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Nursing Care Plan Format: Urinary Retention Case Study, Study notes of Nursing

A nursing care plan format for a patient with urinary retention caused by neurological impairment secondary to diabetes. It includes assessment data, nursing diagnoses, patient goals and outcome criteria, nursing actions, and scientific principles. The document serves as a guide for nurses to develop individualized care plans for patients with urinary retention.

What you will learn

  • What nursing actions are recommended for a patient with urinary retention?
  • What are the patient goals and outcome criteria for a patient with urinary retention?
  • What are the nursing diagnoses for a patient with urinary retention?

Typology: Study notes

2021/2022

Uploaded on 09/27/2022

anshula
anshula 🇺🇸

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NURSING PROCESS CARE PLAN FORMAT EVALUATION
PATIENT’S INITIALS: STUDENTS NAME:
DATES OF CARE:
ASSESSMENT
ANALYSIS
PLANNING
IMPLEMENTATION
EVALUATION
SUPPORTIVE
DATA
----------------------------------
S. What the client says
about this problem
O. What you observe:
see, hear, feel, smell,
and measure
+
Client lab values, test
results
+
Medications
+
Doctor’s diagnosis
From this data, the reader
must be able to tell that
he/she really has a problem
NURSING
DIAGNOSIS
------------------------------
Statement of Problem
(Nursing diagnosis
[NANDA List] plus
etiology)
NOT doctor’s diagnosis
Only one diagnosis per
page
PATIENT GOALS/
OUTCOME
CRITERIA
--------------------------------
Goal Statement
Outcome criteria define
goals. They define what
will be observed when
goal is met
Provide time frame
Are measurable
Both goals and outcome
criteria stated as
behavioral objective
NURSING
ACTIONS
--------------------------------
Actions to relieve problem
and help client achieve
goal (use textbooks)
Each must be specific and
complete statements,
including who, what,
where, when, how, how
long, and how often, etc.
Label:
I/Independent actions
nurses can do without
doctor’s order
D/Dependent – what the
doctor orders for this
problem
C/Collaborative – require
knowledge, skill, and
expertise of another health
care professional
SCIENTIFIC
PRINCIPLES/
RATIONALE
---------------------------------
Tells why each action
should help achieve the
goal
Must have statement for
each action
OBSERVATIONS/
CONCLUSIONS
--------------------------------
Have goals been partially
or fully met?
Describe in terms of the
outcome criteria
Should plan be revised or
continued?
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NURSING PROCESS CARE PLAN FORMAT EVALUATION

PATIENT’S INITIALS:

STUDENT’S NAME:

DATES OF CARE:

ASSESSMENT

ANALYSIS

PLANNING

IMPLEMENTATION

EVALUATION

SUPPORTIVE

DATA

---------------------------------- S.

What the client says about this problem

O.

What you observe: see, hear, feel, smell, and measure

Client lab values, testresults

Medications

Doctor’s diagnosis From this data, the readermust be able to tell thathe/she really has a problem

NURSING

DIAGNOSIS

------------------------------ Statement of Problem (Nursing diagnosis[NANDA List] plusetiology) NOT

doctor’s diagnosis

Only one diagnosis perpage

PATIENT GOALS/

OUTCOME^ CRITERIA

-------------------------------- Goal Statement Outcome criteria definegoals. They define whatwill be observed whengoal is met Provide time frame Are measurable Both goals and outcomecriteria stated asbehavioral objective

NURSING ACTIONS

-------------------------------- Actions to relieve problemand help client achievegoal (use textbooks) Each must be specific andcomplete statements,including who, what,where, when, how, howlong, and how often, etc. Label: I/Independent actionsnurses can do withoutdoctor’s order D/Dependent – what thedoctor orders for thisproblem C/Collaborative – requireknowledge, skill, andexpertise of another healthcare professional

SCIENTIFIC

PRINCIPLES/^ RATIONALE

--------------------------------- Tells why each actionshould help achieve thegoal Must have statement foreach action

OBSERVATIONS/

CONCLUSIONS

-------------------------------- Have goals been partiallyor fully met? Describe in terms of theoutcome criteria Should plan be revised orcontinued?