NURSING CARE PLAN

Name of Patient: Denies Bungisngis Date Admitted: May 7, 2022 Chief Complaint: Impaired Urinary Elimination Case Number: 1

Age: 28 Gender: Female Civil Status: Single Address: Los Banos Laoang AP: Jonathan Mercado Raul Sy
 NURSING GOALS AND
ASSESSMENT RATIONALE NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS OBJECTIVES
Subjective Data: Impaired urinary IUE is a hysterectomy Short Term Goals and Independent: Independent: Short term Goal and
Elimination related to complication that can cause Objectives: 1. Establish rapport with 1. To gain the patient’s Objectives:
“I experience sensation of surgical manipulation bladder over-distension and patient and significant trust as well as for active
specifically long-term bladder Within 24 hours of providing others participation in care. Within 24 hours of patient
bladder fullness but only
nursing care, the patient will 2. Document patient’s 2. Documenting the
pass little urine and Hysterectomy as dysfunction. Risk factors for care, desired outcomes are met
be able to: voiding pattern as well patient’s voiding pattern
sometimes none” as evidenced by low urine Impaired Urinary  Empty Bladder may provide information and patient is now able to:
as urinary output
verbalized by the patient output and elimination includes type of Completely and for further complications  Empty bladder
verbalization of little to anesthesia used, how the regularly such as urinary retention completely and
“I frequently feel the urge unable to pass urine hysterectomy is performed,  Achieve normal if voiding is frequent Regularly
to urinate and have trouble despite a strong urge to use of post-operative elimination pattern and in small amounts  Achieved normal
urinate narcotics, pre-operative without frequency 3. Palpate bladder and 3. Recognition of bladder elimination pattern
urinating”
and urgency assess for any fullness, bladder
urinary retention, and with no frequency
 Void in sufficient discomforts, fullness, distension above
Objective Data: possibly aggressive bladder and urgency
quantity with no symphysis pubis can
dissection. and inability to void  Voids in sufficient
palpable bladder indicate urinary
Decreased (less than 30 distention retention. quantity with no
ml/hr) urinary output for 2 4. Encourage appropriate 4. Providing routine bladder distention
consecutive hours perineal cleansing and voiding measure can
Long Term Goals and promote relaxation of
care of catheter (if
Objectives: perineal muscles and
Bladder distension present) Long Term Goals and
facilitate voiding efforts
5. Assessing urine Objectives:
Within 5 days of nursing
intervention, the patient will: 5. Assess urine characteristics would
characteristics such as enable the nurse to asses Within 5 days of patient care,
 Be able to verbalize
urine color, clarity, and risk for infection the desired goals are now met
changes in diet to
odor. especially if patient has and the patient is:
incorporate
improvement of indwelling catheters or  Able to verbalize
urinary elimination perineal sutures.
importance of diet
 Verbalize ways on 6. Provide and elaborate 6. This promotes perineal
muscle relaxation and change and
how to prevent routine voiding measures
may facilitate voiding incorporates it for
urinary retention and efforts such as
and infection efforts. urinary elimination
normal positioning while
improvement
urinating or pouring
 Able to identify ways
lukewarm water over the
on how to prevent
perineum.
urinary retention and
infections.
Collaborative:
Collaborative:
1. Catheterize patient when
1. Edema may cause
indicated if patient is
further complications
unable to void or is
such as bladder atony or
becoming uncomfortable
urinary retention.
Catheterization enables
emptying of bladder
2. Decompress the patient’s
2. When bladder is full and
bladder slowly
large amount of urine
accumulates,