Clinical Findings

Neuro: Frustration, anxiety, difficulty sleeping.

Resp: Unremarkable.

CV: Unremarkable.

Skin: Unremarkable.

GI/GU: Difficulty initiating stream, inability to void, feeling of not emptying bladder, bladder distention, and spasm, voiding in frequent, small amounts.

MS: Lower abdominal pain.

Possible Causes: Obstruction in bladder or urethra, neurogenic bladder (secondary to CVA, spinal trauma/tumor, multiple sclerosis, neuropathy), long period of inactivity or bedrest, surgery, low fluid intake, benign prostatic hyperplasia, kidney stones, UTI, medications including antihypertensives, antihistamines (can be OTC), anticholinergics, sedatives, spinal anesthesia.

Collaborative Management

• Palpate bladder to assess distention and tenderness.
• Assist Pt to assume natural voiding position if possible (stand male Pts; assist females to commode or raise head of bed when using bedpan).
• Implement triggers to help initiate stream (Credé’s maneuver, running water, pouring warm water over perineum).
• If Pt still cannot empty bladder, obtain bladder scan to assess amount of residual urine and check for PRN straight catheter order. If ordered, catheterize Pt; note amount and characteristics of urine. Remove catheter. Do not catheterize Pt if suspected pelvic trauma or blood at meatus.
• Notify HCP if residual volume excessive (>500 mL).
• Establish IV access and administer IVF as ordered.
• Review Pt history to determine possible cause of retention (recent abdominal surgery; medications known to cause retention such as antispasmodic, opioids, antidepressants and others; neuromuscular disease, back injury, prostate enlargement among others).
• Assess voiding patterns, recent urological procedure or procedure requiring anesthesia, medications, history of benign prostatic hyperplasia (BPH), urethral stricture, history of incontinence.
• Assess temperature; recent white blood cell count, and urinalysis.
• Assess I&O, daily weights, mucous membrane moistness, VS.
• Evaluate subsequent attempts to void and postvoid residual (PVR).
• Collect sterile urine sample.
• Initiate timed voiding and obtain PVR until PVR <100 mL.
• Place indwelling urinary catheter if ordered.
• Teach self-intermittent catheterization.