Initiate interventions for urinary retention

Nursing interventions for urinary retention focus on promoting bladder emptying and relieving the
obstruction or underlying causes. These interventions may include assisting the patient with toileting
or providing bladder stimulation techniques, such as warm water sitz baths or applying a warm
compress to the lower abdomen, encouraging increased fluid intake to promote urinary flow,
monitoring the patient’s intake and output, collaborating with the healthcare team to explore
medications or interventions that can help stimulate bladder contractions, and ensuring proper
catheter care and management if necessary

1. Start the following techniques to facilitate voiding:

1.1. Promote fluids, if not contraindicated. Unless medically restricted, fluid intake should be at least
1500 mL/24 hr.

1.2. Encourage regular intake of cranberry juice. Cranberry juice keeps the acidity of urine. This aids
in preventing infection.

1.3. Place the patient in an upright position to facilitate successful voiding. An upright position on a
commode or in bed on a bedpan increases the patient’s voiding success through the force of gravity.

1.4. Provide privacy. Privacy aids in the relaxation of urinary sphincters.

1.5. Encourage the patient to void at least every 4 hours. Voiding at frequent intervals empties the
bladder and reduces the risk of urinary retention.

1.6. Allow the patient to listen to the sound of running water, dip hands in warm water/pour
lukewarm water over the perineum. These actions promote urination.

1.7. Offer fluids before voiding. Sufficient urine volume is necessary to stimulate the voiding reflex.

1.8. Perform Credé’s maneuver. Credé’s method (pressing down over the bladder with the hands)
enhances urinary bladder pressure, and this consequently induces relaxation of the sphincter to
allow voiding.

2. Decompress bladder moderately.

Once a huge amount of urine has accumulated, fast urinary bladder decompression produces
pressure on pelvic arteries and may cause venous pooling.

3. Encourage patient to take bethanechol (Urecholine) as indicated.

Bethanechol stimulates parasympathetic nervous system to release acetylcholine at nerve endings

and to enhance the tone and amplitude of contractions of smooth muscles of the urinary bladder.

4. If incomplete emptying is presumed, catheterize and measure residual urine.

Urinary retention predisposes the patient to urinary tract infection and may be a sign of the need for
an intermittent catheterization program.

5. Keep indwelling catheter patent; maintain drainage tubing kink-free.

These provide free drainage of urine, decreasing the possibility of urinary stasis or retention and
infection.

6. Secure the catheter of the male patient to the abdomen and thigh for the female.

This technique prevents urethral fistula and avoids accidental dislodgement.

7. Educate the patient on the importance of meatal care. This should be done twice daily with soap
and water and dry thoroughly.

Meatal care reduces the risk for infection.

8. Discuss the importance of adequate fluid intake.

Increased fluid stimulates voiding and decreases the risk of urinary tract infections.

9. Inform the patient and significant other to observe the different signs and symptoms of bladder
distention like reduced or lack of urine, urgency, hesitancy, frequency, distention of lower abdomen,
or discomfort.

Knowledge of the signs and symptoms allows the patient, significant other, or caregiver to recognize
them and seek treatment.

10. Instruct the patient and significant other to observe the different signs and symptoms of urinary
tract infection like chills and fever, frequent urination or concentrated urine, and abdominal or back
pain.

Knowledge of the signs and symptoms allows the patient, significant other, or caregiver to recognize
them and seek treatment.

11. Teach the patient to achieve an upright position on the toilet if possible.

An upright position is the natural position for voiding and uses the force of gravity.

12. Teach the patient about possible surgical treatment as needed.

If prostate enlargement is involved, surgery may be required. Women may need surgery to lift a
fallen bladder or rectum. A urethral stent may be required to treat a urethral stricture.

13. Suggest a sitz bath as ordered.

A sitz bath supports muscle relaxation, reduces edema, and may improve voiding attempts.