NR 305 Week 6 Urinary Retention Case Analysis Example

Case Study Analysis: Acute Urinary Retention in a 71-Year-Old Man After an Over-the-Counter Sleep Aid

Student Name

College of Nursing, Chamberlain University

NR 305: Health Assessment for the Practicing RN

Instructor Name

Month Day, Year

Case Study Analysis: Acute Urinary Retention in a 71-Year-Old Man After an Over-the-Counter Sleep Aid

Findings Restated Briefly

Person: Mr. B., 71, retired, brought to the emergency department by his wife at 0600.

Reported: Unable to pass urine since the previous evening despite a strong urge; increasing lower abdominal pain overnight. For about two years, a weak stream, hesitancy and getting up twice a night to urinate. Three nights ago started a bedtime sleep product bought at the pharmacy, diphenhydramine 50 milligrams, because of trouble sleeping. Also took an over-the-counter cold tablet containing pseudoephedrine yesterday. No fever, no blood in the urine noticed, no back pain.

Observed: Restless, holding his lower abdomen. Temperature 37.0 degrees Celsius, pulse 104, blood pressure 162/94, respirations 20.

Examination: Lower abdomen visibly rounded above the pubic bone; a firm, tender midline mass rising to about halfway between the pubic bone and the umbilicus, dull to percussion. Bladder scan: estimated volume 880 milliliters.

After catheterization: 910 milliliters of clear yellow urine drained; pain relieved within minutes.

What Falls Outside Expected Values

Four findings sit outside the expected range for a resting man his age. The first is the bladder volume: a bladder scan estimate of 880 milliliters, confirmed by 910 milliliters drained, is far above the volume at which most adults feel a strong urge to void and consistent with acute retention (Selius & Subedi, 2008). The second is the palpable, percussible suprapubic mass, which in this context is the distended bladder. The third and fourth are a raised pulse and blood pressure, which fell after drainage and are best explained by pain and distress rather than by a separate cardiovascular problem, although they should be rechecked. The two-year history of weak stream, hesitancy and nocturia is not an acute abnormality, but it describes lower urinary tract symptoms that, in a man of 71, commonly reflect benign enlargement of the prostate (Jarvis & Eckhardt, 2024).

The Mechanism Behind the Findings

The case supplies two contributing mechanisms, and they act together. The first is a partial obstruction that was already present: an enlarged prostate narrows the urethra, so the bladder must contract more forcefully to empty, and a man with long-standing symptoms has been voiding against resistance for years. The second is two medications taken in the days before the event. Diphenhydramine is an antihistamine with strong anticholinergic effects; by blocking acetylcholine at muscarinic receptors in the bladder wall, it weakens contraction of the detrusor muscle, which is the force that empties the bladder. Pseudoephedrine is a decongestant that stimulates alpha-adrenergic receptors, which increases the tone of smooth muscle at the bladder neck and in the prostate, tightening the outlet. The result is a weaker pump pushing against a tighter outlet in a system that was already partly obstructed. Selius and Subedi (2008) list anticholinergic and sympathomimetic medications among the common precipitants of acute retention, particularly in men with prostatic enlargement.

The timing supports this explanation. Mr. B. had lived with symptoms for two years without retention, began the sleep aid three nights before the event and added the decongestant the day before. The analysis does not claim certainty that the medications caused the retention, but it names them as the most likely precipitants in the case supplied.

What the Case Does Not Settle

Several questions remain open and would need further assessment. The case does not include a prostate examination, urinalysis, kidney function tests or a post-void residual after the catheter is removed, all of which would help determine whether the retention is likely to recur and whether the kidneys were affected. It does not say whether Mr. B. has other conditions, such as diabetes or a neurologic disorder, that could affect bladder function. And it does not describe his sleep problem, which prompted the medication in the first place and will persist unless addressed. The analysis therefore stops at the most likely explanation for the acute event.

How the Assessment Would Be Extended

If the nurse were continuing Mr. B.'s assessment after drainage, several additions would sharpen the picture. A focused history of his lower urinary tract symptoms using a structured symptom score would document their severity over time and give his primary care clinician a baseline. Intake and output for the next several hours, including the volume of each void once the catheter is removed and a bladder scan after voiding, would show whether he is emptying adequately without the medications. Assessment for signs of complications of acute retention would include checking for blood in the urine after rapid drainage, which can occur, and watching for a sudden increase in urine output from a kidney that had been under back pressure. A cognitive screen would matter too, because anticholinergic medications can cause confusion in older adults, and a man who did not recognize over-the-counter products as medications may need his wife included in teaching. Finally, a full medication reconciliation with the pharmacist would identify any other anticholinergic products in his home, such as allergy tablets or other sleep aids, that could repeat the problem.

Each of these extends the assessment in the direction the analysis points, toward preventing a second episode, rather than toward a broader examination that the case does not call for.

Nursing Implications

Three nursing implications follow from the analysis. First, medication history must include over-the-counter products. Mr. B. did not think of a sleep aid or a cold tablet as medications, and a history that asked only about prescriptions would have missed the precipitants. Second, older adults should be taught to avoid first-generation antihistamines; the American Geriatrics Society Beers Criteria name diphenhydramine as a drug to avoid in older adults because of its anticholinergic effects, including urinary retention, and advise particular caution in men with lower urinary tract symptoms or prostatic enlargement (American Geriatrics Society Beers Criteria Update Expert Panel, 2023). Third, his sleep complaint deserves assessment and nondrug strategies, such as a consistent sleep schedule and limiting evening fluids and caffeine, so that he does not reach for another sleep aid with the same effect. Before discharge, Mr. B. and his wife should be able to name the two products he should avoid and the symptoms that should bring him back: inability to pass urine, a weak stream that worsens or fever. The clinic nurse should phone him within 48 hours of going home to confirm that he is voiding well.

References

American Geriatrics Society Beers Criteria Update Expert Panel. (2023). American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 71(7), 2052-2081. https://doi.org/10.1111/jgs.18372

Jarvis, C., & Eckhardt, A. (2024). Physical examination and health assessment (9th ed.). Elsevier.

Selius, B. A., & Subedi, R. (2008). Urinary retention in adults: Diagnosis and initial management. American Family Physician, 77(5), 643-650.