Urinary Bladder Mass

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NURSING CARE PLAN

Patient’s Initials: V.D Chief Complaint: Hematuria Name of Student Nurse:


Age & Gender: 75yrs. Old/Male Karl Adrianne C. De Guzman

Birthdate: May 23, 1954 Admitting Diagnosis: Impaired Urinary Elimination r/t Level/Block/Group:
Urinary Bladder Mass AEB Hematuria 4BSN-06

Address: Bani, Pangasinan, Philippines Hospital/Area: Dagupan Doctors


Villaflor Memorial Hospital/
Medical-Surgical Ward
Date of Confinement: 07/22/2022 Clinical Instructor:
Prof. Catherine N. Nicolas
Date: 08/03/2022

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION


ANALYSIS INTERVENTIONS

Subjective Data: A urostomy is a Desired  Record urinary  Sudden decrease in Goals met.
“Hindi ko surgical procedure Outcomes/ output. urine flow may indicate After nursing
nararamdaman yung ihi that creates a stoma Evaluation Investigate obstruction or interventions,
ko eh” as verbalized by (artificial opening) for Criteria: sudden reduction dysfunction, such as the patient
the patient. the urinary system. A or cessation of blockage by edema or can:
urostomy is made to After nursing urine flow mucus, or
Objective Data: avail for urinary interventions, the dehydration. - Display
 Oriented diversion in cases patient is continuous flow
 Observe and
 Coherent where drainage of expected to: of urine, with
urine through the record color of  Continued bleeding, output
 Irritability urine. Note frank blood in the
bladder and urethra - Display adequate for
 Anxious hematuria or pouch, or
is not possible, e.g., continuous flow individual
after extensive of urine, with bleeding from oozing around the situation.
surgery or in case of output adequate stoma. base of stoma requires
Vital Signs taken: obstruction. for individual medical - Maintained
 BP- 140/90 situation.  Position tubing evaluation and appropriate
mmHg and drainage intervention. mental and
 HR- 70 bpm - Maintain pouch so that it physical
appropriate allows unimpeded functioning.
 RR- 20 cpm  Blocked drainage
mental and flow of urine.
 Temp- 36.5 physical allows pressure to - Demonstrated
degrees Celsius Monitor and
functioning as build within urinary active
protect stents.
long as possible. tract, risking participation in
 Encourage anastomosis leakage necessary and
increased fluids and damage to renal desired
- Demonstrate and maintain parenchyma activities in
active accurate intake activity levels.
participation in  Maintains hydration
NURSING DIAGNOSIS necessary and and good urine flow.
 Monitor vital
desired activities
signs. Assess
Impaired Urinary in activity levels.
peripheral pulses,  Indicators of fluid
Elimination r/t Urinary
Bladder Mass AEB skin turgor, balance. Reflects level
Hematuria capillary refill, and of hydration and
oral mucosa. effectiveness of fluid
Weigh daily replacement therapy

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