NURSING CARE PLAN

Cues Nursing Rationale to Goals and Objectives Nursing Interventions Rationale to Evaluation
Diagnosis Nursing Nursing
Diagnosis Interventions
Subjective cues: Urinary retention Urinary retention Short term range Independent: Short term:
“I noticed my (acute or chronic) is the inability to At the end of hours After 8 hours of nursing
urinary frequency related to bladder empty the of nursing care, the 1. Review 1. Suggest intervention the patient was
during the day for obstruction, bladder. With patient will be able medical detrusor able to:
the past 2 weeks, I Decompensation chronic urinary to: history for muscle  Void in sufficient
doesn’t feel that my of detrusor retention, you  Void in diagnosis atrophy and amounts with no
bladder is empty of musculature. may be able to sufficient such as or chronic palpable bladder
urinating. I also get urinate, but you amounts with prostatic over desertion.
up for two or three have trouble no palpable hypertrophy, distention  Verbalized
times during night starting a stream bladder scarring, because of understanding of
to urinate. Lastly, I or emptying your distention. recurrent tone outlet causative factors and
had difficulty bladder  Verbalize information. obstruction. appropriate
starting urination completely. You understanding 2. Ask client 2. High urethral interventions
and dribbles may urinate of causative about stress pressure demonstrate
afterward.” as frequently; you factors and incontinence inhibits techniques/behaviors
verbalized by the patience. may feel an appropriate when moving, bladder to alleviate/prevent
urgent need to interventions. sneezing, emptying or retention.
urinate but have Demonstrate coughing, can inhibit  Voiding pattern
little success techniques / laughing or voiding until normalized.
Objective Cues: when you get to behaviors to lifting objects. abdominal Long term Range:
Temperature: the toilet; or you alleviate/ 3. Monitor vital pressure
o o may feel you still prevent signs increase
38.1 C (100.6 F) have to go after retention. 4. Observe enough for
Pulse: 89 beats/min you’ve finished Voiding urinary urine to be
urinating. With pattern stream, size involuntarily
Respirations:
acute urinary normalized and force. lost.
20/min
retention, you 5. Prepare for 3. To record/
Blood pressure: can’t urinate at and assist notify if there
146/86 mmHg all, even though Long term range: with urinary are any Long term range:
you have a full After 2-3 days of nursing drainage, such changes. After 2-3 of nursing
Catheterization for bladder. Acute intervention the patient as emergency intervention the patient has
urinary retention urinary retention will be having urine cystostomy. 4. Evaluating urine volume greater than or
yielded 300 mL; is a medical volume that greater than 6. Prepare for degree of equal to 300 ml with each
amber urine. Foley emergency or equal to 300 Ml with procedure, obstruction voiding and residual volume
left in place for 2 requiring prompt each voiding and such as the and choice of less than 100 ml.
days action. Chronic residual volume less than following: intervention.
Diagnostic Data urinary retention 100 Ml. laser,
may not seem life transurethral 5. May be
CBC normal threatening, but it microwave, indicated to
Urinalysis: amber, can lead to serious thermotherap drain bladder
clear problems an y (TUMT), during acute
should also cortherm, episode.
pH: 6.5
receive attention prostration,
spGr: 1.025, from a health and 6. Done to
negative for professional. transurethral quickly create
glucose, protein, needle a wide open
ketone, RBCs, and ablation prostatic
Source: Gil
bacteria (TUNA), fossa, often
Wayne, BSN,
IVP: evidence of R.N. (2017), Urethral stent, resulting in
enlarged prostate Impaired Gas open prostate immediate
gland Exchange Nursing resection restoration of
Care Plan, procedure, normal urine
 urinary such as flow.
nurseslabs.com
retention, TURP.
 hematuria,
 fever
Dependent:
1. Suggest sits 1. A sitz bath
bath as supports
ordered muscle
relaxation,
reduces
edema, and
may improve
voiding
attempt.
Collaborative:
1. Teach the patient 1. If prostate
about possible enlargement
surgical treatment as is involved,
needed. surgery may
be required.
Women may
need surgery
to lift a fallen
bladder or
rectum. A
urethral stent
may be
required to
treat a
urethral
structure.