Assessment Subjective Cues: “nhihirapan akong makaihi at makadumi dahil sa operasyon ko” as verbalized by the client’s son.

Objective Cues: Irritability Restlessnes s • Guarding Behavior • Foley Catheter at right side of the bed Measurements: Vital Signs: BP= 130/70 PR= 77 bpm RR= 18 cpm T = 36.5 C • •

Nursing Diagnosis

Scientific Analysis

Planning

Intervention

Rationale

Evaluation Goal: Met

Short term goal: Independent: Impaired Urinary Dysfunction in Elimination related to urine elimination Post surgical procedure as manifested by Irritability, Restlessness, guarding Behavior and Attached foley Catheter at the right side of the bed. Psychomotor: After 5 minutes of nursing care, client will be able to be relieve of impaired elimination and signs of comfort will be observable. Affective: After 5 minutes of nursing care, client behavior in impaired elimination will change to a more relaxed and comfortable behavior Cognitive: After 5 minutes of nursing care client will be able to understand the factors of impaired elimination Note Client’s previous elimination pattern To obtain bais for the present situation of the client

After 5 minutes of nursing care, patient was Provide teachings Provide able to on the causes and Information understand factors of the factors the factors impaired affecting on elimination elimination impaired pattern elimination , Check catheter To see if the demonstrat device if it is device impedes ed the dislodge elimination understandi ng and Assess factors To have the client was that impairs basis for the able to elimination type of eliminate intervention to adequately be applied on the client Check for frequency and consistency of client’s voiding To obtain baseline data on elimination pattern Source: Doenges, M.E.,et. al., Nurse’s Pocket Guide 11th Ed., p. 721-726