and its management (Gray, 2000a).
·     Question the client concerning specific risk factors for urinary retention including:
o  Disorders affecting the sacral spinal cord such as spinal cord injuries of vertebral levels T12 to L2, disk problems, cauda equina syndrome, tabes dorsalis
o  Acute neurological injury causing sudden loss of mobility such as spinal shock
o  Metabolic disorders such as diabetes mellitus, chronic alcoholism, and related conditions associated with polyuria and peripheral polyneuropathies
o  Heavy metal poisoning (lead, mercury) causing peripheral polyneuropathies
o  Advanced stage AIDS
o  Medications, including antispasmodics/parasympatholytics, alpha-adrenergics, antidepressants, sedatives, narcotics, psychotropic medications, illicit drugs
o  Recent surgery requiring general or spinal anesthesia
o  Bowel elimination patterns, history of fecal impaction, encopresis
Urinary retention is related to multiple factors affecting either detrusor contraction strength or urethral (bladder outlet) resistance of flow (Gray, 2000a; Kruse, Bray, deGroat, 1995; Pertek, Haberer, 1995; Anders, Goebel, 1998; Ginsberg et al, 1998).
·  Perform a focused physical assessment or review the results of a recent physical including perineal skin integrity; neurological examination, inspection, percussion, and palpation of the lower abdomen for obvious bladder distension; neurological examination including perineal skin sensation and the bulbocavernosus reflex; and vaginal vault examination in women/digital rectal examination in men. The physical assessment provides clues to the likely etiology of urinary retention and its management.
·  Determine the urinary residual volume by catheterizing the patient immediately after urination, or by obtaining a bladder ultrasound following micturition. Catheterization provides the most accurate method to determine urinary residual volume, but the procedure is invasive, carries a risk of infection, and may be uncomfortable for the patient. A bladder ultrasound is not as accurate as catheterization; nonetheless it is adequate for clinical judgments and is noninvasive (Bent, Nahhas, Mclennan, 1997; Lewis, 1995).
·  Complete a bladder log, including patterns of urine elimination, patterns of urine loss (if present), nocturia, and volume and type of fluids consumed for a period of 3 to 7 days. The bladder log provides an objective verification of urine elimination patterns and allows comparison between fluids consumed and urinary output in a 24-hour period (Nygaard, Holcomb, 2000).
·  Consult with the physician concerning eliminating or altering medications suspected of producing or exacerbating urinary retention. Medication side effects may cause or greatly exacerbate urinary retention in susceptible individuals (Gray, 2000a, 2000b).
·  Assess the severity of retention and its impact on quality of life using a symptom score such as the AUA Prostate Symptom Score (BPH Guideline Panel, 1994). A symptom allows rating of the severity of obstructive and irritative symptoms, providing baseline assessment and evaluation of the efficacy of management.
·  Teach the patient with mild to moderate obstructive symptoms to double void by urinating, resting in the rest room for 3 to 5 minutes, then making a second effort to urinate. Double voiding promotes more efficient bladder evacuation by allowing the detrusor to contract initially, then rest and contract again (Gray, 2000b).
·  Teach the patient with urinary retention and infrequent voiding to urinate by the clock. Timed or scheduled voiding may reduce urinary retention by preventing bladder overdistension (Gray, 2000b).
·  Advise the male patient with urinary retention related to benign prostatic hyperplasia (BPH) to avoid risk factors associated with acute urinary retention by doing the following:
·     Avoiding over-the-counter cold remedies containing a decongestant (alpha-adrenergic agonist)
·     Avoiding over-the-counter dietary medications (which frequently contain alpha-adrenergic agonists)
·     Discussing voiding problems with a health care provider before beginning any new prescription medications
·     After prolonged exposure to cool weather, warming the body before attempting to urinate
·     Avoiding overfilling the bladder by adhering to regular urination patterns and refraining from excessive intake of alcohol
These manageable factors predispose the patient to acute urinary retention by overdistending the bladder and compromising detrusor contraction strength, or by increasing outlet resistance (Gray, 2000b).
