VIII.

NURSING CARE PLAN

ASSESSMENT

NURSING
DIANOSIS
OBJECTI VES INTERVENTIONS RATIONALE

Subjective Cues:
The patient
verbalized
difficulty in
urinating.

Objective Cues:
(+)incontinence
(+) dysuria
(+) facial
grimacing upon
urination
With FBC to
UDB
Dyspnea with
exertion
Fatigue and
weakness
Vital Signs:
T: 35.2 C
P: 112 bpm
R: 25 cpm
BP: 120/68
mmHg


Impaired
urinary
elimination
related to
increase
urethral
occlusion

Short term goal:
After 8 hours of
holistic nursing
intervention, the
patient and S.O.
will be able to :
Verbalized
understanding
of condition
Participate in
measures to
correct or
compensate
for defects.
Demonstrate
behavior and
techniques to
prevent
urinary
infection.

I ndependent:
1. Monitor vital signs closely.
Observe for hypertension,
peripheral/ dependent
edema, and changes in
mentation. Maintain
accurate I &O.

2. Encourage oral fluids up to
3000 mL daily, within
cardiac tolerance,
if indicated.








3. Encourage patient to
void every2-4 hours and
when urge is noted.
4. Encourage
meticulous catheter
and perineal care.

Dependent:
1. Administer
medications as
prescribed.



1. Loss of kidney
function results in
decreased fluid
elimination and
accumulation of toxic
wastes may progress to
complete renal shutdown.
2. Increased circulating
fluid maintains
renal perfusion and
flushes kidneys, bladder,
and ureters of
sedimented bacteria.
Note: Initially, fluids may
be restricted to prevent
bladder distension until
adequate urinary flow is
reestablished.

3. May minimize over
distension of the bladder.

4. Reduces risk of
ascending infection



1. Pharmacologic regimen
helps in faster recovery.