Section 325/Group 17 NURSING CARE PLAN Patient s Name: Mr.

RCV Age : 75 GOAL: Improved pattern of urinary elimination ASSESSMENT Subjective: The patient may verbalize difficulty in urinating. Objective: Patient may manifest one or more of the following: - (+) nocturia - (+) incontinence - (+) dysuria - (+) facialgrimacesuponurination - (+) edema - pt may also beseen with an indwelling catheter connected with the urine bag. NURSING DIAGNOSIS Impaired urinary elimination r/t increase urethral occlusion PLANNING After 3 hours ofnursingintervention thepatient will be able to manage themanifestation ofthe disease INTERVENTIONS 1. Monitor vital signs closely. Observe for hypertension, peripheral/dependent edema, changes in mentation. Maintain accurate I&O. RATIONALE - Loss of kidney function results in decreased fluid elimination and accumulation of toxic wastes may progress to complete renal shutdown. - *Increased circulating fluid maintains renal perfusion and flushes kidneys, bladder, and ureters of sediment and bacteria. Note: Initially, fluids may be EVALUATION -Does the patient able to manage the manifestationsof the disease; a. nocturia b. dysuria c. incontinence d. hesitancy to urinate?

2. Encourage oral fluids up to 3000 mL daily, within cardiac tolerance, if indicated.

Encourage meticulous catheter and perineal care . Encourage patient to void every 2-4 hours and when urge is noted. 4. 3.may minimize over distension of the bladder.restricted to prevent bladder distension until adequate urinary flow is reestablished.reduces risk of ascending infection . .

(+) body malaise .To prevent injury . Encourage to eat foods rich in vitamin C and intake of nutritious food. Encourage to increase fluid intake. Does he able to increase muscle strength? 2.To promoteproper blood circulation -To optimize circulation to all tissues and to relieve pressure . Encourage pt to use appropriate assistive devices. INTERVENTIONS 1.GOAL: Improved physical mobility ASSESSMENT Subjective: The patient may verbalize body malaise. RATIONALE .To optimize hydration status .To know the present status of the patient .(+) edema NURSING DIAGNOSIS Activity intolerance r/t body malaise. Monitor vital signs. 3.(+) facialgrimacesupon moving . 4. 5. Encourage pt to change position every 2 hours. Encourage pt to perform PROM as tolerated. PLANNING After 3 hours ofnursingintervention thepatient will beable to verbalize understanding of the health teachings given to increase muscle strength. . Objective: Patient may manifest one or more of the following: .To increase body resistance EVALUATION a. 6. Does the patient able to understand the health teachings given? b.

Emphasize good hand washing technique for all individuals coming in contact with patient.(+) hematuria .(+) body malaise . 5.(+) nocturia . Encourage meticulous catheter and perineal care. 4. Does the patient understand individual causative or risk factors? b. Objective: Patient may be seen with an indwelling catheter connected with the urine bag. reduces risk of acquired infection.To maintain renal function and prevent development infection. 3.Prevents crosscontamination from visitors.GOAL: Reduce or prevent risk of infection ASSESSMENT Subjective: The patient may verbalize body malaise. Does the patient able to identify interventions to reduce or prevent risk of infection? 2. Provide sterile or freshly laundered bed linens/gowns. EVALUATION a. PLANNING After an hour of nurse patient interaction. Monitor vital signs for fever. if necessary. . .Prevents exposure to infectious organisms. . . . 6. Administer antibacterial as ordered.(+) febrile NURSING DIAGNOSIS Risk for infection r/t periodic catheterization. RATIONALE .Reduces risk of ascending infection. 7. .Prevents crosscontamination.Reduces bacteria present in urinary tract and those introduced by . Encourage to increase fluid intake. the patient will be able to verbalize understanding on the health teachings given. . Monitor/limit visitors. INTERVENTIONS 1.Indicators of sepsis requiring prompt evaluation and intervention.

. Does the patient able to understand all the information given? b. PLANNING After an hour of nurse patient interaction. and the complications that the disease could develop. 3. Encourage fluid intake. . GOAL: Understanding of the diagnosis and ability to care for self ASSESSMENT Subjective: The patient may verbalize concerns regarding his condition.To diminish client s anxiety regarding the process of his disease. the patient will be able to understandthe course of his disease. how it works. . Explain medications. its side .minimal response upon assessment and questioning NURSING DIAGNOSIS Ineffective therapeutic regimen r/t lack of understanding of disease. how to prevent and alleviate its complications. and medical treatments. manifestations. Provide teachings about BPH regarding the disease process.Patient with BPH tend to limit their fluid intake to combat its manifestion needless did they know that a concentrated urine exacerbate LUTS and increase risk of UTI. treatment and diet. Is there a significant changes that occur on the patients knowledge regarding: -disease condition -diet -treatment -medication -self-care needs 2. RATIONALE . INTERVENTIONS 1.drainage system. Objective: Patient may manifest one or more of the following: .To provide knowledge about the EVALUATION a. manifestations and medical treatments.frequently asking about his condition.with worried gaze . the effects of this disease to his lifestyle.

duration. Assess pain. however.(+) restless NURSING DIAGNOSIS Pain r/t progression of disease and treatment modalities. the patient will report pain relieved/controll ed. Does the patient able to comply with the entire therapeutic regimen given? GOAL: Relief of pain ASSESSMENT Subjective: The patient may verbalize pain at hypogastric region. Tape drainage tube to thigh and catheter to the abdomen (if traction not required). RATIONALE . medications being given to the patient.Provides information to aid in determining choice/effectiveness of interventions. Is there a significant change that occur on the patients quality and intensity of pain? c. .Prevents pull on the bladder and erosion of the penile-scrotal junction. appears relaxed and be able to rest or sleep appropriately. early ambulation can help restore normal voiding patterns and relieve colicky pain.Promotes relaxation. Objective: Patient may manifest one or more of the following: . Does the patient able to relieve pain? b. Recommend bed rest as indicated. INTERVENTIONS 1. c.(+) grimacing . PLANNING After an hour of nurse patient interaction. .effects and precautions. Does the patient able to comply with the entire therapeutic 2.(+) reports of pain .(+) distraction behaviours . noting location. -Bed rest may be needed initially during acute retention phase. .(+) narrowed focus . 3. EVALUATION a. intensity (scale of 0 10).

Provide comfort measures. back rub. helping patient assume position of comfort. and may enhance coping abilities. Administer medications as indicated. Suggest use of relaxation or deep breathing exercises. provide physical and mental relaxation .g.autonomic response 4. regimen given? .diversional activities. e. 5. refocuses attention..Given to relieve severe pain.

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