NURSING CARE PLAN

Assessment Nursing Diagnosis Expected Outcomes Implementation Rationale Evaluation

Subjective Data Actual diagnosis The Patient will

Urinary tract infection Relief of pain from the UTI Administer antispasmodics, and Bactrim & antispasmodics are used to Patient experiences relief of pain
Bactrim treat patients with UTI, and to relieve
69 year old white Increased knowledge of bladder irritability/ pain Teach back of UTI & treatment
woman R/T sepsis preventive measures, and Encourage patient increase fluid
treat modalities intake Increasing fluid intake can help flush No complications / Uti present
Previously discharged out bacteria in urinary tract
from hospital for sepsis AEB: Guarding behavior/ Absence of complications Encourage patient to void every 2-3
confusion, decreased hours Voiding frequently can lower urine
Has Parkinson’s physical activity, spasms bacterial counts reduce urinary stasis,
disease, diabetes in lower back and Avoid irritants such as coffee, tea, and prevent infection
mellitus, and atrial bladder area soda
fibrillation

Objective Data Risk for/Potential

Alert & oriented to self, Nursing DX: altered

and daughter, yet metabolic states,
slightly confused Immunosuppression,
 NURSING CARE PLAN
Urethral mucosa
unable to respond to abrasion
questions asked about
her whereabouts
R/T UTI
Patient is unsteady and
uses a walker to
ambulate

patient is paranoid, and

slurring her words

patient can feed herself

but has not been eating
well

patient medications are

: Levodopa, atenolol,
Plavix, potassium
chloride, metformin,
oxazepam, docusate,
acetaminophen, &
Bactrim