WESLEYAN UNIVERSITY-PHILIPPINES
Cushman Campus
Mabini Extension, Cabanatuan City
Philippines, 3100
ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION EVALUATION
WESLEYAN UNIVERSITY-PHILIPPINES
Cushman Campus
Mabini Extension, Cabanatuan City
Philippines, 3100
SUBJECTIVE DATA: Impaired urinary elimination SHORT TERM GOALS: INDEPENDENT: SHORT TERM GOAL: WAS MET
“ Feeling ko ihing-ihi nako pero wala related to urinary urgency
After 8 hours of nursing intervention - After 8 hours of nursing
naman lumalabas or patak-patak secondary to Urinary Tract Infection
the patient will be able to: intervention:
lang .” as verbalized by the client. (UTI) as manifested by presence of 1. Encourage the patient to
bacteria, dysuria and “feeling ko 1. Verbalize understanding rest and relax. Rationale: - The patient verbalized
ihing-ihi nako pero naman toward appropriate amount This will provide comfort for understanding toward
Pain scale- 5/10
lumalabas or patak-patak lang” as of water/fluid intake for the the patient and will appropriate amount of
OBJECTIVE DATA:
stated by the client. condition and hydration contribute to the client’s water/fluid intake for the
● Vital Signs: (March 23,2024) support. abdominal pain. condition and hydration
BP: 130/90mmHg 2. Report reduction in the 2. Encouraging the patient to support.
Temp: 36.4c abdominal pain using drink plenty of fluids. - The patient reported a
PR: 86bpm pharmacological Rationale: This will help the reduction in his abdominal
RR: 21cpm intervention with the scale patient to normalize the pain with the pain scale of
● Urinalysis shows presence of 2/10 from 5/10. urine pattern as well as to 2/10 from 5/10 using
of bacteria 3. Verbalize understanding on flush toxins in the body. pharmacological
● Abdominal pain when how good practice hygiene 3. Inform or educate the client intervention.
urinating and avoid tight-fitting about the importance of - Verbalized understanding on
clothing/underwear. good hygiene practices. how good hygiene
Rationale: Good hygiene
( Impaired Urinary Elimination )
PATIENT X
- Sepsis s/t complicated UTI
WESLEYAN UNIVERSITY-PHILIPPINES
Cushman Campus
Mabini Extension, Cabanatuan City
Philippines, 3100
-Dysuria practices can avoid the practice and avoid tightfitting
recurrence of a certain clothing/underwear.
LONG TERM GOALS:
infection.
After 7 days of nursing intervention
the patient will be able to:
-
DEPENDENT: LONG TERM GOAL: WAS
1. Be free from infection. MET
1. Administering antibiotic as
2. Report normal urinary prescribed, (Cephalexin After 7 days of nursing
- intervention:
pattern. three times a day 500mg for
7 days.) (if on hospital
3. Verbalize the patient on settings) . Rationale: This Is now free from the
how unprotected sexual will kill the bacteria that - infection.
intercourse can cause causes the patient’s current
infection even after diagnosis.
discharge. 2. Administering drug for pain The patient reported normal
medication as prescribed. voiding pattern with relief
Rationale: To decrease the and comfort.
intensity of pain, and to
improve client’s condition.
3. Administering IV fluids and The patient verbalized on
electrolyte as prescribed. understanding that
Rationale: This will help to unprotected sexual
improve client’s condition intercourse can cause
and can contribute for the infection even after her
healing of the patient. discharge in the hospital.
COLLABORATIVE:
WESLEYAN UNIVERSITY-PHILIPPINES
Cushman Campus
Mabini Extension, Cabanatuan City
Philippines, 3100
1. Referral to a Medical
Technologist for urinalysis
tests. Rationale: This will
monitor the client’s urinalysis
tests and read the results
accurately.
