Chapter 26

The most important cue for the nurse to recognize is that the patient is unable to void. This is concerning since the patient has been in the hospital for over six hours at this point.

Since the patient was given a diuretic six hours prior, the nurse would have expected the patient to void by now. This is concerning for urinary retention.

Patients with urinary retention may be asymptomatic, so it can be difficult to assess for. However, the nurse could assess for bladder distension on palpation, lower abdominal discomfort, and an inability to initiate or sustain a stream of urine.

First, the nurse should report the findings to the provider. It is likely the provider will order a bladder scan to measure how much urine is in the bladder. This is done with a bladder scanner (ultrasound) at the bedside by the nurse.

The nurse should anticipate that the provider will order a straight catheterization to empty the bladder. The provider might order an indwelling Foley catheter if the patient requires strict input and output documentation, or if the patient’s condition worsens.

If performing straight catheterization, the nurse would expect to remove 500 mL of urine from the patient. If less is excreted, there may have been a problem with the catheter that warrants follow-up. The patient should also report less abdominal discomfort and lower abdomen distension if the interventions were effective.