CUES BACKGROUND NURSING PLANNING IMPLEMEN- RATIONALE EVALUATION

KNOWLEDGE DIAGNOSIS TATION

Subjective: Short term: Independent Goal partially met.

“Minsan, pag maiihi na Double J stent is a Impaired Urinary After 1-2hrs of 1. Discuss condition  Understanding After 2 hours of discussion,
ako, hindi pa ako thin tube inserted to Elimination (Urge discussion, patient related to medical of his condition the patient was able to
nakakarating ng banyo, the ureter to prevent or Incontinence) related will be able to diagnosis and will help patient enumerate 4 out of 5
lalabas na agad.” as treat obstruction of the to increased urinary verbalize explain the causes what to methods in managing
verbalized by patient urine flow from the output secondary to understanding of and its effects to anticipate and urinary elimination.
kidney. Double J Stent presence of DJ stent condition elimination gain
Objective: have multiple in right ureter cooperation for The patient verbalized
• Stent inserted in R perforations to allow MANAGING implementing fewer incidences of urge
(Ureter) the urine to drain from Within 8 hours of URINARY interventions. incontinence
the kidney down the duty, patient will be ELIMINATION:
ureter to the bladder. able to enumerate at
least 5 ways of
managing urinary
elimination. 1. Limit fluids 2-3  Limit
hours prior to incidences of
bedtime nocturia

2. Provide assistance
or devices, as  Urinary devices
indicated (urinal, help client to
bedpan) within conserve energy
client’s reach when client
finds it hard to
have access to
the bathroom.

3. Assist with
developing  Bladder
toileting routines training aids
• establish the patient to
voiding lengthen the
time between
urges to go to
 the bathroom


schedule based on  . This also helps
client’s usual voiding to develop
pattern and gradually regular voiding
increase time interval habits

• recommend
consciously
delaying
voiding by
using  Behavioral
distraction techniques for
(e.g. slow, urge
deep breaths), suppression
self-
statements
(e.g. “I can
wait”), and
contracting
the pelvic
muscles when
exposed to
triggers

• encourage
regular pelvic
floor
strengthening  These exercises
exercises or help strengthen
Kegel the muscles that
exercises control the
bladder.
4. Advise patient to
 avoid caffeinated
beverages and  Caffeine has a
Long term: alcohol diuretic effect
on the body.
After 3 days of Alcohol halts
follow up visits, the production
patient will be able of ADH,
to resulting in
• verbalize 1. Encourage patient frequency of
control over and SOs to monitor voiding.
voiding and record daily fluid
• report intake and  Observe for
fewer elimination during progression of
incidences hospital stay condition and
of urge evaluate
incontinenc effectiveness of
e interventions
th
Davis, F.A. (2008) Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales (11 ed) FA Davis Co.