EVALUATION/EXPECT

ASSESSMENT EXPLANATION OBJECTIVE INTERVENTION RATIONALE

ED OUTCOME
Subjective Data: Short-Term Diagnostic: Goal met if:
Reference: Objective (STO) Assess the patient’s This information is – After 48 hours of
– After 8 hours of normal pattern of the source for an nursing interventions,
Objective Data: nursing urination and episode individualized the patient will report
interventions, of incontinence. toileting program. of being able to start
the patient will Monitor urinary These parameters and stop stream, and
Nursing Diagnosis: experience less elimination, including help determine empty bladder
dribbling and consistency, odor, adequacy of urinary completely.
nocturia. volume, and color. tract function.
Complete a focused This provides Goal partially met if:
Long-Term record of the evidence to the – After 48 hours of
Objectives (LTO) incontinence causes, the severity nursing interventions,
– After 48 hours of including duration, of the condition, and the patient will report
nursing frequency and its management. of having difficulty
interventions, severity of leakage initiating urine
the patient will episodes, and stream, but
be able to start alleviating and experienced less
and stop aggravating factors. dribbling and
stream, Take a specimen of Successful nocturia.
and empty urine for culture. management of a
bladder urinary tract Goal not met if:
completely. infection may – After 48 hours of
reduce or improve nursing interventions,
incontinence. the patient will report
Observe the results of Cystometry is a of having difficulty
cystometry. diagnostic testing initiating urine
used to measure stream, and is still
bladder pressures experiencing
and fluid volume dribbling and
during filling, nocturia.
storage, and
urination. The
results of this test
may show the
underlying problem.
Therapeutic: To strengthen or
Encourage patient to retrain pelvic floor
perform kegel muscles and
exercises. sphincter muscles.
Promote hygiene, Hygiene and skin
skin care and prevent care is strictly
infection by using a observed for
non-allergenic soap patients with urinary
with lukewarm water, incontinence
and patting dry the problem to avoid
perineal area. occurrence of
complications such
as skin problems,
bed sore, skin and
urinary infection.
Promote positive Promote role
feedback and performance, body
optimistic attitude to image and relieving
reinforce patient’s anxiety and stress.
ego and esteem.
Periods of continence
and successful
voidings are
positively reinforced.
Instruct patient that This promotes
fluid intake should be continuous sleep
consumed before and rest of the
evening. patient to minimize
the need to void
frequently during
the night.
Educative:
Explain to patient and Successful overflow
caregiver the continence requires
rationale behind and consistency in use
implementation of a of a toileting
toileting program. program.