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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.
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What the client says about this problem
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
------------------------------ Statement of Problem (Nursing diagnosis[NANDA List] plusetiology) NOT
doctor’s diagnosis
Only one diagnosis perpage
-------------------------------- 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
-------------------------------- 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
--------------------------------- Tells why each actionshould help achieve thegoal Must have statement foreach action
-------------------------------- Have goals been partiallyor fully met? Describe in terms of theoutcome criteria Should plan be revised orcontinued?