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]
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.
May be present)
(_) The individual states that it feels as though the bladder is not empty after voiding.


Date &
Plan and Outcome
[Check those that apply]
Nursing Interventions
[Check those that apply]
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:________________


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