ASSESSMENT NURSING GOAL INTERVENTION RATIONALE IMPLEMENTATION(CONTROL EVALUATION

DIAGNOSIS (PRESCRIPTIVE OPERATION) (REGULATORY

(DIAGNOSTIC OPERATION) OPERATIONS)
OPERATION)

Observe the Useful in On assessment patient

SUBJECTIVE DATA urinary stream, evaluating the having difficulty in Patient
Patient verbalized Impaired Urinary The client will noting size and degree of emptying the bladder due maintains
that “I am having Elimination related void in sufficient force. obstruction to enlarged prostate adequate fluid
difficulty while to enlarged prostate amounts with no and choice of level in the body
passing urine’’ gland as evidenced palpable bladder Percuss and intervention Percussion and palpation as evidenced by
by dribbling of urine distension. palpate done.No bladder maintaining
OBJECTIVE DATA after voiding suprapubic area. A distended distention noted negative balance
bladder can be of 500 ml for last
On assessment Monitor vital felt in the Vital signs monitored 24 hours
urinary stream is signs closely. suprapubic Bp 110/80
decreased and Observe for area. HR;86
patient feel hypertension, RR:17
urinary retantion
peripheral and Loss of kidney
dependent edema, function Weight measured and
and changes in results in noted that 1 kg weight
mentation. decreased and gain than previous
accumulation measurement 2 months
Weigh daily. of toxic wastes; back
Maintain may progress
accurate I&O. to complete
renal
shutdown No post obstructive
Watch closely for dieresis noted.He is
signs of post- This may lead vitally stabble
obstructive to serious
diuresis (such as dehydration,
increased urine lower blood
output and volume, shock,
hypotension). electrolyte loss,
and anuria.