Care Plan

NURSING EXPECTED PATIENT ASSESSMENT ACTION TEACHING

DIAGNOSES OUTCOMES interventions: interventions: interventions:
(consider orders, (consider home
(note priority for Be sure they are S. (assess /
safety, allergies, regimens,
each below) M. A. R. T. (Specific, monitor for )
code status, fall procedures,
measureable,
(Be sure to use risk, etc.) discharge plan,
achievable/
related to and etc.)
attainable, relevant
as evidenced
and time-bound)
by)

1st priority: Demonstrate Obtain a Perform bladder Encourage the

Urinary consistent ability to focused urinary scan if patient to report
retention urinate when desire history including necessary. and inability to
related to reflex to void is perceived. questioning the Document void. Teach
arc inhibition as Have measured patient about intake and patient with mild
evidence by urinary residual episodes of output. Perform to moderate
absent urinary volume of less than acute urinary in and out obstructive
output, 200 to 250mL. retention or catherization as symptoms to
dribbling of Experience chronic needed and use double void by
urine, and correction or relief retention. indwelling urinating, resting
bladder from dribbling of Perform a catherization if in the bathroom
distention when urine. focused physical ordered. for 3-5 minutes,
admitted. assessment and then trying
including to urinate. Teach
perineal skin the patient to
integrity and urinate by the
inspection, clock.
percussion, and
palpitation of
lower abdomen.
Assess for
specific risk
factors of
urinary
retention.
Assess for
impaction when
urinary
retention id
 documented or
suspected.
Monitor older
male clients for
retention
related to BPH
or prostate
cancer.

2nd priority: Remains free from Assess ability to Fall risk Teach the
Risk for falls falls. Change move. Complete precaution. patient and the
related to environment to a fall risk Encourage family about fall
history of falling, minimize the assessment. patient to use reduction
use of assistive incidence of falls. Complete a fear walking aids measures that
device, decrease Explain methods to of falling when are being used to
in lower prevent injury. assessment. ambulating. prevent falls.
extremity Utilize safety Teach patient
strength, and belt when how to safely
difficulty with walking with ambulate at
gait. assistance. home and use of
Instruct to call side rails.
nurse for Encourage
assistance. patient to wear
Bedside table supportive, low-
within reach. heeled shows
Call light within with good
reach. Bed traction when
wheels locked. ambulating.
Bed in low Teach the client
position. Upper the importance
side rails up. of maintaining a
regular exercise
program.