Nursing Process Care Plan Format Evaluation Page 3
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3NURSING PROCESS CARE PLAN FORMAT
PATIENT’S INITIALS:
STUDENT’S NAME:
DATES OF CARE:
ASSESSMENT
ANALYSIS
PLANNING
IMPLEMENTATION
EVALUATION
CLIENT GOALS/
SCIENTIFIC
SUPPORTIVE
NURSING
OUTCOME
NURSING
PRINCIPLES/
OBSERVATIONS/
DATA
DIAGNOSIS
CRITERIA
ACTIONS
RATIONALE
CONCLUSIONS
Subjective:
Urinary retention r/t
The patient will void
1. Palpate the bladder q
1. Palpation allows the
The patient had no bladder
neurologic impairment
sufficient amounts AEB
nurse to determine the
distention; however, had a
AI have to keep changing
4Ε. Ind.
of the bladder secondary
presence of bladder
PVR or 100 ml on my
my pajamas because I can=t
to diabetes
STG:
distention.
shift.
keep them dry.@
≅ No bladder distention
2. These measures may
STG partially met. Con-
and no overflow
2. Implement techniques
Objective:
≅ Residual urine >100 ml
initiate the voiding
tinue with goals.
dribbling during my
that encourage void-
reflex.
≅ Small frequent voiding
shift
ing like positioning
Patient not discharged
and relaxation. Ind.
of less than 50 cc
≅ Has post void residual
during my shift.
≅ Dribbling (soiled
3. Catheterization is used
3. Catheterize the client
volume of less than 50
pajamas and bed linen
as a last resort because
Continue with LTG. Goal
if voiding is repeat-
ml
≅ Bladder distention
of the danger of UTI.
not met.
edly unsuccessful or
as ordered. Depend.
LTG:
≅ Demonstrates no s/s of
4. Early recognition of
4. Instruct the client in
a UTI by discharge
reportable s/s of UTI
infection facilitates
prompt intervention to
(chills, fever, flank
alleviate the problem.
pain, hematuria).
Ind.
71
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