NURSING CARE PLAN
Name of Students: MONTANER, MUNIEZA, NARDO, ORTIZ, OSORIO,
PAMUGAS, PANAGUITON, PANERIO, PARIÑAL, PIMPING, RANARIO,
Year and Section: BSN 1K
Clinical Instructors: CHRISTOPHER T. PALMARES, DR. CARLANE TORRES
NURSING DIAGNOSIS
Impaired urinary elimination related
to enlarged prostate gland as
evidenced by:
SUBJECTIVE:
 Frequent voiding for the past 4
weeks
 He doesn’t feel he has emptied his
bladder after urinating.
 He is irritable, looks tired,
verbalized that he had only 4 hours
of sleep.
OBJECTIVE:
 Medical Diagnosis of Benign
Prostatic Hypertrophy (BPH)
 Diagnostic Results:
 Urinalysis- amber, clear;
pH=6.5; specific gravity=1.035;
(-) glucose, protein, and RBC
 Ultrasound result: enlarged
prostate gland.
RLE Group: 3
GOALS/OBJECTIVES INTERVENTION
After 30 minutes, the patient will be INDEPENDENT NURSING
able to empty his bladder completely INTERVENTIONS
with no palpable bladder distension. 1. Encourage fluid intake up to 1.5-
2L per day
2. Demonstrate proper positioning
of retention catheter and bag
DEPENDENT NURSING INTERVENTION
1. Bethanechol Chloride
(Urecholine) 10mg/tab, 1 tab TID
PO
INTERDEPENDENT NURSING
INTERVENTION
1. Collaborate with medical
technologists in undergoing
laboratory tests for the patient,
particularly urea nitrogen (BUN) and
creatinine.
RATIONALE EVALUATION
Goal not met. Patient verbalized
“Diutay gyapon gagwa nga ihi ko.”
1. Help maintain renal function, There is still palpable bladder
prevent infection, and distension.
encrustation around retention Also, the patient’s Post-Void Residual
catheter Volume (PVR) test result = >300mL
2. Facilitate drainage, prevent
reflux, and complications of
infection
1. Cholinergic agonist which aids in
muscle contraction to encourage
urination
1. The specific laboratory tests will
differentiate between renal failure
and urinary retention.
 NURSING CARE PLAN
Name of Students: MONTANER, MUNIEZA, NARDO, ORTIZ, OSORIO, RLE Group: 3
PAMUGAS, PANAGUITON, PANERIO, PARIÑAL, PIMPING, RANARIO
Year and Section: BSN 1K
Clinical Instructors: CHRISTOPHER T. PALMARES, DR. CARLANE TORRES
NURSING DIAGNOSIS GOALS/OBJECTIVES INTERVENTION RATIONALE EVALUATION
INDEPENDENT NURSING
Pyrexia related to illness as evidenced Within 3 hours, the client’s body INTERVENTIONS Goal met. The client's fever subsided
by: temperature will lessen from 38.9’C to 1. Assess the patient's vital signs at 1. To assist in creating an accurate and the body temperature dropped
37.0’C. The client will no longer have a least every 4 hours. diagnosis and monitor from 38.9°C to 37.0°C within 3 hours.
SUBJECTIVE: fever. effectiveness of medical Patient verbalized “Nadula na lagnat
 Verbalized that he had only 4 treatment, particularly the ko.”
hours of sleep antibiotics and fever-reducing Sweating exhibited by the patient.
OBJECTIVE: drugs (e.g. Paracetamol) BP=120/80mmHg
 Medical Dx of Benign Prostatic administered. Facilitate drainage, PR=80bpm
Hyperplasia (BPH) prevent reflux, and complications
 He is irritable, looks tired of infection
 T=38.9’C 2. Remove excessive clothing, 2. To regulate the temperature of
 BP=140/90mmHg blankets and linens. Adjust the the environment and make it
 PR= 95bpm room temperature. more comfortable for the
patient.

DEPENDENT NURSING INTERVENTION

1. Paracetamol (Biogesic) 1 tab Q4H
for T>37.5
2. Apply cold compress on the
forehead QH for T>37.5
1. Antipyretic and analgesic,
relieves pain and reduces fever
2. Applied cryotherapy and static
compression, relieves pain and
inflammatory treatments

INTERDEPENDENT NURSING
INTERVENTION
1. With the advice of a nutritionist, 1. To meet the increased
provide a high-calorie diet metabolic demand of patients.
 NURSING CARE PLAN
Name of Students: MONTANER, MUNIEZA, NARDO, ORTIZ, OSORIO, RLE Group: 3
PAMUGAS, PANAGUITON, PANERIO, PARIÑAL, PIMPING, RANARIO
Year and Section: BSN 1K
Clinical Instructor: CHRISTOPHER T. PALMARES, DR. CARLANE TORRES
NURSING DIAGNOSIS GOALS/OBJECTIVES INTERVENTION RATIONALE EVALUATION
Goal not met. After 2 hours, the patient
Impaired urine elimination related to The patient will have tolerable pain and INDEPENDENT NURSING verbalized “sakit man sa gyapon
hematuria as evidenced by: symptoms related to hematuria within INTERVENTIONS mangihi, kag dulom gyapon kulay na.”
SUBJECTIVE: 2 hours. 1. Encourage the patient to urinate 1. Avoid urine accumulation
 He has difficulty starting urination every to 3 hours Diagnostic Urinalysis Test Result:
and dribbles afterwards. 2. Encourage increased fluid intake 2. Promote patient’s micturition Color=amber
OBJECTIVE: of 2-4 L QD Specific gravity = 1.035
 Medical Dx of Benign Prostatic
Hypertrophy (BPH).
 Diagnostic result: DEPENDENT NURSING INTERVENTION
*Urinalysis- amber, clear; pH=6.5; 1. Finasteride (Proscar) 5mg/tab, 1. 5α-Reductase inhibitor, blocks
specific gravity=1.035 1 tab QD PO the production of a hormone that
causes the prostate to enlarge
2. Doxasozin Mesylate (Cardura) 2. Alpha-adrenergic blocker, relaxes
1mg/tab, 1 tab QD PO prostate muscles and the neck of
the bladder for easier urination

INTERDEPENDENT NURSING
INTERVENTION
1. Refer to an urologist for further
counseling about the said illness.
1. To get time-to-time records
about the patient’s health. Also,
to have an examination of the
entire urinary tract to try to
localize the source of the blood.