Assessment Nursing Analysis Planning/Objectives Intervention Rationale Evaluation

Subjective: At risk for an • Identify individual • Encourage increased  Increased hydration

“ Sumasakit ang likod involuntary loss of risk factors and fluid intake. flushes bacteria and
ko”, as verbalized by urine associated with a appropriate toxins.
the pt. sudden, strong interventions. • Investigate report
 (+) constipation sensation or urinary of bladder fullness.  Urinary retention may
urgency. • Demonstrate develop, causing tissue
Objective: behaviors or lifestyle distention ( bladder or
 (+) facial grimace Acute pain may be r/t changes to prevent kidney), and potentiates
After 8 hours of
 restlessness physical factors development of risk for further
nursing
 (+) weakness (disruption of problem. • Observe for infection.
interventions, the pt.’s
skin/tissues, presence changes in mental
pain will be relieved or
V/S are taken as of incisions/drains), • To be able to avoid status, behavior or  Accumulation of
controlled.
follows: biological factors the pt. every 3 to 4 level of uremic waste and
T → 36.7°C (activity of dse. hrs. in individually consciousness. electrolyte
P → 71 bpm process, such as appropriate amounts. Imbalances may be toxic
R → 23 bpm cancer, trauma), and • Provide comfort to the CNS.
BP→ 110/70 mmHg psychological factors measure like back
(fear, anxiety), possibly rub, helping patient •  Promotes
evidences by verbal assume position of relaxation,
reports, self-focusing, comfort. Suggest refocuses attention, and
guarding/ distraction use of relaxation may enhance coping
behaviors, technique and deep abilities.
restlessness, and breathing exercises.
autonomic responses
(changes in V/S).
• Encourage use of
sitz baths, warm •  Promotes muscle
soaks to the relaxation.
perineum.

Collaborative:
 • Administer
antibacterial as •  Reduces bacteria
prescribed. present in urinary tract
and those introduced by
drainage system
Submitted by: Charmaine B. Dematawaran Submitted to: Mrs. Shana Ann Cuison
BSN2/Blk.6 Clinical Instructor