Assessment Nursing Diagnosis Planning Nursing Interventions Rationale Evaluation

(Desired or Expected
Outcomes)

Subjective: Impaired urinary INDEPENDENT Goal met as evidenced

“Mga alas-dose maka-ihi elimination related to by patient:
ko dayun kung mu-ihi obstruction secondary to At the end of my 1. Assess for voiding 1. An identifies
bitaw ko maglisod ko.” enlarged prostate. pattern(Frequency characteristics of
as verbalize by the shift the patient and amount). blladder function  Demonstrating
patient. Compare urine (effectiveness of
will: output with fluid bladder behaviors and
intake. Note emptying, renal
 Demonstrate techniques to prevent
Objective: specific gravity. function, and
fluid intake.)
behaviors and retention/ urinary in
Patient may manifest one
or more of the techniques to prevent 2. Palpate for bladder 2. To determine the fection.
following:- distension and urinary retension
(+)nocturia retention/ urinary in observe for and reflux  Maintaining balanced
(+)incontinence overflow. incontinence.
(+) dysuria ( difficulty in fection. I&O and free bladder
urinatning)
(+)facial grimace  Maintain balanced 3. Encourage 3. Sufficient dystension/urinary
adequate fluids up hydration
- pt may also beseen with I&O. to 32-4 L per day promotes urinary leakage.
an indwelling catheter output andd aids
connected with the urine in preventin
bag. infection, fluid
maintains renal
perfusion and
 flushes kidneys,
bladder, and
ureters
of sediment
and bacteria.

Note: Initially, fluids may

be restricted to prevent
4. Encourage the bladder distension until
patient to void 2- adequate urinary flow
4 hours and when re-established
urge is noted.
4. May minimize over
distension of the bladder.
5. Encourage
meticulous
catheter and
perineal care. 5. Reduce risk of
ascending infection.

DEPENDENT:

Administer medication as
prescribed
To promote urination
and bladder relaxation.

Assessment Nursing Diagnosis Planning Nursing Interventions Rationale Evaluation

(Desired or Expected
Outcomes)
Subjective: Anxiety related to Patient will be able to: INDEPENDENT: After 1 hr of nursing
concerns and lack of 1. Provide an Establishing rapport is intervention the patient:
“Mahadlok ko sa opera knowledge about the *lessen his anxiety atmosphere of essential to a therapeutic
basin maunsa pa lang diagnosis, treatment acceptance and relationship and supports 1. Appears relaxed
ko” as verbalized by the plan, and prognosis *Improved ability to establish rapport the client in self-
patient. cope reflection. Recognizing 2. States that anxiety
problems and sharing has been reduced or
*relax feelings is best brought relieved
about in an atmosphere 3. Demonstrates
Objective: of warmth and trust understanding of
illness, and
According to the nurse 2. Open, diagnostic tests and
on duty that time: nonthreatening treatment if
2. Encourage discussions questioned.
-BP and Heart rate verbalization of facilitate the
elevates feelings, identification of
-Cold sweat perceptions, and causative and
- fears. contributing
factors
3. To develop
3. Encourage the appropriate
patient to identify strategies for
her own strengths coping based on
and abilities. personal
strengths and
previous
experiences.
Improves
 selfconcept and
4. Obtain health sense of ability to
history to manage stress.
determine the
following: Patient 4. To clarifies
concerns, his information and
label of facilities patient’s
understanding, his and
support systems understanding
and coping and coping
methods.
5. Assesss his
psychoological
reaction to his
diagnosis/prognos
is and how he has
coped with past
stresses
6.

Assessment Nursing Diagnosis Planning Nursing Interventions Rationale Evaluation

(Desired or Expected
Outcomes)

SUBJECTIVE: Deficient knowledge GOAL: INDEPENDENT After 2 days of nursing

“Basin mawal-an kog about factors related to After 8 hours of nursing interventions, the client
itlog” as verbalized by the disorder and interventions, the patient 1. Encourage 1. This is designed to was able to:
the patient. treatment protocol. will be able to: communication establish rapport -verbalize understanding
with the patient. and trust. of condition/disease
 verbalize process and potential
 2. Review disease 2. Provides complications
understanding of process / prognosis and knowledge base -correctly perform
condition/disease future expectations from which necessary procedures and
process and patient can make explain reasons for the
potential informed choices actions
 complications -demonstrate /initiate
 correctly perform 3.Review dietary necessary lifestyle
necessary restrictions, including: 2. Retention of changes
phosphorus (e.g. Phosphorus stimulates -participate in treatment
procedures and
carbonated drinks, the parathyroid glands to regimen
explain reasons
processed foods, poultry, shift calcium from bones
for the actions
corn, peanuts) and accumulation of
 demonstrate magnesium magnesium can impair
/initiate necessary fluid and sodium neuromuscular function
lifestyle changes restrictions where and mentation
 participate in indicated if fluid retention is a
treatment problem, patient may
regimen need to restrict intake of
. fluid to 1100cc or less
and restrict dietary
sodium
4..Encourage adequate
calorie intake, especially 3.Spares protein, prevent
from carbohydrates in the wasting, and provides
non-diabetic patient energy.
 Assessment Nursing Diagnosis Planning Nursing Rationale Evaluation
(Desired or Expected Interventions
Outcomes)

