Assessment Nursing Inference Planning Nursing Rationale Evaluation

Diagnosis Intervention
Bacteria lodges
Subjective: Acute pain to urethra and Short term: Independent: After 4 hours
related to bladder of nursing
“Masakit ang biological factors After 4 hours of - Assess pain, - Provides intervention,
pag-ihi ko as such as activity nursing noting location, information to patient’s pain is
verbalized by the of disease Invades intervention, intensity (Scale aid in relieved and
patient” process. epithelium cells patient’s pain will of 1-10), and determining controlled.
be relieved or duration. choice or
Objective: controlled. effectiveness of
Evade host intervention.
- Facial grimace defenses Long term:
- Irritability - Encourage - Increase
- Pain scale of 7 After 8 hours of increase fluid hydration flushes
out of 10 Inflammation nursing intake. bacteria and
- Unable to sleep occurs intervention, the toxin.
- V/S as follows: patient will no
BP: 120/90 longer feel any - Investigate - Urinary
RR: 19 bpm Pain during pain or report of bladder retention may
PR: 88 bpm urination discomfort fullness develop causing
Temp. : 38.7 tissue distention
‘C and potentiates
risk for further
infection.

- Observe for - Accumulation

changes in of uremic waste
mental status, and electrolyte
behavior or level imbalances may
of be toxic to CNS.
consciousness.

- Provide - Promotes
comfort relaxation,
measures like refocuses
backrub, helping attention and
patient assume may enhance
position of coping abilities.
comfort. Suggest
use of relaxation
technique and
deep breathing
exercise.

- Encourage use - Promotes

of sitz baths, muscle
warm soaks to relaxation.
the perineum.

Dependent:

- Administer anti- - Reduces

bacterial as bacteria present
prescribed. in the urinary
tract and those
introduced by
drainage
system.
- Administer
analgesics as - Reduces pain.
prescribed.