This free nursing care plan and diagnosis example is for the following conditions: Urinary Tract Infection, UTI, Bladder Infection, Kidney Infection, Kidney Stone, and Urinary Retention.
What are nursing care plans? How do you develop a nursing care plan? What nursing care plan book do you recommend helping you develop a nursing care plan?
This care plan is listed to give an example of how a Nurse (LPN or RN) may plan to treat a patient with those conditions.
Important Disclosure: Please keep in mind that these care plans are listed for Example/Educational purposes only, and some of these treatments may change over time. Do not treat a patient based on this care plan.
Care Plans are often developed in different formats. The formatting isn’t always important, and care plan formatting may vary among different nursing schools or medical jobs. Some hospitals may have the information displayed in digital format, or use pre-made templates. The most important part of the care plan is the content, as that is the foundation on which you will base your care.
Nursing Care Plan for: Diabetes, Urinary Tract Infection, UTI, Bladder Infection, Kidney Infection, Kidney Stone, and Urinary Retention.
If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below. Otherwise, scroll down to view this completed care plan.
Scenario: |
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A 53 year old woman present to the ER with complaints of bladder fullness, incomplete bladder emptying, and severe pain on right flank. She rates the pain 9 on 1-10 scale. Pt states she has a history of having kidney stones. She also states when she is able to void it burns and has a foul odor. Pt VS: HR 85, BP 120/80, O2 Sat 98% on RA, RR 16, Temp. 101.4 ‘F. Pt takes the following medications: AsA 81 mg PO Daily, HCTZ 25mg PO Daily, Detrol LA 2mg PO Daily, and Tylenol 325mg Po every 6 hours as needed for pain. Lab work: WBC 26, Urinalysis: WBC (too many to count), Bacteria (5+ large), negative for protein and ketones, leukoesterase positive. Renal ultrasound show 2cm renal calculi.
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Nursing Diagnosis: |
| Urinary retention related to bladder fullness and hesitancy as evidence by urinary tract infection and urethral blockage. |
Subjective Data: |
| Complaints of bladder fullness, incomplete bladder emptying, and severe pain on right flank. She rates the pain 9 on 1-10 scale. Pt states she has a history of having kidney stones. She also states when she is able to void it burns and has a foul odor. |
Objective Data: |
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VS: HR 85, BP 120/80, O2 Sat 98% on RA, RR 16, Temp. 101.4 ‘F. Pt takes the following medications: AsA 81 mg PO Daily, HCTZ 25mg PO Daily, Detrol LA 2mg PO Daily, and Tylenol 325mg Po every 6 hours as needed for pain. Lab work: WBC 26, Urinalysis (UA): WBC (too many to count), Bacteria (5+ large), negative for protein and ketones, leukoesterase positive. Renal ultrasound show 2cm renal calculi.
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Nursing Outcomes: |
| -Pt will maintain an output 30 cc per hour during hospitalization.-Pt UA will be free from any WBCs, Bacteria, and leukoesterase by discharge.
-Pt will empty bladder completely within 24 hours. -Pt will rate pain less than 3 on 1-10 scales within 5 hours of hospitalization. |
Nursing Interventions: |
| -Pt’s input and output will be measured hourly.-Pt will be started on IV antibiotic therapy per md order and an UA will be collected within 24 hours.
-Pt will be encouraged to void every 4 hours. -Pt’s abdomen will be bladder scanned after each void to ensure the bladder is emptying completely. -Pt will be given PRN pain medication per md order for pain rating greater than 3 on 1-10 scale. |