Patient’s identification :

Name : Babu Kaji Maharjan

Age : 68 years
Sex: male
DOA : 078/04/21
Ward: semi nephro
Diagnosis : BPH
Chief complain:
 Abdominal pain since 4-5 days.
 Difficulty in voiding urine since 4-5 days.
 Dizziness / Weakness since 4-5 days.
Patient’s problems:
 Difficulty in voiding urine
 Nocturia
 Body malaise
 Burning sensation while urinating
 Sleep disturbance due to nocturia.
Nursing diagnosis :
 Impaired urinary elimination related to increased urinary obstruction
 Activity intolerance related to body malaise
 Sleep pattern disturbance related to urinary incontinence
 Ineffective therapeutic regimen related to lack of understanding of disease,
manifestations and medical treatments.
 Impaired nutrition requirement less than body requirement related to inadequate
dietary intake.
 Impaired urinary elimination related to urethral obstruction.
Assessment Nursing Goal Planning implementation Rationale evaluation
diagnosis
Subjective: Impaired After 3 1. Monitor 1.monitotred 1.loss of Goal was
Patient may urinary hours of vital signs vital sign and kidney fully met
verbalize in elimination nursing closely. observed for function as patient
difficulty in related to intervention, Observe for HTH, oedema Results in was able
urinating. increase the patient hypertension Decreased to void
Objective: Urethral will be able Fluid urine
Oedema Obstruction to void Elimination easily.
Dysuria urine easily.
nocturnal 2.Oedema Maintained Accumulation
Maintain Accurate intake Of toxic
accurate O. and output. wastes
and I May progress
to complete
Renal
shutdown.

3.encourage encouraged increased

oral fluid up fluid intake up circulating
to to 3000ml daily. fluid maintains
3000ml renal perfusion
Daily. and flushes
kidneys
Bladder and
ureters.
 Activity intolerance related to body malaise:
Assessment Nursing Goal Planning implementation Rationale evaluation
diagnosis
Subjective: Activity Patient -monitor vital -monitored vital -to know the Goal was
The patient intoleranc will be signs. signs. present status fully met, as
Verbalize e related able to of patient. my patient
body to body gain his was able to
weakness malaise. muscle -encourage -encouraged to -to optimize regain his
objective: strength To increase increase fluid in- hydration muscle
Patient back fluid intake. take. status. strength after
seems weak after nursing
and nuesing -encourage -encouraged to -increase bod interventions.
lethargic. interve To eat food eat food rich in resistance.
ntions. rich in vitamin vitamin C and
C and intake of intake of
nutritious food. nutritious diet.

-encourage
patient to -encouraged -to optimize
change patient to circulation.
position every change position
2 hours. every 2 hours.
 Sleep pattern disturbance related to urinary incontinence
Assessment Nursing Nursing Planning Implementation Rational
diagnosis goal
Sleep After 2 To provide quiet Provides quiet and It helps to prepare
Subjective: pattern hours of and comfortable comfortable for sleep and calms
I am not able to disturbance nursing environment. environment by the mind
sleep properly . related to interventio avoiding noise
Objective frequency of ns patient pollution and proper It helps to cope with
:Appears weak urination will be able positioning the situation and
and irritable during night to To establish explanation can
Dark circles and urine understand good rapport, Established good reduce anxiety.
Restless incontinence individual with patient and rapport, with patient
Frequent yawing . appropriate answer her and answer her
interventio
- queries. queries.
Reassessment: n to
Subjective: I feel promote To limit fluid It helps to reduce
comfortable and sleep intake in evening Encouraged to limit night-time
want to sleep. and encourage fluid at evening and elimination and
Objective: not to take nap daytime nap. promote sleep.
Patient looks during daytime.
relaxed,
energetic To provide Explaining about It helps to build
psychological disease condition, rapport and gives
support to the causes, diagnosis times to know each
patient. and treatment other.
provided
psychological
support.
 Ineffective therapeutic regimen related to lack of understanding of disease,
manifestation and medical management.
assessment diagnosis Go al Planning Intervention Rationale Evaluation
subjective: Ineffective After 2 -provide -provided -to reduce Goal was
the patient therapeutic hours of teaching about teaching about clients anxiety fully met
may regimen nursing BPH regarding BPH regarding regarding as ,my
verbalize related to lack intervention the disease the disease disease patient
concerns of Patient will process, how to process hoe to condition. was able
regarding understanding be able to prevent and prevent and to gain
his of diseases, gain alleviate its alleviate knowledge
condition. Manifestation knowledge complications. complications. About
And medical about disease
treatment. disease. -encourage -encouraged -Helps to condition.
fluid intake. Fluid intake. prevent
dehydration
and prevent
form severe
UTI.

-explain -explained -to provide

medications Medications knowledge
how it works its how it works its about the
side effects and side effects medications
precautions. and being given to
precautions. the patient.
Assessment Nursing Nursing Planning Implementation Rational Evalua-
diagnosis goal tion
Subjective: Imbalance Patient will -To assess the -Assessed the -It helps to find Goal
Patient said “I nutrition less have patient’s level of patient’s level of out the cause of was
don’t like to eat than body adequate nutrition status and nutrition status loss of appetite, fully
any food” requirement dietary cause of loss of and cause of loss level of nutrition achieved
Objective: patient related to intake during appetite. of appetite (cause status and further patient
is thin. inadequate 2 days. of loss of appetite management. had
Patient intake is dietary was altered taste adequate
less and output is intake. sensation. dietary
also less intake
Intake =700ml after 2 -
Output= 950ml -To give frequent -Oral care was -Unpleasant 3days.
Weight=39kg oral care. provided. tastes smells are
prime cause of
Reassessment: loss of appetite
Subjective: and cause nausea
I like to eat any and vomiting.
kind of food
nowadays.
Objectives: -To provide food in - Provided food -It helps to
Patient look like a small amount in a small amount increase the
active such as 100ml, and such as 100ml, appetite and food
Intake=1250 ml serve food in an and served food serving in
Output = 1150ml attractive way and in an attractive attractive way
advice the family way and advice increases
member to provide the family salivation and
food according to member to attracts towards
patient choice. provided food food.
according to
patient choice.
-To encourage a - Patient was - Helps to reduce
rest period of 1 encouraged a rest
fatigue during
hour before and period of 1 hourmealtime and
after meals. before and afterprovides
meals. opportunity to
increase total
calories intake.
-To administer -Administered - It maintains
intravenous fluids intravenous fluids plasma
and electrolytes as and electrolytes electrolytes
prescribed. as prescribed. concentration and
replaces the
calories
requirements as
well as fluid
volume in body.