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What can a nurse use to measure the post void residual volume in a patient with urinary retention select all that apply?

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Use this nursing diagnosis guide to help you create nursing interventions for impaired urinary elimination nursing care plan.

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    • Goals and Outcomes
    • Nursing Assessment
    • Nursing Interventions
  • Recommended Resources
  • See also

Goals and Outcomes

The following are the common goals and expected outcomes for impaired urinary elimination:

  • Patient demonstrates behaviors and techniques to prevent retention/urinary infection.
  • Patient identifies the cause of incontinence.
  • Patient maintains balanced I&O with clear, odor-free urine, free of bladder distension/urinary leakage.
  • Patient provides rationale for treatment.
  • Patient verbalizes understanding of the condition.

Nursing Assessment

Focus assessment is necessary in order for the nurse to determine whether incontinence is transient, in response to an acute condition, or established in response to various chronic neural or genitourinary conditions.

AssessmentRationales
Assess voiding pattern (frequency and amount). Compare urine output with fluid intake. Note specific gravity. Identifies characteristics of bladder function (effectiveness of bladder emptying, renal function, and fluid balance). Note: Urinary complications are a major cause of mortality.
Palpate for bladder distension and observe for overflow. Bladder dysfunction is variable but may include loss of bladder contraction and inability to relax urinary sphincter, resulting in urine retention and reflux incontinence. Note: Bladder distension can precipitate autonomic dysreflexia.
Note reports of urinary frequency, urgency, burning, incontinence, nocturia, and size or force of urinary stream. Palpate bladder after voiding. This provides information about degree of interference with elimination or may indicate bladder infection. Fullness over bladder following void is indicative of inadequate emptying or retention and requires intervention.
Review drug regimen, including prescribed, over-the-counter (OTC), and street. A number of medications such as some antispasmodics, antidepressants, and narcotic analgesics; OTC medications with anticholinergic or alpha agonist properties; or recreational drugs such as cannabis may interfere with bladder emptying.
Assess the availability of toileting facilities. Patients may need a bedside commode if mobility limitations interfere with getting to the bathroom.
Assess the patient’s usual pattern of urination and occurrence of incontinence. Many patients are incontinent only in the early morning when the bladder has stored a large urine volume during sleep.

Common Assessment Findings

  • Urgency
Strong desire to void my be caused by inflammations or infections in the bladder or urethra
  • Dysuria
Painful or difficult voiding
  • Frequency
Voiding that occurs more than usual when compared with the person’s regular pattern or the generally accepted norm of voiding once every 3 to 6 hours
  • Hesitancy
Undue delay and difficulty in initiating voiding
  • Polyuria
A large volume of urine or output voided at any given time
  • Oliguria
A small volume of urine or output between 100 to 500 mL/24 hr
  • Anuria
Lack of urine production
  • Nocturia
Excessive urination at night interrupting sleep
  • Hematuria
RBCs in the urine

Nursing Interventions

The following are the therapeutic nursing interventions for impairment in urinary elimination:


