Silva, Queenie Rose V.

BSN 3-C

ASSESSMENT NURSING OUTCOME PLANNING NURSING INTERVENTION EVALUATION

DIAGNOSIS IDENTIFICATION
Subjective After 2-3 days of Short term After 2-3 days of
Impaired urinary
“Nahihirapan po ako nursing After 8 hours of nursing  Note reports of urinary nursing
and bowel
umihi at di na din po elimination related interventions, the intervention, the patient frequency, urgency, interventions, the
to nervous system
ako nadudumi ilang patient will will identify the cause incontinence and size or patient will
dysfunction
araw na” as demonstrate of incontinence and force of the urinary stream. demonstrate
verbalized by the behaviors and evacuates a soft, formed Palpate bladder after behaviors and
client techniques to prevent stool. voiding. techniques to
retention/urinary Rationale: Provides prevent
Objective infection and Long term information about the retention/urinary
●Pale in verbalizes feelings of After 2-3 days of degree of interference with infection and
appearance self-control nursing interventions, elimination or may indicate verbalizes feelings
● Weak looking regarding bowel the patient will maintain a bladder infection. of self-control
● Poor skin movements. balanced I&O with Fullness over bladder regarding bowel
turgor clear, odor-free urine, following void is indicative movements.
● Restlessness free of bladder of inadequate emptying or
distension/urinary retention and requires
VS taken as follows: leakage and participates intervention.
BP: 100/70mmHg in a daily bowel
RR: 20cpm program until a bowel  Teach self-catheterization
PR: 98 bpm pattern develops. and instruct in use and care
T: 36.5 c of indwelling catheter.
Rationale: This method
helps patient maintain
autonomy and encourages
self-care. Indwelling
catheter may be required,
depending on patient’s
abilities and degree of
urinary problem.
 Institute bladder training
program or timed voidings
as appropriate.
Rationale: Helps restore
adequate bladder functioning;
lessens the occurrence of
incontinence and bladder
infection.
 Recommend good hand
washing and proper perineal
 care.
Rationale: Reduces skin
irritation and the risk of
ascending infection.
 Ensure fluid consumption
of at least 3000 mL/day,
unless contraindicated.
Rationale: This prevents
impaction because a moist
stool can move through the
bowel more easily.
 Encourage the intake of
natural bulking agents to
thicken stools, for example,
foods such as banana, rice,
and yogurt.
Rationale: These foods help
provide bulk to the stool by
absorbing fluids from the stool.
 Educate the patient and
caregiver the importance of
fluid and fiber in
 maintaining soft, bulky
stool.
Rationale: This improves
personal efficacy and can
enhance compliance and
participation with the
therapeutic regimen.

 Educate the patient on the

importance of establishing a
regular schedule for bowel
elimination.
Rationale: Knowledge
helps the patient and family
understand the rationale for
treatment and assists the
patient in assuming
responsibility for self-care
later.