·  Teach the elderly male client with BPH to self-administer finasteride or an alpha-adrenergic blocking agent such as doxazosin, terazosin, or tamsulosin as directed. Provide careful instruction concerning the dosage, administration schedule, and side effects of these drugs, including possible adverse effects when multiple doses are inadvertently missed. Finasterid is a 5-alpha reductase inhibitor that reduces the risk of acute urinary retention when taken by men with BPH for a prolonged period (McConnell et al, 1998). The magnitude of obstruction associated with BPH is also reduced by routine administration of alpha-adrenergic blocking agents including tamsulosin, terazosin, or doxazosin. However, these agents must be taken regularly to reduce the risk of side effects, including postural hypotension (Narayan, Tewari, 1998; Lepor et al, 1997, 1998).
·  Teach the client who is unable to void specific strategies to manage this potential medical emergency including:
·     Drinking a cup of hot tea or coffee
·     Attempting urination in complete privacy
·     Placing the feet solidly on the floor
·     If unable to void using these strategies, taking a warm sitz bath or shower and voiding (if possible) while still in the tub or the shower
·     If unable to void within 6 hours, or if bladder distension is producing significant pain, seeking urgent or emergency care
A warm cup of coffee or tea stimulates the bladder and may promote voiding. Attempting urination in complete privacy and placing the feet solidly on the floor help relax the pelvic muscles and may encourage voiding. Warm water also stimulates the bladder and may produce voiding, while the cooling experienced by leaving the tub or shower may again inhibit the bladder (Gray, 2000b).
·  Remove the indwelling urethral catheter at midnight in the hospitalized patient to reduce the risk of acute urinary retention. Removal of indwelling catheters offers several advantages to morning removal, including a larger initial voided volume (Crowe et al, 1994) or early hospital discharge with no increased risk for readmission when compared with those undergoing morning removal (McDonald, Thompson, 1999).
·  Consult the physician about bladder stimulation in the patient with urinary retention caused by deficient detrusor contraction strength. Electrical stimulation of the bladder neck has been reported to provide beneficial results among persons with urinary retention resulting from deficient detrusor contraction strength (Moore et al, 1993).
·  Teach the client with significant urinary retention to perform self-intermittent catheterization as directed. Intermittent catheterization allows regular, complete bladder evacuation without serious complications (Horsley, Crane, Reynolds, 1982).
·  Advise the person managed by intermittent catheterization that bacteria are likely to colonize the urine but that this condition does not indicate a clinically significant urinary tract infection. Bacteriuria frequently occurs in the patient managed by intermittent catheterization; only symptoms producing infections warrant treatment (Maynard, Diokno, 1984).
·  Insert an indwelling catheter for the individual with urinary retention who is not a suitable candidate for intermittent catheterization. An indwelling catheter provides continuous drainage of urine; however, the risk of serious urinary complications with prolonged use are significant (Anson, Gray, 1993; Stickler, Zimakoff, 1994).
·  Advise the person managed by an indwelling catheter that bacteria in the urine is an almost universal finding after the catheter has remained in place for a period of weeks or months and that only symptomatic infections warrant treatment. The indwelling catheter is associated with frequent bacterial colonization. Most bacteriuria does not produce significant infection and attempts to eradicate bacteriuria often produce subsequent morbidity because resistant bacteria are encouraged to reproduce while more easily managed strains are eradicated (Moore, Rayome, 1995; White, Ragland, 1995).
Geriatric
·         Aggressively assess the elderly client for urinary retention, particularly the client with dribbling urinary incontinence, urinary tract infection, or related conditions. Elderly women (and men) may experience retention of urine of 1500 ml or more with few or no apparent symptoms; a urinary residual volume and related assessments are necessary to determine the presence of retention in this population (Williams, Wallhagen, Dowling, 1993)
·         Assess the elderly client for impaction when urinary retention is documented or suspected. Impaction is a common and reversible factor associated with urine loss and retention among elderly persons (Urinary Incontinence Guideline Panel, 1996).
·         Assess the elderly male client for retention related to BPH or prostate cancer. The incidence of urinary retention related to BPH and prostate cancer increase with aging (BPH Guideline Panel, 1994).
Client/Family Teaching
·         Teach techniques for intermittent catheterization including use of clean rather than sterile technique, washing using soap and water or a microwave technique, and reuse of the catheter.
·         Teach the person with an indwelling catheter to assess the tube for patency, maintain the drainage system below the level of the symphysis pubis, and to routinely cleanse the bedside bag.
·         Teach the person managed by an indwelling catheter or intermittent catheterization the symptoms of a significant urinary infection, including hematuria, acute onset incontinence, dysuria, flank pain, or fever.
 

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