[Type text]

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION









Urinary
retention
(acute or
chronic)
related to
bladder
obstruction,
Decompens
ation of
detrusor
musculature
Urinary
retention is
the inability
to empty the
bladder.
With chronic
urinary
retention,
you may be
able to
urinate, but
you have
trouble
starting a
stream or
emptying
your
bladder
completely.
You may
urinate
frequently;
you may
feel an
urgent need
to urinate
but have
little
At the end of 8
hours of nursing
care, the patient
will be able to:
Void in
sufficient
amounts
with no
palpable
bladder
distention.
Verbalize
understandi
ng of
causative
factors and
appropriate
interventions
,
Demonstrat
e
techniques/b
ehaviors to
alleviate/pre
vent
retention.
Voiding
pattern
normalized.
Review medical
history for
diagnoses such
as prostatic
hypertrophy,
scarring, recurrent
stone formation






Ask client about
stress
incontinence
when moving,
sneezing,
coughing,
laughing, or lifting
objects.







Monitor vital signs
Suggest
detrusor
muscle
atrophy
and/or
chronic
overdistenti
on because
of outlet
obstruction.


High
urethral
pressure
inhibits
bladder
emptying or
can inhibit
voiding until
abdominal
pressure
increases
enough for
urine to be
involuntarily
lost.

After 8 hours of
nursing intervention
the patient was able
to:
Void in sufficient
amounts with no
palpable bladder
distention.
Verbalize
understanding of
causative
factors and
appropriate
interventions ,
Demonstrate
techniques/beha
viors to
alleviate/prevent
retention.
Voiding pattern
normalized.
.



[Type text]

success
when you
get to the
toilet; or you
may feel
you still
have to go
after you've
finished
urinating.
With acute
urinary
retention,
you can't
urinate at
all, even
though you
have a full
bladder.
Acute
urinary
retention is
a medical
emergency
requiring
prompt
action.
Chronic
urinary
retention
may not
seem life



Observe urinary
stream, size and
force.




Prepare for and
assist with urinary
drainage, such as
emergency
cystostomy.

Prepare for
procedures, such
as the following:
laser,
transurethral
microwave
thermotherapy
(TUMT),
Cortherm,
Prostatron, and
transurethral
needle ablation
(TUNA), Urethral
stent, Open
prostate resection
procedures, such
as TURP

Evaluating
degree of
obstruction
and choice
of
intervention.

May be
indicated to
drain
bladder
during acute
episode.

Done to
quickly
create a
wide open
prostatic
fossa,
often
resulting in
immediate
restoration
of normal
urine flow





[Type text]

threatening,
but it can
lead to
serious
problems
and should
also receive
attention
from a
health
professional
.



















NURSING CARE PLAN

ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
[Type text]

S: Ahhewanko. Joke
lang! Di
konamatandaan. Wag
kanatanong ng tanong.
As verbalize by the
patient.

O:
Disorientation to
time
Observed
experience of
forgetting
Scratches his
head when he is
unable to recall
information
Uses alibi that
she is only joking
when she cant
remember
things.

Impaired
memory
related to
neurological
disturbances

Impaired
memory is
directly
related to
effects of
general
medical
condition or
ongoing
effects of
substance.
Depending o
n the areas
of the brain,
the client are
unable to
recall
information,
either
remote or
recent. The
client may
confabulate
to fill in
those lost
memories.
At the end of 2
hours of nursing
care, the patient
will be able to
Verbalize
awareness
of memory
problems;
and
Accept
limitations of
current
condition
Provide
opportunities
for
reminiscence
or recall past
events.

Encourage
ventilation of
feelings of
frustration,
helplessness,
and so forth.
Refocus
attention to
areas of focus
and progress.
Allow the
client to
answer
questions on
his own, but
do not rush
him to answer
it. Make the
client feel that
he can still do
things
independently
.
Monitor
clients
behavior and
Long-term memory may
persist after loss of recent
memory. Reminiscence is
usually an enjoyable activity
for the client.





To lessen feelings of
powerlessness/hopelessness.








It is important to maximize
independent function, assist
the client when memory has
deteriorated further.







To reduce frustration



After 2 hours of
nursing
intervention the
patient was able
to:

The
patient
was able
to
verbalize
awareness
of memory
problems
[Type text]









assist in use
of stress-
management
techniques