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MEDICAL DIAGNOSIS: List all current medical diagnoses. Overactive Bladder PRIORITIZED LIST OF RELEVANT NURSING DIAGNOSIS: List all nursing diagnoses relevant to the patient’s condition & based on the assessment
- Deficient knowledge related to new diagnosis of overactive bladder and medication regimen as evidenced by patient questions about medication.
- Risk for impaired skin integrity related to frequent urinary leakage and moisture exposure.
- Impaired urinary elimination related to detrusor muscle overactivity and bladder irritability as evidenced by urge incontinence. 1 MSW 4/
Student Name: Jessica Pittman Date: 3/22/2026 Class: NUR 168 Cohort TB Patient Initials: JS A care plan should start with the major issues for that client. Write the top three priority nursing diagnosis for this client, with the highest priority first. Be sure to include “related to”, “as evidenced by”, or “risk factors” (if at risk diagnosis) for each medical diagnosis. Write at least one short term and one long term (“expected outcome”) measurable goal per nursing diagnosis stated in terms of client achievement (“the client will…”). List 3 specific nursing actions (interventions) for each nursing diagnosis and give the scientific rationale for selecting the action you will use to work toward that goal, along with the cited reference of that rationale. Evaluate if goal was met and list specific assessment data to support it (How did you know goal was met?) NURSING DIAGNOSIS (NANDA APPROVED)
EXPECTED
OUTCOME
(Measurable Goal with dates) ST: within time frame of clinical LT: can be outside of time frame of clinical
NURSING
INTERVENTIONS
(What do you plan to do for the client to accomplish the goal? Be specific and include time frames)
RATIONALE
(Why are you doing this?) (Citation for each rationale)
EVALUATION
(If goal not met, need to evaluate why? And what to do to meet goal?)
- Deficient knowledge related to new diagnosis of overactive bladder and medication regimen as evidenced by patient questions about medication. ST: Patient will verbalize understanding of overactive bladder and its treatment. 1. Educate patient about the cause and symptoms of overactive bladder. 1. Understanding the condition improves treatment adherence. (Ackley et al., 2023, p. 188) ST: Goal met as evidenced by patient accurately describing overactive bladder symptoms, triggers and treatment strategies after teaching. LT: Patient will demonstrate proper medication use and lifestyle modifications. 2. Teach proper use of mirabegron including dosage, timing and side effects. 2. Proper medication administration improves symptom control and reduces complications. LT: Goal met as evidenced by patient correctly explaining medication regimen for mirabegron, reciting potential side effects NURSING CARE PLAN
- Apply moisture barrier creams if needed.
- Barrier products protect skin from urine exposure. (Ackley et al., 2023, p. 626)
- Impaired urinary elimination related to detrusor muscle overactivity and bladder irritability as evidenced by urge incontinence. ST: Patient will report decreased urinary urgency within 48 hours.
- Assess urinary patterns: frequency, urgency and nocturia.
- Assessment provides baseline data and helps evaluate treatment effectiveness. (Ackley et al., 2023, p. 752) ST: Goal met as evidenced by patient reporting decreased episodes of urinary urgency and improved ability to delay urination using bladder training techniques during the shift. LT: Patient will demonstrate improved bladder control and decreased frequence of incontinence episodes.
- Encourage scheduled voiding or bladder training.
- Timed voiding helps retrain the bladder and reduce urgency episodes. (Ackley et al., 2023, p. 756) LT: Goal met as evidenced by patient demonstrating improved bladder control with fewer reported episodes of urinary leakage and adherence to scheduled voiding regimen.
- Encourage pelvic floor muscle exercises.
- Strengthening pelvic floor muscles improves bladder control. (Ackley et al., 2023, p. 757)
REFERENCES: (APA format) Ackley, B. J., Ladwig, G. B., Makic, M. B. F., Martinez-Kratz, M. R., & Zanotti,
M. (2023). Nursing diagnosis handbook: An evidence-based guide to
planning care (12th ed., revised reprint). Elsevier.
