Alteration in Patterns of Urinary Elimination: Retention

Published on Saturday March 10th , 2007

Alteration in Patterns of Urinary Elimination: Retention

(_)Actual (_) Potential

**Related To:**
*[Check those that apply]*
(_) Anxiety (_) Fecal impaction (_) Flaccid bladder (_) Medications (_) Packing (_) Stones (_) Weak or absent sensory and/or motor impulses (_) Other:_____________________________ ____________________________________ ____________________________________

**As evidenced by:**
*[Check those that apply]*
Major: (Must be present)	(_) Bladder distention (not related to acute, reversible etiology). (_) Distention with small frequent voids or dribbling (overflow incontinence). (_) 100 ml or more residual of urine.
Minor: (May be present)	(_) The individual states that it feels as though the bladder is not empty after voiding.

Date &
Sign.

Plan and Outcome
[Check those that apply]

Target
Date:

Nursing Interventions
[Check those that apply]

Date
Achieved:

The patient will:

(_) Void in the amount of:
__________

(_) Have urine resicual less than 30cc.

(_) Verbalize knowledge of signs and symptoms of infection.

(_) Other:

(_) Palpate bladder for distention q___ hours or after each void.

(_) Monitor I & O.

(_) Attempt to stimulate relaxation of urethral sphincter by:

running water
providing warm water for patient to place hand/fingers in
other:

(_) Provide privacy.

(_) Intermittent straight cath q___ hours per physician order.

(_) Other:________________
________________________
________________________
________________________

__________________________
Patient/Significant other signature

__________________________
RN signature

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