DAVAO DOCTORS COLLEGE

Gen. Malvar St., Davao City

Nursing Program

NURSING CARE PLAN

Name of Patient: Patient P.S Date of Admission: 03/01/2023 Room: 210 Age: 27 years old
Sex: Female Civil Status: Single Chief Complaint: feeling of fatiguability, palpitations, severe headache, nausea and vomiting, tremors and moist hands.
Religion: Roman Catholic Attending Physician: Dr. Ngo

DATE &
TIME CUES NURSING DIAGNOSIS GOAL & OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
March 01, Subjective: Impaired Urinary After 8 hours of care, the 1. Begin bladder 1. Timing and type of After 8 hours of care, the
2023 “Then, pati yung pag Elimination related to Renal patient will be able to: retraining per bladder program patient was able to:
2:30 PM ihi ko, parang ang Dysfunction Imbalanced • maintain balanced protocol when depend on type of • maintain balanced
dami parati at ang Autonomic Nervous I&O with clear, appropriate (fluids injury (upper or lower I&O with clear,
dalas. Maybe it’s from System Secondary to odor-free urine, free between certain neuron involvement). odor-free urine,
my high-fiber intake Hyperthyroidism of bladder hours, digital Note: Credé’s free of bladder
kaya ganun siguro ihi distension/urinary stimulation of maneuver should be distension/urinary
ko?” leakage. trigger area, used with caution leakage.
• Demonstrate contraction of because it may • Demonstrate
Objective: behaviors and abdominal muscles, precipitate behaviors and
Vital Signs: techniques to Credé’s maneuver). autonomic techniques to
BP: 130/90 prevent dysreflexia. prevent
HR: 120 retention/urinary 2. Encourage 2. Sufficient hydration retention/urinary
RR: 16 infection adequate fluid promotes urinary infection
Temp: 36.8 • Verbalize intake (2–4 L per output and aids in • Verbalize
Intake: 700mL understanding of day), avoiding preventing infection. understanding of
Output: 1200mL SCIENTIFIC BASIS: condition caffeine and use of Note: When patient condition
The imbalanced aspartame, and is taking sulfa drugs,
autonomic nervous limiting intake sufficient fluids are GOAL MET
during late evening necessary to ensure
system present in
and at bedtime. adequate excretion
hyperthyroidism may Recommend use of of drug, reducing risk
cause lower urinary tract cranberry of cumulative effects.
symptoms. Urinary juice/vitamin C. Note: Aspartame, a
incontinence (UI) is the sugar substitute
most bothersome lower 3. Observe for cloudy (e.g., Nutrasweet),
urinary tract symptom; or bloody urine, foul may cause bladder
however, in the literature, odor. Dipstick urine irritation leading to
reports regarding urinary as indicated. bladder dysfunction.
dysfunction and/or 3. Signs of urinary tract
incontinence among or kidney infection
hyperthyroid patients are that can potentiate
sepsis. Multistrip
scarce. This population- dipsticks can provide
based cohort study 4. Promote continued a quick
aimed to examine the mobility. determination of pH,
relationship between nitrite, and leukocyte
hyperthyroidism in 5. Cleanse perineal esterase suggesting
women and the risk of area and keep dry. presence of
developing UI. Provide catheter infection.
care as appropriate. 4. This decreases risk
of developing UTI.
6. Recommend good 5. Proper perineal
hand washing and hygiene decreases
proper perineal risk of skin irritation
care. or breakdown and
development of
7. Refer to urinary ascending infection.
continence 6. Handwashing and
specialist as perineal care reduce
indicated. skin irritation and risk
of ascending
infection.
7. Collaboration with
specialists is helpful
8. Teach Kegel for developing
exercises. individual plan of
care to meet
patient’s specific
9. Educate patient needs using the
about the latest techniques,
importance of continence products.
limiting intake of 8. These exercises
alcohol and improve pelvic floor
caffeine. muscle tone and
10. Refer for further urethrovesical
evaluation for junction sphincter
tone.
 bladder and bowel 9. These chemicals are
stimulation. known to be bladder
irritants. They can
increase detrusor
overactivity.
10. Clinical research is
being conducted on
the technology of
electronic bladder
control. The
implantable device
sends electrical
signals to the spinal
nerves that control
the bladder and
bowel. Early results
look promising.

Reference: Bsn, G. W., RN. (2022, March 19). Impaired Urinary Elimination Nursing Care Plan. Nurseslabs. https://nurseslabs.com/impaired-urinary-elimination/