NURSING DIAGNOSIS: Urinary Elimination, impaired/Urinary Retention [acute]
May be related to
- Mechanical trauma, surgical manipulation, presence of local tissue edema, hematoma
- Sensory/motor impairment: nerve paralysis
Possibly evidenced by
- Sensation of bladder fullness, urgency
- Small, frequent voiding or absence of urinary output
- Overflow incontinence
- Bladder distension
Desired Outcomes
Urinary Elimination (NOC)
- Empty bladder regularly and completely.
6 Hysterectomy Nursing Care Plan (NCP)
- Low Self-Esteem — Hysterectomy Nursing Care Plan (NCP)
- Impaired Urinary Elimination — Hysterectomy Nursing Care Plan (NCP)
- Constipation/Diarrhea — Hysterectomy Nursing Care Plan (NCP)
- Ineffective Tissue Perfusion — Hysterectomy Nursing Care Plan (NCP)
- Sexual Dysfunction — Hysterectomy Nursing Care Plan (NCP)
- Knowledge Deficit — Hysterectomy Nursing Care Plan (NCP)
Impaired Urinary Elimination — Hysterectomy Nursing Care Plan (NCP): Nursing Interventions & Rationale
| Nursing Interventions | Rationale |
| Note voiding pattern and monitor urinary output. | May indicate urinary retention if voiding frequently in small/insufficient amounts |
| Palpate bladder. Investigate reports of discomfort, fullness, inability to void. | Perception of bladder fullness, distension of bladder above symphysis pubis indicates urinary retention. |
| Provide routine voiding measures, e.g., privacy, normal position, running water in sink, pouring warm water over perineum. | Promotes relaxation of perineal muscles and may facilitate voiding efforts. |
| Provide/encourage good perianal cleansing and catheter care (when present). | Promotes cleanliness, reducing risk of ascending urinary tract infection (UTI). |
| Assess urine characteristics, noting color, clarity, odor. | Urinary retention, vaginal drainage, and possible presence of intermittent/indwelling catheter increase risk of infection,especially if patient has perineal sutures. |
| Catheterize when indicated/per protocol if patient is unable to void or is uncomfortable. | Edema or interference with nerve supply may cause bladder atony/urinary retention requiring decompression of the bladder.Note: Indwelling urethral or suprapubic catheter may be inserted intraoperatively if complications are anticipated. |
| Decompress bladder slowly. | When large amount of urine has accumulated, rapid bladderdecompression releases pressure on pelvic arteries, promoting venous pooling. |
| Maintain patency of indwelling catheter; keep drainage tubing free of kinks. | Promotes free drainage of urine, reducing risk of urinary stasis/retention and infection. |
| Check residual urine volume after voiding as indicated. | May not be emptying bladder completely; retention of urine increases possibility for infection and is uncomfortable/painful. |