Subjective: Impaired urinary After nursing Independent: After nursing

“Musakit nasad akong elimination r/t interventions, the client Assess voiding pattern Identifies characteristics of interventions, the client
pantog” as verbalize bladder outlet will be able to: (frequency and bladder function (effectiveness was able to:
by the patient obstruction, surgery  demonstrates amount). Compare of bladder emptying, renal  demonstrates
behaviors and urine output with fluid function, and fluid balance). behaviors and
Objejctive: techniques to prevent intake. Note specific techniques to prevent
March 9, 2019 retention/urinary infect gravity. retention/urinary infect
Total Urine output ion. ion.
in 24 hours  identifies the cause of Palpate for bladder Bladder dysfunction is variable  identified the cause of
-Catheter:2,250 incontinence. distension and but may include loss of bladder incontinence.
Total Intake in 24  maintains balanced observe for overflow. contraction and inability to  maintain balanced
hours- 850 I&O with clear, odor- relax urinary sphincter, I&O Free of bladder
 Tender on free urine, free of resulting in urine retention and distension/urinary
suprapubic or bladder reflux incontinence. leakage.
hypogastric region distension/urinary  Verbalized
leakage. understanding of
Lab result:  verbalizes Note reports of This provides information about the condition.
understanding of urinary frequency, degree of interference with
 WBC: 10.2 ; the condition. urgency, burning, elimination or may indicate
NV:5-10x 10/L incontinence, bladder infection. Fullness over
 Creatinine nocturia, and size or bladder following void is
1.1 force of urinary indicative of inadequate
NV:0.6-1.2 mg/dL stream. Palpate emptying or retention and
bladder after voiding. requires intervention.
Encourage adequate Sufficient hydration promotes
fluid intake (2–4 L per urinary output and aids in
day), avoiding preventing infection.
caffeine and use of
aspartame, and
limiting intake during
late evening and at
bedtime. Recommend
use of cranberry
juice/vitamin C.

Dependent:

Review drug regimen, A number of medications such

including prescribed, as some
over-the-counter antispasmodics, antidepressants
(OTC), and street. , and narcotic analgesics; OTC
medications with
anticholinergic or alpha agonist
properties; or recreational drugs
such as cannabis may interfere
with bladder emptying.

Catheterize as Catheterization may be

indicated. necessary as a treatment and for
evaluation if patient is unable to
empty bladder or retains urine.
Administer These drugs reduce bladder
medication as spasticity and associated
indicated symptoms of frequency,
urgency.

Keep bladder deflated These reflect renal function and

by means of identify complications.
indwelling catheter
initially. Begin
intermittent
catheterization Indwelling catheter is used
program when during acute phase for
appropriate. prevention of urinary
retentionand for monitoring
output.

Collaborative:

Refer to urinary
continence specialist Collaboration with specialists is
as indicated. helpful for developing
individual plan of care to meet
patient’s specific needs using
 the latest techniques, continence
products

Refer for further

evaluation for bladder Clinical research is being
and bowel conducted on the technology of
stimulation. electronic bladder control. The
implantable device sends
electrical signals to the
spinal nerves that control the
bladder and bowel.

Flushing when pain is

present. It indicates clotting and bladder
spasm.

Assessment Nursing Diagnosis Planning Nursing Interventions Rationale Evaluation

(Desired or Expected
Outcomes)

Subjective: Imbalanced nutrition: After nursing Independent: After nursing

“Diko ganahan mukaon.” less than body interventions, the client interventions, the client
as verbalized by the requirements r/t will be able to: 1.Assess the amount of this assessment will help was able to:
patient. decreased oral intake. food eaten determine nutrient
 presents intake.  Present
understanding of understanding of
Objejctive: significance of weighing the patient on significance of
Weight: 75 nutrition to healing 2. Routinely weight the same scale under nutrition to healing
Weak muscle strength process and general patient similar conditions can process and general
Lack of subcutaneous fat health. help monitor changes in health.
 weight.
 verbalizes and  verbalized and
demonstrates demonstrates
selection of foods or selection of foods or
meals that will 3. Elicit patient’s explanation may present meals that will
accomplish a explanation of why she is easily corrected accomplish a
termination of weight unable to eat more practices. termination of weight
loss. loss.
 demonstrates he will be more likely to  Demonstrate
behaviors, lifestyle 4. Cater to his individual consume larger servings behaviors, lifestyle
changes to recover food preferences (e.g. if food is palatable and changes to recover
and/or keep avoiding foods that are appealing and/or keep
appropriate weight. too spicy or too cold) appropriate weight.
 shows no signs of  shows no signs of
malnutrition. Inform patient that aging and disease malnutrition.
 Patient takes alterations in taste can process can reduce taste  Take adequate
adequate amount of occur sensitivity amount of calories or
calories or nutrients. nutrients.
 Patient maintains  Maintain weight or
weight or displays 6.Educate patient about displays weight gain
weight gain on the appropriate oral hygiene food will be more on the way to
way to preferred interventions palatable and appealing preferred goal, with
goal, with normalization of
normalization of laboratory values.
laboratory values. Dependent:


a. Administer prescribed
antiemetic agents, around Use measure to control
the clock if necessary nausea and vomiting:
b. Provide rest periods
after small meals – prevention of nausea and
vomiting can stimulate
appetite