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Alteration in Patterns of Urinary Elimination: Retention
Alteration in Patterns of Urinary Elimination: Retention
(_)Actual (_) Potential
| (_)
Anxiety (_) Fecal impaction (_) Flaccid bladder (_) Medications (_) Packing (_) Stones (_) Weak or absent sensory and/or motor impulses (_) Other:_____________________________ ____________________________________ ____________________________________ |
| 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:
(_) Provide privacy. (_) Intermittent straight cath q___ hours per physician order. (_)
Other:________________ |
__________________________
Patient/Significant other signature
__________________________
RN signature