ASSESSMENT DIGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

RATIONALE
SUBJECTIVE Impaired urinary Na and water After 1-2 hours of Assess Identifies The client was
CUES: elimination r/t retention nursing voiding characteristics of able to
Na and water intervention the pattern bladder function demonstrate
“Madalas lang retention as patient mother (frequency (effectiveness of behaviors and
siya umihi sa evidenced by will able to and amount). bladder techniques to
isang araw “as edema. alteration of the demonstrate Compare emptying, renal prevent urinary
verbalized by Starling forces behaviors and infection
which control urine output function, and
patient’s mother techniques to with fluid fluid balance).
transfer of fluid
from the vascular prevent intake. Note Note: Urinary
compartment to retention/urinary
specific complications
OBJECTIVE CUES: surrounding infection.
tissue spaces
gravity are a major
cause of
*Edema in the
After 1-2 days of mortality.
left lower
extremities nursing
collection of fluid intervention the
*c within the body's client will able to
interstitial space achieve normal Note reports This provides
*Urinary elimination of urinary information
frequency pattern or frequency, about degree of
participate in urgency, interference with
measures to burning, elimination or
*anuria Eedema correct or
incontinence, may indicate
compensate for
nocturia, and bladder infection
defects.
size or force . Fullness over
of urinary bladder following
stream. void is indicative
Palpate of inadequate
bladder after emptying or
voiding. retention and
requires
intervention.
Encourage Sufficient hydration
fluid intake 6- promotes urinary
8 glasses per output and aids in
day. preventing infection.

Recommend Handwashing and

good hand perineal care reduce
washing and skin irritation and risk
of ascending
proper
infection.
perineal care.

Collaboration with
Refer to specialists is helpful
urinary for developing
continence individual plan of care
specialist as to meet patient’s
indicated. specific needs using
the latest techniques,
continence products.
 ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION
RATIONALE
SUBJECTIVE CUES: Excess fluid Renal failure After 8 hours of Assess patient For baseline data The client/family
volume r/t nursing condition demonstrate
excessive fluid intervention ,the behaviors to
intake as patient shall monitor fluid
evidenced by ↓ blood flow to demonstrate Emphasize the Fluid status and reduce
OBJECTIVE CUES: edema. the kidneys behaviors to importance of management is recurrence of fluid
*Edema monitor fluid dietary and fluid usually calculated excess
*ascities status and reduce restrictions to prevent further
recurrence of fluid fluid retention
↓ perfusion in excess
kidney
Place in Semi- To facilitate
After 2-3 days of fowler’s position movement of
nursing as appropriate diaphragm, thus
↓ urinary output intervention, the improving
patient will respiratory effort.
Manifest stabilize
fluid volume AEB
balance I & O, Instruct Accurate I and O
water retention normal VS, stable client/family in is necessary for
weight ,and free use of voiding determining renal
from signs of records ,I&O function and Fluid
edema replacement need
sand reducing risk
Fluid volume of fluid overload
excess