Navarro, Princess Averin F.

BSN-G2C3

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Impaired urinary elimination Desired Outcomes: Independent:

related to oliguria as The goal was met after 8
“Hirap po ako maka-ihi manifested by decreased After an 8 hour shift of Observe for cloudy or Signs of urinary tract hours of nursing
kakaunti lang po ang ihi urine output. nursing interventions, the bloody urine, foul odor. or kidney infection that can intervention as evidenced
ko.” as manifested by the client will be able to urinate Dipstick urine as indicated. potentiate sepsis. Multistrip by the patient was able to:
patient. smoothly, without any dipsticks can provide a
bladder distention. quick determination of pH, 1. demonstrate behaviors
Objective: nitrite, and leukocyte and techniques to prevent
Short Term: esterase suggesting retention/urinary infection.
•decreased urine output presence of infection. 2. identify the cause of
•retention of urine After 8 hrs of nursing incontinence.
•400 cc of urine interventions, the patient Promote continued 3. verbalize understanding
will be able to: mobility. This decreases the risk of of the condition
developing UTI
1. demonstrate behaviors Cleanse perineal area and
and techniques to prevent keep dry. Provide catheter
retention/urinary infection. care as appropriate. Proper perineal hygiene
2. identify the cause of decreases risk of skin
incontinence. irritation or breakdown and
3. verbalize understanding
development of ascending
of the condition DEPENDENT:
infection.
Catheterize as indicated.
 Catheterization may be
necessary as a treatment
Administer medications as and for evaluation if patient
needed: Oxybutynin is unable to empty bladder
(Ditropan), propantheline or retains urine.
(Pro-Banthine),
hyoscyamine sulfate
(Cytospaz-M), flavoxate
hydrochloride (Urispas),
tolterodine (Detrol).

COLLABORATIVE: These drugs reduce

bladder spasticity and
Refer to urinary continence associated symptoms of
specialist as indicated. frequency, urgency,
incontinence, nocturia.

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

Navarro, Princess Averin F.

BSN-G2C3

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Acute pain related to tissue Desired Outcomes: Independent: The goal was met after 8
“Sa sobrang sakit po hindi trauma/stretching as After an 8 hour shift of hours of nursing
ako makakilos ng maayos;” manifested by the nursing interventions, the Obtain client’s assessment To rule out worsening of intervention as evidenced
as manifested by the positioning to avoid pain. client’s pain is relieved and of pain to include location, underlying condition/ by the patient was able to:
patient. controlled. characteristic, onset, development of
frequency, quality, complications. 1. report the characteristic
Objective: Short Term: intensity, and precipitating of pain.
•Guarding behavior After 8 hrs of nursing factors. Reassess each 2. perform pain
• Facial grimace interventions, the patient time pain is reported. management.
• Expressive behavior will be able to: rest and sleep
(irritability) continuously.
• Slowed movement 1. report the characteristic Observe nonverbal cues/ Observations may or may
of pain. pain behaviors. not be congruent with
2. perform pain verbal reports or may be
management. only indicator present when
rest and sleep client is unable to verbalize.
continuously.

Demonstrate and To promote

encourage deep breathing nonpharmacological pain
exercises. management.

DEPENDENT:

-Manage pain by -Mechanism of action is to

administering appropriate reduce pain
pain medications such as
analgesics as ordered by
the physician.

-Anticipate the need for any -To find out if there are
laboratory examination as complications in relation to
supervised by the physician pain

COLLABORATIVE:

-Ask the relatives of the -To provide immediate

patient to refer to physician medical intervention
any abnormalities that may
be observed
Navarro, Princess Averin F.
BSN-G2C3

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: related to as manifested Desired Outcomes: Independent:

by The goal was met after 8
” as manifested by the After an 8 hour shift of Observe for cloudy or Signs of urinary tract hours of nursing
patient. nursing interventions, the bloody urine, foul odor. or kidney infection that can intervention as evidenced
client will be able to urinate Dipstick urine as indicated. potentiate sepsis. Multistrip by the patient was able to:
Objective: smoothly, without any dipsticks can provide a
bladder distention. quick determination of pH, 7. demonstrate behaviors
• nitrite, and leukocyte and techniques to prevent
Short Term: esterase suggesting retention/urinary infection.
presence of infection. 8. identify the cause of
After 8 hrs of nursing incontinence.
interventions, the patient Promote continued 9. verbalize understanding
will be able to: mobility. This decreases the risk of of the condition
 developing UTI
4. demonstrate behaviors Cleanse perineal area and
and techniques to prevent keep dry. Provide catheter
retention/urinary infection. care as appropriate. Proper perineal hygiene
5. identify the cause of
decreases risk of skin
incontinence.
6. verbalize understanding irritation or breakdown and
of the condition DEPENDENT: development of ascending
infection.
Catheterize as indicated.

Catheterization may be
Administer medications as necessary as a treatment
needed: Oxybutynin and for evaluation if patient
(Ditropan), propantheline is unable to empty bladder
(Pro-Banthine), or retains urine.
hyoscyamine sulfate
(Cytospaz-M), flavoxate
hydrochloride (Urispas),
tolterodine (Detrol).
These drugs reduce
COLLABORATIVE: bladder spasticity and
associated symptoms of
Refer to urinary continence frequency, urgency,
specialist as indicated. incontinence, nocturia.
Collaboration with
specialists is helpful for
developing individual plan
of care to meet patient’s
specific needs using the
latest techniques,
continence products.