InterventionsRationales
Begin bladder retraining per protocol when appropriate (fluids between certain hours, digital stimulation of trigger area, contraction of abdominal muscles, Credé’s maneuver). Timing and type of bladder program depend on type of injury (upper or lower neuron involvement). Note: Credé’s maneuver should be used with caution because it may precipitate autonomic dysreflexia.
Encourage adequate fluid intake (2–4 L per day), avoiding caffeine and use of aspartame, and limiting intake during late evening and at bedtime. Recommend use of cranberry juice/vitamin C. Sufficient hydration promotes urinary output and aids in preventing infection. Note: When patient is taking sulfa drugs, sufficient fluids are necessary to ensure adequate excretion of drug, reducing risk of cumulative effects. Note: Aspartame, a sugar substitute (e.g., Nutrasweet), may cause bladder irritation leading to bladder dysfunction.
Observe for cloudy or bloody urine, foul odor. Dipstick urine as indicated. Signs of urinary tract or kidney infection that can potentiate sepsis. Multistrip dipsticks can provide a quick determination of pH, nitrite, and leukocyte esterase suggesting presence of infection.
Promote continued mobility. This decreases risk of developing UTI.
Cleanse perineal area and keep dry. Provide catheter care as appropriate. Proper perineal hygiene decreases risk of skin irritation or breakdown and development of ascending infection.
Recommend good hand washing and proper perineal care. Handwashing and perineal care reduce skin irritation and risk of ascending infection.
Refer to urinary continence specialist as indicated. Collaboration with specialists is helpful for developing individual plan of care to meet patient’s specific needs using the latest techniques, continence products.
Administer medications as indicated:
Oxybutynin (Ditropan), propantheline (Pro-Banthine), hyoscyamine sulfate (Cytospaz-M), flavoxate hydrochloride (Urispas), tolterodine (Detrol). These drugs reduce bladder spasticity and associated symptoms of frequency, urgency, incontinence, nocturia.
Catheterize as indicated. Catheterization may be necessary as a treatment and for evaluation if patient is unable to empty bladder or retains urine.
Teach self-catheterization and instruct in use and care of indwelling catheter. This method helps patient maintain autonomy and encourages self-care. Indwelling catheter may be required, depending on patient’s abilities and degree of urinary problem.
Obtain periodic urinalysis and urine culture and sensitivity as indicated. These tests monitor renal status. Colony count over 100,000 indicates presence of infection requiring treatment.
Administer anti-infective agents as necessary:
Nitrofurantoin macrocrystals. (Macrodantin); co-trimoxazole (Bactrim, Septra); ciprofloxacin (Cipro); norfloxacin (Noroxin). Bacteriostatic agents inhibit bacterial growth and destroy susceptible bacteria. Prompt treatment of infection is necessary to prevent serious complications of sepsis/shock.
Urinary Catheterization:
Monitor BUN, creatinine, white blood cell (WBC) count. These reflect renal function and identify complications.
Keep bladder deflated by means of indwelling catheter initially. Begin intermittent catheterization program when appropriate. Indwelling catheter is used during acute phase for prevention of urinary retention and for monitoring output. Intermittent catheterization may be implemented to reduce complications usually associated with long-term use of indwelling catheters. A suprapubic catheter may also be inserted for long-term management.
Measure residual urine via postvoid catheterization or ultrasound. Measuring residual urine via postvoid catheterization or ultrasound is helpful in detecting presence of urinary retention and effectiveness of bladder training program. Note: Use of ultrasound is noninvasive, reducing risk of colonization of bladder.
Refer for further evaluation for bladder and bowel stimulation. Clinical research is being conducted on the technology of electronic bladder control. The implantable device sends electrical signals to the spinal nerves that control the bladder and bowel. Early results look promising.
More interventions:
Teach Kegel exercises. These exercises improve pelvic floor muscle tone and urethrovesical junction sphincter tone.
Educate patient about the importance of limiting intake of alcohol and caffeine. These chemicals are known to be bladder irritants. They can increase detrusor overactivity.

Recommended nursing diagnosis and nursing care plan books and resources.

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy.

  • Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
    An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use.
  • Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
    A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively.
  • NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
    The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales.
  • Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
    Another great nursing care plan resource that is updated to include the recent NANDA-I updates.
  • Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
    Useful for creating nursing care plans related to mental health and psychiatric nursing.
  • Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
    Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans.
  • Maternal Newborn Nursing Care Plans (3rd Edition)
    If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you.
  • Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
    An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023.
  • All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
    Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.

See also

Other recommended site resources for this nursing care plan:

  • Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
    Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
  • Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
    Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.

Gil Wayne graduated in 2008 with a bachelor of science in nursing. He earned his license to practice as a registered nurse during the same year. His drive for educating people stemmed from working as a community health nurse. He conducted first aid training and health seminars and workshops for teachers, community members, and local groups. Wanting to reach a bigger audience in teaching, he is now a writer and contributor for Nurseslabs since 2012 while working part-time as a nurse instructor. His goal is to expand his horizon in nursing-related topics. He wants to guide the next generation of nurses to achieve their goals and empower the nursing profession.

How is post void residual urine measured?

Post void Residual Urine Post-void residual (PVR) urine is defined as the amount of urine left in the bladder at the end of micturition. It can be measured by catheterization or non-invasively by ultrasonography. PVR varies in a given individual, hence multiple measurements are often necessary.

What device is used to measure urine residuals?

Evaluating for post-void residual is typically performed using ultrasound, a bladder scanner, or with a urinary catheter.

What can a nurse use to measure the Postvoid residual?

Nurses typically receive orders to measure post-void residual amounts when urinary retention is suspected. Post-void residual measurements are taken after a patient has voided by using a bladder scanner or inserting a straight urinary catheter to determine how much urine is left in the bladder.

What are the nursing measures for urinary retention?

Nursing Interventions for Urinary Retention.
Provide patient with routine voiding measures including privacy, normal voiding positions, sound of running water, etc. ... .
Encourage/provide appropriate perineal cleansing. ... .
Provide appropriate catheter care when catheter is present. ... .
Catheterize patient when indicated..

nurse measure post void residual volume patient urinary retention select apply Post void residual

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