NURSING CARE PLAN

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

ANALYSIS

Short
SUBJECTIVE:  Ascertain the client’s  Comparison of the past and Goals are met.
 “2 buwan ko ng Frequent urination previous pattern of current situation will lead to Patient’s current
nararanasan na means having an elimination for comparison know if the interventions done temperature:
maya’t maya urge to pass urine with current situation. are effective or not. 36.5*C. Patient
iihi.
mahapdi,
Minsan

minsan naman
more often than
usual. It can disrupt
one’s normal
Term 
Note reports of problems.

Determine the client’s  Fullness over bladder

also
successfully
verbalized

Goals:
hindi” as routine, interrupt usual daily fluid intake. following void is indicative of understanding
verbalized by the sleep cycle, and Note the condition of skin inadequate emptying or of current
the patient. it can be a sign of and mucous membrane. retention and requires condition.
OBJECTIVE: an underlying intervention. Elimination
 Dysuria
 Bladder
infection
medical condition.
Fever and dysuria
might possibly be a
After Observe
 These are signs of urinary
tract or kidney infection that
can potentiate sepsis.
pattern returned
back to normal,
no signs of pain

2-4
 Dehydration, sign of infection. when urinating
dry lips
 V/S taken:
T: 38.5*C
Due to excessive
loss of water from
the body,
for  This provides information
about degree of interference
with elimination or may
and pt. did not
have signs of
hydration.
BP:
mmHg
RR:
120/70

27
dehydration
also
Lifestyle-based
may
occur. hours cloudy,
indicate bladder infection,

 Sufficient hydration promotes

Health teaching
was successful,
pt.

of
cycles/min causes include urinary output and aids in demonstrated
PR:
beats/min
87 drinking a lot of
fluids, especially if
they contain
or preventing infection, proper hygiene
and verbalized
its importance.
caffeine or alcohol.
NURSING DIAGNOSIS At night, this can
interrupt the sleep
nursin bloody  Proper perineal hygiene
decreases risk of skin irritation

g
Impaired urinary cycle with urges to or breakdown and
elimination r/t frequent urinate. Frequent
urination as evidenced urination can also
by dysuria
urine development of ascending
infection..

interve
develop as a habit.

with
ntions, foul
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 the odor
client
 Observe for cloudy, or
bloody urine with foul
odor.

can  Investigate reports of pain,

noting location, duration,
and intensity.

verbali  Encourage adequate fluid

intake 2-4 liters per day if
tolerated, avoiding

ze caffeine, and limiting

intake during late evenings
& bedtime.

unders Health
tandin teachin
g of g in
the regard
conditi to the
on importa
Short nce of
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 Term proper
Goals: hygiene
After such as
2-4 hand
hours washing
of and
nursin perineal
g care, as
interve well as
ntions, being
the hydrate
client d
Health teaching in regard
to the importance of proper
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 can
hygiene such as hand
washing and perineal care,
as well as being hydrated

verbali
ze
unders
tandin
g of
the
conditi
on
STG:
After 2-4 hrs. of nursing
interventions, the client will:
 verbalize
understanding of the
condition.
 feel no signs of fever.

LTG:
After 2-3 days of nursing
intervention, the client will:
 Achieve normal
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 elimination pattern
and participate in
measures to correct it.
 Have relief from the
occasional pain from
urinating.
 Proper hydration will
be observed.

CRISTOBAL, STEVIEN C. 3BSN11

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