Navarro, Princess Averin F.
BSN-G2C3
Assessment
Subjective:
“Hirap po ako maka-ihi
kakaunti lang po ang ihi
ko.” as manifested by the
patient.
Objective:
•decreased urine output
•retention of urine
•400 cc of urine
Diagnosis Planning
Impaired urinary elimination Desired Outcomes:
related to oliguria as
manifested by decreased After an 8 hour shift of
urine output. nursing interventions, the
client will be able to urinate
smoothly, without any
bladder distention.
Short Term:
After 8 hrs of nursing
interventions, the patient
will be able to:
1. demonstrate behaviors
and techniques to prevent
retention/urinary infection.
2. identify the cause of
incontinence.
3. verbalize understanding
of the condition
Intervention
Independent:
Observe for cloudy or
bloody urine, foul odor.
Dipstick urine as indicated.
Promote continued
mobility.
Cleanse perineal area and
keep dry. Provide catheter
care as appropriate.
DEPENDENT:
Catheterize as indicated.
Rationale Evaluation
The goal was met after 8
Signs of urinary tract hours of nursing
or kidney infection that can intervention as evidenced
potentiate sepsis. Multistrip by the patient was able to:
dipsticks can provide a
quick determination of pH, 1. demonstrate behaviors
nitrite, and leukocyte and techniques to prevent
esterase suggesting retention/urinary infection.
presence of infection. 2. identify the cause of
incontinence.
3. verbalize understanding
This decreases the risk of of the condition
developing UTI
Proper perineal hygiene
decreases risk of skin
irritation or breakdown and
development of ascending
infection.
 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
” as manifested by the After an 8 hour shift of
patient. nursing interventions, the
client will be able to urinate
Objective: smoothly, without any
bladder distention.
• nitrite, and leukocyte
Short Term:
After 8 hrs of nursing
interventions, the patient
will be able to:
Observe for cloudy or
bloody urine, foul odor.
Dipstick urine as indicated.
Promote continued
mobility.
The goal was met after 8
Signs of urinary tract hours of nursing
or kidney infection that can intervention as evidenced
potentiate sepsis. Multistrip by the patient was able to:
dipsticks can provide a
quick determination of pH, 7. demonstrate behaviors
and techniques to prevent
esterase suggesting retention/urinary infection.
presence of infection. 8. identify the cause of
incontinence.
9. verbalize understanding
This decreases the risk of of the condition

4. demonstrate behaviors
and techniques to prevent
retention/urinary infection.
5. identify the cause of
incontinence.
6. verbalize understanding
of the condition
Cleanse perineal area and
keep dry. Provide catheter
care as appropriate.
DEPENDENT:
Catheterize as indicated.
Administer medications as
needed: Oxybutynin
(Ditropan), propantheline
(Pro-Banthine),
hyoscyamine sulfate
(Cytospaz-M), flavoxate
hydrochloride (Urispas),
tolterodine (Detrol).
COLLABORATIVE:
Refer to urinary continence
specialist as indicated.
developing UTI
Proper perineal hygiene
decreases risk of skin
irritation or breakdown and
development of ascending
infection.
Catheterization may be
necessary as a treatment
and for evaluation if patient
is unable to empty bladder
or retains urine.
These drugs reduce
bladder spasticity and
associated symptoms of
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.