NURSING CARE PLAN

DIAGNOSIS: Impaired Urinary elimination related to urinary retention as evidenced by decrease urinary output
ASSESSMEN PLANNING NURSING RATIONALE EVALUATION
T INTERVENTION
SUBJECTIVE At the end of 8 hours of INDEPENDENT: At the end of 8 hours
DATA: nursing intervention, the 1. Determine 1. For further evaluation and of nursing
“Makaihi ko patient will: pathology of treatment options to discover interventions, the
pero ginagmay bladder specifics of individual goals were met as
ra, tas halos dili dysfunction situation such as cholecystitis evidenced by:
mapuno akong Short term: which can result to bladder
relative to
diaper” as • Verbalize medical distention. Short – term:
verbalized by understanding of diagnosis • FULLY MET
the patient condition. identified. - Verbalized
• Demonstrate 2. Assess understanding
OBJECTIVE behaviors and 2. Identifies characteristics of
DATA: voiding bladder function (effectiveness of condition.
techniques to pattern of bladder emptying, renal • FULLY MET
prevent urinary (frequency
Vital Signs as function, and fluid balance). -
infection. and amount).
follows: Demonstrated
T: 36.9 C • Manage care for Compare behaviors and
PR: 84 bpm disposing urine output techniques to
RR: 19 bpm diapers and with fluid prevent urinary
BP: 110/80 proper perineal intake. 3. Bladder dysfunction is infection.
mmHg care measures. variable but may include loss
3. Palpate for • FULLY MET
O2 sat: 95% Long term: bladder of bladder contraction and
- Managed
Urinary • Achieve normal distension inability to relax urinary
care for
Output: Diaper elimination and observe sphincter, resulting in urine
per shift –250 g retention and reflux disposing
pattern or for overflow. diapers and
participate in incontinence.
4. Review drug proper perineal
Diagnostic measures to
Test: regimen, 4. A number of medications such care measures.
correct or including as some
Electrolyte: compensate for prescribed, antispasmodics, antidepressant Long term:
Sodium (168.3 defects. over-the- s, and narcotic analgesics; • PARTIALLY
mmol/L) • Maintain counter OTC medications with MET -
balanced I&O (OTC), and anticholinergic or alpha Achieved
Physical with clear, odor- street. agonist properties; or normal
Assessment: free urine, free 5. Assess the recreational drugs such elimination
availability as cannabis may interfere with
of bladder pattern or
Full bladder bladder emptying.
distension/urinar of toileting participate in
noted (when 5. Patients may need a bedside
y leakage. facilities. measures to
palpated in the commode if mobility
lower part of 6. Instruct to limitations interfere with correct or
the abdomen apply hot and getting to the bathroom. compensate for
patient feels the cold defects.
urge to void) compress in 6. To stimulate urinary • PARTIALLY
the lower elimination. MET -
part of the Maintains
abdomen balanced I&O
alternatively. with clear,
7. Encourage odor-free
adequate urine, free of
fluid intake 7. Sufficient hydration promotes bladder
(2–4 L per urinary output and aids in
distension/urin
day), avoidin preventing infection.
y leakage.
g caffeine
and use of
aspartame,
and limiting
intake during
late evening
and at
bedtime.
Recommend
 use of
cranberry
juice/vitamin
C.
8. Promote
continued
mobility. 8. This decreases risk of
developing UTI.
9. Cleanse
perineal area
9. Proper perineal hygiene
and keep dry. decreases risk of skin irritation
10. Recommend or breakdown and
good hand development of ascending
washing and infection.
proper 10. Handwashing and perineal
perineal care. care reduce skin irritation and
risk of ascending infection.
DEPENDENT:
1. Begin 1. Timing and type of bladder
bladder program depend on type
retraining per of injury (upper or lower
protocol when neuron involvement).
appropriate.
2. Administer
2. To prevent dehydration and
IV Fluids as
achieve optimum fluid intake.
prescribed.