A Nursing Care Plan

In Partial Fulfillment of the

Requirement on NCM-209 RLE

PEDIATRIC NURSING ROTATION

Submitted to:

MR. JULIUS V. ALTERADO, RN

Clinical Instructor

Submitted by:

GIAN KYLE D. ARADILLOS, St.N

BSN-2L GROUP 1

April 20, 2023

Name: ___M.I.U. K____________________ Age: ___32 YRS. OLD_______ Gender: _FEMALE______ Ward: _ST. MARY_

Room & Bed No: ____242-1_______Chief Complaint: ________________________Diagnosis: ____POST NSVD______

Physician: ____________________________

Date/Time Cues Need Nursing Diagnosis Patient Nursing Intervention Implementati Evaluation
Outcome on

April 14, Subjective: Within 4 hours  Assess patient’s April 14, 2023
2023 of nursing individual risk of urinary
“Wala pa jud ko E Urinary retention 1 @
interventions retention.
@ ka kaihi Sir related to weakened
L the patient will 6:00 AM
sukad gikan kog bladder muscle R: Reviewing patient’s chart
2:00 AM be able to:
DR” as I evidenced by absence and medical history will help “Goal Completely Met”
verbalized by of urinary output. The patient will the nurse to identify if the
the patient. M be able to patient is at risk of urinary After 5 hours of nursing
empties retention based on other interventions the patient was
Objective: I
Rationale: Postpartum bladder medical conditions, history able to:
- Absence of N urinary retention (PUR) completely. of recent surgery, or
The patient urinated and
urine output is a common postpartum medications.
A complication emptied bladder completely,
- difficulty of characterized by dysuria Assess patient’s voiding “nakaihi na jud ko Sir” as
T or a complete inability to pattern/intake and output. verbalized by the patient.
urinating
urinate after delivery.
I R: If patient is voiding
- epidural PUR can result in
anesthesia O bladder overdistension, frequently, small amounts of
which may lead to urine could be an indication
N bladder neuromuscular of urinary retention. Gian Kyle D. Aradillos, St.N
damage and
subsequently voiding Perform abdominal
dysfunction. Several assessment.
studies have reported
R: Palpating the bladder
primiparity, epidural may assist the nurse in
analgesia, instrument- determining if there is
assisted delivery, vaginal abdominal tenderness or if
or perineal trauma, there is bladder distention.
duration of labour, and
neonatal birth weight to Ask patient about stress
be independent risk incontinence when
factors for PUR. moving, sneezing,
Bibliography: coughing, laughing, and
lifting objects.
Cao, D., Rao, L., Yuan,
J., Zhang, D., & Lu, B. R: High urethral pressure
(2022). Prevalence and can inhibit voiding until
risk factors of overt abdominal pressure
postpartum urinary increases enough for urine
retention among to be involuntarily lost. Also,
primiparous women after hinders bladder emptying.
vaginal delivery: a case-
control study. BMC Provide patient with
Pregnancy and routine voiding measures
Childbirth, 22(1). including privacy, normal
https://doi.org/10.1186/s voiding positions, sound
12884-021-04369-1
of running water, etc.

R: These measures can

assist with the relaxation of
the perineal muscles which
can further help to promote
appropriate, effective
voiding.

If incomplete emptying is
presumed, catheterize and
measure residual urine.

R: Urinary retention
predisposes the patient to
urinary tract infection and
may be a sign of the need
for an intermittent
catheterization program.

 Encourage/provide
appropriate perineal
cleansing.

R: Appropriate cleansing will

decrease risk of infections
which can further contribute
to urinary retention.

Educate the patient on the

importance of meatal care.
This should be done twice
daily with soap and water
and dry thoroughly.

Discuss the importance of

adequate fluid intake.

R: Increased fluid stimulates

voiding and decreases the
risk of urinary tract
infections.

Inform the patient and

significant other to
observe the different
signs and symptoms of
bladder distention like
reduced or lack of urine,
urgency, hesitancy,
 frequency, distention of
lower abdomen, or
discomfort.

R: Knowledge of the signs

and symptoms allows the
patient, significant other,
or caregiver to recognize
them and seek treatment.

REFERENCE:

 Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). (n.d.). NURSING DIAGNOSES Definitions and Classification (12th ed.). Thieme
Medical Publishers, Inc.
 Bsn, G. W., RN. (2023). Urinary Retention Nursing Care Plan. Nurseslabs. https://nurseslabs.com/urinary-retention/