NURSING CARE PLAN

ASSESSMENT NURSING RATIONALE PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
Subjective: Impaired Urinary urgency is After 2 hours of Independent: After 2 hours of
“cge la akon ihi pero Urinary the sudden urge to nursing intervention  Monitor patient’s  Serve as a nursing intervention
tala gudti la an Elimination urinate, due to the patient will be pattern of basis for the patient was able
nagawas” as stated related to involuntary able to: elimination determining to:
by the patient urethral contractions of the appropriate
inflammation bladder smooth  Identify self- Interventions  Identify
as evidenced muscle. Urinary care alleviating
Objective: by minimal urgency is one of alleviating  Encourage  To help improve factors as
 Frequent urine output the hallmark interventions patient to renal blood flow evidenced by
voiding noted symptoms of  Demonstrate increase fluid self-care
 Minimal Urinary Tract behavior of intake management
amount of Infection (UTI) and relief and  Demonstrate
urine can be related to absence of  Advice the  To reduce the behavior of
 Dysuria other conditions, as malaise patient and SO risk of relief as
 Body malaise well. Urinary  Verbalize for proper infection/skin evidenced by
noted Urgency is related stability of hygienic breakdown the absence of
 Microscopic to and often urinary output techniques facial grimace
hematuria accompanied by  Verbalize
urinary frequency,  Palpate the  To determine
(0.2 RBC in normal and
the need to urinate client’s bladder the presence of
urinalysis) spontaneous
frequently every 4 hours urinary retention urination

SOURCE:
Medical-Surgical GOAL MET
Nursing 6th edition Dependent:
 Administer IVF  To prevent
pg. 748
PLR 1L @ 34- dehydration
35cc/H

 Assist in giving  Ural works to

Ural sachet increase the pH
 in the urinary
making urine
less acidic
Collaborative:

 Collect specimen  Urine specimen

for urinalysis used for urine
analysis in
diagnosing the
cause of
inflammation
 Advice to consult
 Sodium intake
for dietician in
decreases pH of
minimizing
urine
sodium intake

 Consult any  Health care

medical team for providers give
any further prior emergency
alteration interventions

SOURCE:
Medical-Surgical
Nursing 6th edition pg.
747

ASSESSMENT NURSING RATIONALE PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
SUBJECTIVE: Deficient A lack or absent of After 2 hours of Independent: After 2 hours of
“pirmi ko knowledge cognitive counseling the  Advice the  To prevent from nursing intervention
ginpupugngan akon related to information or patient will be able patient to dehydration the patient as well as
pag ihi, ngan mahilig disease psychomotor ability to: increase fluid the significant other
ak kumaon process as needed for health intake were able to:
chichiriya” as stated evidenced by restoration,  Analyze  Instruct to do  Proper hygiene
by the patient the onset of preservation or factors proper hygiene restricts from  Identify risk
infection health. leading to the such as wiping pathogen factors caused
OBJECTIVE: onset of from front to susceptibility by the onset of
 No SOURCE: infection back during her infection
information Pg.505, Nurse’s  Initiate micturition
on risk factors Pocket Guide 14th actions to  Performed
of limiting Edition lessen and to  Encourage to eat  Carbonated and actions
urgency to prevent healthy instead high sodium alleviating
urinate worsening of of carbonated content foods signs and
 Unhealthy the infection and high sodium increase symptoms
diet noted  Verbalize content foods irritation to the
 Frequent urge clarity and bladder
to urinate with understandin  Verbalized
dysuria g  Instruct to empty  Stagnant urine understanding
bladder as increases the about
 WBC- 11.10
needed proliferation of prevention
g/dl (high)
pathogen and health
 Ultrasound
impression- promotion
Dependent:
Bilateral
GOAL MET
Pyelonephritis  Prevents from
 Comply
medications as drug resistance
prescribed by that further
the doctor complicates
condition

Collaborative:

 Advice to contact  Health support

or consult health system provides
continuous care
 care team
SOURCE:
Medical-Surgical
Nursing 6th edition pg.
773

ASSESSMENT NURSING RATIONALE PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
SUBJECTIVE: Acute pain Pathogen invasion After 4 hours of nursing Independent: After 4 hours of
“Masakit akon related to of the epithelial cells intervention the patient nursing intervention
puson ngan akon inflammatory which activates the will be able to:  Monitor vital  Which are the patient was able
pag-ihi processes as immune system.  Determine signs usually altered to:
” as stated by the evidenced by Releasing T-helper aggravating in acute pain
patient facial grimace cells and B-cells. T- factors  Provide proper  Clearance of  Determined
helper cells contributing pain ventilation and the environment factors that
OBJECTIVE: releases cytokines  Measure the level clearance of the promotes triggers her
 Dysuria which releases of pain from 7 to at area ventilation pain
 Hypogastric chemical mediators least 5 out 10  Measured
pain; PS such as scale of pain  Advice to  To prevent from pain scale
7/10 prostaglandins, Verbalize tolerance and increase fluid dehydration from at 7 to
 facial leukotrienes etc. decreasing pain as intake at least 4 out
grimace which is responsible evidence by facial  Place patient on  Positioning of 10
noted for the inflammation grimace her desired alleviates from  Verbalized
 Diaphoretic response. comfort position pain decreased
 Instruct for pain as
 VS TAKEN SOURCE: proper hygienic  Decreases evidence by
AS Medical-Surgical care susceptibility the absence
FOLLOWS: Nursing 6th edition and invasion of of facial
Temp- 37.7◦c pg. 750 pathogens grimace
PR- 128bpm
RR-18cpm Dependent:
GOAL MET
 Administer  Analgesics halts
ibuprofen as release of
prescribed by prostaglandins
the doctor
 Give Ural  Ural sachet
sachet as increases urine
prescribed by pH and
the physician decreases
acidity

Collaborative:
 Prepare the  Ultrasonograph
patient for y views
 ultrasonography underlying
as requested condition and
helps in
diagnosing
 Consult the
physician for  Medical team
any emergency helps in
maintaining
health of the
patient

SOURCE: pp-748
Medical-Surgical
Nursing 6th edition