Assessment Diagnosis Background Planning Intervention Rationale Evaluation

Study of
Diagnosis
Subjective Data: Decreased Oral fluid STG: Within 8 Independent: Within the 8 hrs
“Konti lang ang urine intake hrs of nursing shift the patient
ihi ko”as elimination intervention - Assess - Obstructed was able to
verbalized by related to normal urine patency of urinary
the patient decreased oral output will be urinary catheter can - sleep for 6
fluid intake as fluid circulating established and catheter give false hrs
Objective Data: manifested by in the blood maintain - Use of proper interpretation - change his
decreased hand hygiene - To minimize clothes
Decreased urine urine output LTG: Within 2 in draining the the rish of - drink 5
output 100ml in 100ml in 8 hrs days of nursing urine bag infection glasses of
8 hrs Less urinary intervention - Assess the - provides water
VS of output the patient will color/ amount information after 8 hrs of
T - 37.2 be able to and about nursing
P - 84 verbalized the consistency of adequacy of intervention the
R - 18 importance of urine urine patients urine
BP – 110/70 adequate oral - Monitor Vital output, output became
fluid intake in Signs condition 540cc
- on DAT his healing and patency of
foley
- c iv of process - Provide a
catheter and
D5LR 1 L quite
debris
environment in urine.

- for baseline
data
Dependent - to promote
- Administer IV rest
fluids as
prescribe by - to replenish
the physician the lost fluids
- Administer in the body
medication as
ordered by the - for
physician phamacologica
l management
Health Teaching:

- Advise the
patient to - to replace the
drink fluids used fluids in
regularly the body

- Advise the
patient to - to promote
change good self
clothing hygiene

- Advise the
patient to take - to promote
naps faster healing
and to have
more energy