University:
West Coast University
Course:
NURS 103 | Fundamentals of Nursing
Academic year:

2021
Views:

274

Pages:

2
Author:

cicwyr4xc

Nursing Care Plan IMPAIRED URINARY ELIMINATION RELATED TO URINARY INCONTINENCE AS EVIDENCED BY EXTREME WEAKNESS ASSESSMENT SUBJECTIVE DATA: N/A Objective Data: weak in appearance dehydrated Vital signs BP: 110/70mmHg Temp: 38°C RR: 118 NURSING DIAGNOSIS Impaired urinary elimination related to urinary incontinence as evidenced by extreme weakness PLANNING Short term: Within 4-6 hours of nursing intervention, the patient will be able to: verbalize understanding of the condition demonstrate improvement in urine elimination as evidenced by fewer episodes of incontinence improve sense of energy. Long term: Within 2-3 days of nursing intervention, the patient will be able to: return of normal voiding pattern as evidenced by no episodes of incontinence and improved urine elimination IMPLEMENTATION RATIONALE INDEPENDENT: Perform a focused history of the incontinence including duration, frequency, and severity of leakage episodes, and alleviating and aggravating factors. The history provides clues to the causes, the severity of the condition, and its management. Monitor urinary elimination, including consistency, odor, volume, and color. These parameters help determine adequacy of urinary tract function. Monitor vital and cognitive signs, watching for change in blood pressure and respiratory rate. To establish baseline data and check for the patient’s improvement of condition. Monitor the patient’s daily fluid intake and output To help determine of hydration. Limit ingestion of bladder irritants (e.g., colas, coffee, tea, alcohol, and chocolate) Alcohol, coffee, and tea have a natural diuretic effect and a bladder irritant. Emphasize importance of having good perineal hygiene. To reduce the risk of infection. Encourage the patient to eat food that is high in fiber (beans, broccoli, and whole grains) To regulate your bowel movements and overflow incontinence. EVALUATION Short term: Within 4-6 hours of nursing intervention, the patient will be able to: verbalize understanding of the condition demonstrate improvement in urine elimination as evidenced by fewer episodes of incontinence improve sense of energy. Long term: Within 2-3 days of nursing intervention, the patient will be able to: return of normal voiding pattern as evidenced by no episodes of incontinence and improved urine elimination Goal was met. Dependent: Administer IV fluid such as PNSS on fast drip as prescribed. By regulating the amount of sodium, the kidney can regulate the volume of body fluids. Administer other medications such as antibiotics. To treat underlying condition. Catheterize when and as indicated: Catheterization can at times be required for evaluation or treatment when a patient retains urine or unable to empty the bladder. Collaborative: Review for laboratory test for changes in renal function. Report to physician if there is no any improvement on patient’s condition To assess for contributing or causative factors. Collaboration with specialists helps develop an individual plan of care to meet patient’s specific needs using the latest techniques, continence products.