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 renal calculi as amounts with no and choice of level in the body
passing urine’’ evidenced by palpable bladder Percuss and intervention Percussion and palpation as evidenced 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
Watch closely for renal
signs of post- shutdown No post obstructive
obstructive dieresis noted.He is
diuresis (such as This may lead vitally stabble
increased urine to serious
output and dehydration,
hypotension).
 Provides
Assess pain, information to Assessment done,patient
noting location, aid in have abdominal pain and The client
SUBJECTIVE DATA Acute pain related to intensity (scale of determining discomfort . reported relief
Patient bladder distention The client will 0–10), and the choice or and control of
complaints secondary to poor report relief and duration. effectiveness of Semi fowlers position pain as
that’’ Ihave prognosis of disease control of pain. interventions. provided.patient flet evidenced by
severe pain on condition To help the more comfortable than resting
lower abdomen patient assume a before comfortably at
position of promotes bed.
OBJECTIVE comfort. relaxation, Deep breathing and
DATA refocuses coughing exercise
Suggest the use of attention, and demonstration
On assessment
relaxation and may enhance dine.patient is following .
patient have pain
deep-breathing coping
while passing
exercises and abilities.
urine
diversional Administer Diclofenac
activities. sodium 10 mg for pain
Medications management.
Administer pain will help to
medications as reduce pain
indicated.
Subjective data
Risk for infection Assess current Understanding
Patient told that”I related to an urinary status the patient's
am having indwelling catheter, and any medical
burning sensation urinary stasis , or Client will be free predisposing history and Assessment done.
while urinating”’ environmental from infection factors such as current Urinary catheter inserted
pathogens as and septicemia urinary urinary status for bladder irrigation
Objective data evidenced by burning catheterization during post operative
sensation around Adequate period Patient protected
On assessment catheter Encourage hydration from infection as
urine become adequate fluid promotes evidenced by
turbid and intake urinary flow Encuraged him to drink clear urine
concentrated and helps flush more fluids to prevent output through
Ensure regular out bacteria infection. foly’s catheter.
cleansing with from the
mild soap and urinary tract.
water. Avoid
irritating Proper Prineal care given twice
substances. perineal daily.
hygiene
- Ensure proper reduces the
catheter care. risk of
Consider introducing Strict intake and output
alternatives to bacteria into calculation done every 8
catheterization the urinary hrly.Patient maintain
when appropriate tract. negative balance
Subjective data Fear and anxiety Assessment Mental status
Patient said related to surgical The client will Assess anxiety will help to examination done to His anxiety level
that’’ I am procedure as exhibit improved level of the prioritize the assess the anxiety decreased as
anxious about evidenced by asking emotional patient plan of care level.Patient have mild evidenced by co
my disease’’ many questions stability anxiety due to operating for pre
Be with him and It will help the hospitalization operative
Objective Data try to answer his patient to preparations.
questions in reduce anxiety Stayed with him during
On assessment simple terms level procedures and
patient is asking explanations given before
many questions Give health Relaxation each procedure
regarding his education about techniques will
illness. relaxation help him to Deep breathing and
techniques like reduce anxiety coughing
Yoga,Mindfulness instructed.Patient is
etc cooperative and following
Verbalization the instructions
Encourage him to will help to
verbalise his ventilate his
feelings feelings Encouraged
verbalization.patient felt
relaxed
P rovide Psychological
psychological support will Psychological support
support help the given.patient clarified his
patient to doubts
regain his
confidence
level