Davao Medical School Foundation. Inc.

Medical School Drive, Bajada, Davao City

College of Nursing

Nursing Care Plan

Assessment Diagnosis Planning Intervention Evaluation
Subjective: Impaired At the end of Independent: Goal met as
Patient urinary my shift the 1. Assess voiding pattern (frequency and amount). Compare urine output with fluid intake. Note evidenced by
verbalized i elimination patient will: specific gravity. patient :
wake up at R/T Rationale: An Identifies characteristics of bladder function (effectiveness of bladder
night around obstruction
demonstrate emptying, renal function, and fluid balance). demonstrating
2 to 3 times secondary behaviors 2. Palpate for bladder distension and observe for overflow. behaviors and
to urinate to enlarged
and Rationale: Bladder dysfunction is variable but may include loss of bladder contraction and techniques to
prostate techniques to inability to relax urinary sphincter, resulting in urine retention and reflux incontinence. prevent
prevent 3. Note reports of urinary frequency, urgency, burning, incontinence, nocturia, and size or force retention/
retention/ of urinary stream. urinary
urinary Rationale: This provides information about degree of interference with elimination or may infection.
infection. indicate bladder infection.
4. Assess the patients usual pattern of urination and occurrence of incontinence. Maintaining
maintain Rationale: Many patients are incontinent only in the early morning when the bladder has balanced I&O
balanced I&O stored a large urine volume during sleep. with clear, odor-
with clear, 5. Encourage adequate fluid intake (24 L per day) free urine, free
odor-free Rationale: Sufficient hydration promotes urinary output and aids in preventing infection. of bladder
urine, free of 6. Observe for cloudy or bloody urine, foul odor. distension/
bladder Rationale: Signs of urinary tract or kidney infection that can potentiate sepsis. urinary leakage
distension/ 7. Cleanse perineal area and keep dry. Provide catheter care as appropriate.
urinary Rationale: Proper perineal hygiene decreases risk of skin irritation or breakdown and
leakage. development of ascending infection.
8. Educate patient about the importance of limiting intake of alcohol and caffeine.
Rationale: These chemicals are known to be bladder irritants. They can increase detrusor
overactivity.
9. Obtain periodic urinalysis and urine culture and sensitivity as indicated.
Rationale: These tests monitor renal status.
Dependent:
1. Administer medications as indicated
Rationale: to promote urination and bladder relaxation
SUBMITTED TO: Mrs. Shirly May G. Dela Cerna RN, MN SUBMITTED BY: Yasierah K.Agalin , St.N DATE: November 17, 2017
Clinical Instructor BSN 4 student