NAME: GENIZA S. MORAN ATTENDING PHYSICIAN: Dr.

Mendoza
AGE/SEX: 30 / F CLINICAL AREA: BJRMH - DR
DIAGOSIS:

NURSING CARE PLAN

PLAN OF
DATE ASSESSMENT NEED DIAGNOSIS INTERVENTION EVALUATION
CARE

Subjective: Nutrition: The client 1. Established rapport. Goal met- After 2

February 13, 2009 “Maglisod ko ug ihi sukad P Altered Urinary will R: Can gain the trust of the patient and will help perform hours span of care,
ng-labor ko.” H Elimination demonstrate the intervention with ease. the client was able
Y related to 2. Assessed patient’s recognition of need to urinate.
7:00am- 3:00pm behaviors to to:
decreased R: Patients with functional incontinence are incontinent
S correct
bladder tone because they cannot get to an appropriate place to
8:00 am Objective: I underlying
from fetal head void. Institutionalized patients are often labeled
• Abdomen soft O condition  Voided 100
pressure during "incontinent" because their requests for toileting are ml and
• Uterus ½ L after 2 hours fundal
labor. unmet.
O span of care height
fingerbreadth above 3. Discussed importance of continuing to drink to help
Rationale: returns to 1-
G as initiate bladder reflex. Also discuss importance of finger-
umbilicus, soft and Altered urinary
I manifested breadth
displaced to the elimination is a emptying bladder.
below
C state in which an by: R: Assessing fundal height and position provides umbilicus
right
individual
- a. attempts evidence about the degree of bladder filling. Retention after
• Bladder firm on experiences a voiding.
N disturbance in common of urine in the bladder predisposes to infection.
palpation above  Ambulated
E voluntary control
measures to 4. Notified team member on call and keep client
symphysis pubis over micturition to the
E initiate informed if he/she has not voided by due time.
• Resonant on (Meiner, 1991). bathroom to
D R: Bladder distension can interfere with uterine
This disturbance is voiding.
percussion void with
more frequently involution and, if followed to persist, may result in
b. Voids
• Diaphoretic discussed as permanent loss of bladder tone. assistance
urinary more than
5. Instigated measures client suggests, such as from health
incontinence (UI), 100ml within
ambulating to bathroom, or hearing water running. care
or the involuntary
loss of any amount 2 hours’ Respected privacy while staying nearby for support. provider.
of urine, with social
time. R: Respecting client’s preferences helps her maintain  Confirmed
or hygienic impact.
feeling of control. Remaining nearby ensures client
Childbirth, surgery, she had
trauma, nervous safety.
been
system disorders or 6. Stressed importance of drinking extra water.
illness may directly drinking 1
R: Women should drink ample fluid to counteract
affect the normal glass of
normal diuresis and ensure good urine output.
process of urinary
7. Stressed the importance of preventing complications
fluid as
elimination. Segal-
Gidan (1990) found such as urinary retention or thrombophlebitis. hour.
that females of
R: The more informed the clients are, the more they  Described
increased age and
can participate in self-care. Kegel
parity were at
higher risk of 8. Instructed client in kegel exercises once voiding exercise
developing pattern is reestablished. that she will
Source:
R: Kegel exercises help strengthen perineal muscles.
http://findarticles.com/
continue to
p/articles/mi_m0FSS/is_ use to
n1_v5/ai_n18607032
strengthen
perineal
muscles.

Assessed by:

Michelle C.
Manaois
SN-SMC
 Criteria:
Data–
Date & Time –
Assessment –
Diagnosis –
Objective-
Intervention –
Evaluation –
Need –

“Altered Urinary Elimination related to decreased bladder tone from fetal

head pressure during labor.”

To be submitted to:
Charlene T. Tumanda R.N
Clinical Instructor

To be submitted by:
Michelle C. Manaois
SN-SMC

February 14, 2009