Alteration in Patterns of Urinary Elimination: Retention

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