Rhea Mae V.

Valles
BSN-III
Pt. A.S. 64y/o

Assessment Diagnosis Planning Interventions Evaluation

Subjective: Urinary After the shift of Nsg. Action Rationale After the shift of
Mayat maya ako retention related nursing 1. Encourage 1. May minimize nursing
umiihi pero paunti- to mechanical interventions, the patient to void urinary interventions, the
unti naman. as obstruction; client will be able every 24 hr and retention and client was able to
verbalized by enlarged to demonstrate when urge is over demonstrate post
patient. prostate as post void residuals noted. distension of void residuals of
evidenced by of less than 50 2. Ask patient about the bladder. less than 50 mL,
Objectives: inability to mL, with absence stress 2. High urethral with absence of
c complaint empty bladder of incontinence pressure dribbling/overflow
of pain on completely. dribbling/overflow when moving, inhibits .
suprapubic . sneezing, and bladder
area, c pain coughing, emptying or
scale of 6, laughing, lifting can inhibit
10 as the objects. voiding until
highest and 3. Observe urinary abdominal
0 as the stream, noting pressure
lowest size and force. increases
c frequent 4. Have patient enough for
urination document time urine to be
c and amount of involuntarily
tenderness each voiding. lost.
of the Note diminished 3. Useful in
bladder urinary output. evaluating
V/S taken Measure specific degree of
as follow: gravity as obstruction
T: 37 indicated. and choice of
P: 68 5. Percuss and intervention.
R: 23 palpate 4. Urinary
BP: 170/80 suprapubic area. retention
6. Encourage oral increases
fluids up to 3000 pressure
mL daily, within within the
cardiac tolerance, ureters and
if indicated. kidneys,
7. Monitor vital which may
signs closely. cause renal
Observe for insufficiency
hypertension, 5. A distended
peripheral and bladder can be
dependent felt in the
edema, changes suprapubic
in mentation. area.
Weigh daily. 6. Increased
Maintain circulating
accurate I&O. fluid
8. Watch closely for maintains
signs of renal
postobstructive perfusion and
diuresis (such as flushes
increased urine kidneys,
output and bladder, and
hypotension). ureters of
9. Provide and sediment and
encourage bacteria.
meticulous Note: Initially,
catheter and fluids may be
 perineal care. restricted to
10. Recommend sitz prevent
bath as indicated. bladder
distension
until adequate
urinary flow is
reestablished.
7. Loss of
kidney
function
results in
decreased
fluid
elimination
and
accumulation
of toxic
wastes; may
progress to
complete
renal
shutdown.
8. May lead to
serious
dehydration,
lower blood
volume,
shock,
electrolyte
loss, and
anuria.
9. Reduces risk
of ascending
infection.
10. Promotes
muscle
relaxation,
decreases
edema, and
may enhance
voiding effort.