Nsg. Diagnosis/Problem: Acute urinary retention related to unknown Nsg.

Diagnosis/Problem: Fluid volume overload related to decreased

facors cardiac output
Supporting Subjective/Objective Data & Findings: Supporting Subjective/Objective Data & Findings:
Abdominal discomfort, distended bladder, decreased urinary output 2+ pitting edema in bilateral lower extremities, patient stated
of an unmeasured amount due to incontinence, residual urine shortness of breath on walking to the bathroom, x-ray results
measuring at 500mL after voiding, patient stating feelings of fullness showed bilateral pleural effusions weight increase from 197 to 209
in 10 days.
Pt. Goal: Patient voids a sufficient amount measuring >300mL per Pt. Goal: Patient will have no evidence of edema in lower
void equaling 600mL or more per shift with <100mL residual volume extremities within 48 hours of administering prescribed IV Lasix and
will continue to on PO Lasix with negative edema until discharge

Nsg. Interventions for Goal and Nsg. Interventions for Goal and rationale:
1. Patient will be giving PO Lasix BID at 8am and
rationale: 4pm to decrease edema
1. Increase fluid intake to 1500mLs or greater to Evaluation of Goal: 2. Patient will be weighed daily to monitor for Evaluation of Goal:
facilitate voiding Pt. Initials: JM Age: 78 fluid loss or retention.
3. Assess urine output in response to diuretic
2. Encourage the patient to attempt to void every 2 Patient had minimal Allergies: No known allergies therapy to ensure effectiveness Patient has minimal edema
hoursto reduce the risk for urinary retention
3. If inadequate bladder emptying occurs, measure amounts of unmeasurable Reason for Hospitalization/visit: 4. Assess for edema by palpating over the ankles in bilateral lower
redidual urine with bladder scanner and straight urine outputs by Shortness of breath on 10/18/18 and feet for decreased fluid accumulation.
extremities, no signs of
catheterize if over 250mLs to decrease the risk or 5. Assess for crackles in the lungs caused by
incontinence, Bladder was resulting in a new diagnosis of heart fluids. crackles in lungs
Urinary tract infection due to urinary retention and
urinary stasis scanned, 500mLs present, failure
4. If incomplete bladder emptying continues, obtain order was obtained for
order for foley catheter to be placedto provide free
drainage of urine to decrease urinary stasis and foley to be placed, patients PMH: Atrial fibrillation,
infection bladder emptied 450mLs. Hypertension, arrhythmia
Recommended continuing
to work on this goal next Assessment Priorities: Monitor
shift. strict intake and output. Monitor
daily weights and blood pressure, Nsg. Diagnosis/Problem: Fatigue related to expanded physical
promote rest, continue to monitor exertion and patient frequently attempting to climb out of bed
for respiratory distress Supporting Subjective/Objective Data & Findings:
Patient stating he was tired all the time and needed more sleep,
Nsg. Diagnosis/Problem: Activity intolerance related to general weakness unable to stay awake to complete thoughts, reports of patient
and imbalanced oxygen supply and demand getting minimal sleep throughout the night shift.
Supporting Subjective/Objective Data & Findings: Pt. Goal: Patient will get adequate rest lasting 1+ hour and able to
Fatigue, difficulty walking to the bathroom, SOB on exertion participate in conversation without fatigue before end of shift.
Pt. Goal: Patient will keep 02 sat at 92 or above during self care and toileting

Nsg. Interventions for Goal and rationale: Nsg. Interventions for Goal and rationale:
1. Assess vital signs prior and after activity for 1. Assess for possible reasons for lack of sleep
orthostatic hypotension through the night to possible resolve issue
2. Provide assistance with self care and allow Evaluation of Goal: resulting in adequate sleep Evaluation of Goal:
time for rest. 2. Restrict environmental stimuli during planned
3. Coordinate with PT/OT to implement a gradual times for rest to promote relaxation
increase in activity to avoid excessive cardiac Patient was transferred to 3. Offer diversional activities that are soothing This patient was able to
workload and oxygen consumption toilet by two assist with a and relaxing such as a massage with lotions take one uninterrupted nap
4. Assist patient with ROM and sitting on side of
gait belt and walker while Student Name: 4. Assist in developing habits to promote
lasting 90 minutes during
bed regularly to prevent DVT effective sleep patterns by allowing time for
maintaining o2 saturation Date: 10/28/18 relaxation prior to sleep as well as allowing for 2- this shift. This allowed him
of 93% on RA 3 hours of uninterrupted sleep sessions to participate more
throughout the night
functionally in conversation
as well as in his care