ASSESSMENT EXPLANATION OF THE PROBLEM
S: >”narigat nak nga Most of the men older than 50
makaisbo nu kwa, nu have some prostatic
imisbo nak ket mejo enlargement, with benign
nasakit ngay ” as prostatic hyperplasia (BPH), the
verbalized by the patient prostate gland enlarges
sufficiently to compress the
O: > urethra and cause some overt
 (+ )Hematuria urinary obstruction. It is the most
 (+)Dysuria common cause of obstruction of
 (+)Constipation urine flow in men. The degree of
 (+)Pain rated as enlargement determines
7/10 whether or not bladder outflow
 (+)Blood in the obstruction occurs. As the
stool urethra becomes obstructed, the
 (+)Frequent muscle inside the bladder
urination hypertrophies in an attempt to
 (+)Nocturnal assist the bladder to force out
urination the urine. BPH may also cause
 Not fund of the formation of a bladder
drinking water diverticulum that remains full of
urine when the patient empties
NURSING DIAGNOSIS: the bladder. Depending on the
 IMPAIRED size of the enlarged prostate, the
URINARY age and health of the patient,
ELIMINATION and the extent of obstruction,
RELATED TO BPH is treated symptomatically
MECHANICAL or surgically. Hence the individual
TRAUMA is identified with nursing
SECONDARY TO diagnosis Impaired urinary
CYSTO TURP elimination, defined as
dysfunction in urine elimination.
OBJECTIVES NURSING INTERVENTION
STO: >within 2 hours of
nursing intervention, the
patient express
willingness to enhance
urinary elimination by
demonstrating any two of
the following:
-increased fluid intake to
at least 240 cc per shift
-stating need of
avoidance of caffeinated
beverages
-stating procedure on or
performing Kegel’s
exercises
-cooperating in bladder
training through accurate
verbal reports of fullness,
urgency, etc.
LTO:>within 8 hours of
nursing intervention, the
patient demonstrate
improved urinary
elimination state as
manifested by two of the
following:
-an hourly urine output
of no less than 40 cc
-urine characteristics
maintained at straw
colored, clear and
aromatic
RATIONALE EVALUATION
DIAGNOSTIC: OBJECTIVE FULLY MET…
>assess previous pattern >provides baseline data >client demonstrated the
of elimination, noting for for comparison and following:
any reports of urgency, determination of -increased fluid intake of
burning or incontinence treatment regimen. 300 cc per shift
-stated need of
>assess urine >changes in urinary avoidance of intake of
characteristics, including elimination and the caffeinated beverages
color, odor, and clarity presence of an IFC -stated procedure on
predispose the client to performing Kegel’s
infection, thereby exercises
aggravating the current -cooperated in bladder
condition training through accurate
verbal reports of fullness,
>assess patency and >any obstructions may urgency, etc
intactness of IFC delay urine flow and
cause bladder distention, OBJECTIVE PARTIALLY
dislodged IFC may cause MET…
further discomfort >client was able to
and/or significant increased fluid intake of
changes in elimination 300 cc per shift but still
complaining of pain rated
>monitor intake and >a urinary output of less as 5/10
output every hour than 30 cc per hour may
indicate renal problems, OBJECTIVE NOT MET..
urinary retention and/or >if the patient did not
ineffective interventions understand the health
teachings, worsen the
THERAPEUTIC: case of the patient, pain
>maintain client on semi- >allows relaxation of rate increased, rated as
fowlers or position of abdominal and perineal 9/10
comfort muscles to promote
bladder emptying
 -no reports of urinary >maintain IV line patency >To promote fluid-
REFERENCES: urgency, incontinence, and regulate IVF to electrolyte replacement
 Doenges, M., pain or burning prescribed rate and balance, and support
Moorhouse, M. et -an I and O difference of circulating blood volume
al(2008).Nurses Pocket no more than 250 cc (for healing). To promote
Guide, 10th ed. Pp 721- accurate measurement of
726, EA Davis Company, fluid input.
Philadelphia
 Nursing Directoy’s(2011) >Provide continuous >Allows the re-
NCP nursing care plan for bladder training. establishment of
benign prostatic satisfactory urinary
hyperplasia. Retrieved elimination patterns.
from: http://
www.nursing >Provide regular catheter > To prevent ascending
directorys.com/2011/01/ Care UTI which may aggravate
ncp-nursing-care-plan- the condition.
for-benign.html > To promote comfort
and hygiene.

.> Drain urine bag > To prevent growth of

aseptically at intervals. MOs in urine bag.
> To promote continuous
urine drainage.

EDUCATIVE:
>Encourage Pt.to >to promote NPI
verbalize any untoward >to allow continuous
feelings, esp. discomfort monitoring and
or pain assessment of patient
condition

>Advised client to >To help maintain renal

increase fluid intake to 2-
3 liters per day or as
tolerated. Instruct to
avoid caffeinated and
carbonated beverages.
>Instructed on the
performance of pelvic
muscle strengthening
exercises
.>Instructed SOs to
promptly report any
untoward observations,
including full drainage
bag, dislodged IFC, etc.
function, prevent
infection and formation
of urinary stones, avoid
encrustation around
catheter.
>Caffeinated and
carbonated beverages
may cause bladder
irritation.
>Kegels exercises helps
restore bladder tone,
minimize incontinence,
and facilitates complete
bladder emptying.
>Promotes continuity of
care.
 ASSESSMENT EXPLANATION OF THE
PROBLEM
S: >”haan nak nga unay Patient is not fund of
umininom iti danom ” as drinking enough water a
verbalized by the patient day. His skin is dry and
decreased in skin turgor,
O: > there for the patient is at
 Dry skin risk for having imbalanced
 Cold clammy skin fluid volume. Risk for
 Decreased skin turgor imbalanced fluid volume is
 (+)Blood in the stool defined as At risk for a
 (+)Frequent urination decrease, an increase, or a
 (+)Nocturnal urination rapid shift from one to the
other of intravascular,
NURSING DIAGNOSIS: interstitial, and/or
 RISK FOR IMBALANCED intracellular fluid. This
FLUID VOLUME refers to body fluid loss,
gain, or both
REFERENCES:
 Doenges, M.,
Moorhouse, M. et
al(2008).Nurses
Pocket Guide, 10th
ed. Pp 263-265, EA
Davis Company,
Philadelphia
OBJECTIVES
STO: >Short Term:
After 2hrs of continuous
nursing care and proper
health teachings the
patient will manifest:
• limits sodium reabsorption
Decrease risk for
complications of Fluid
volume deficit
• >Monitor BP and pulse.
Significant others will have
the proper knowledge
regarding the hydration
status of the patient
• levels, especially sodium.
Significant others will know
the proper intervention
of the problem.
LTO:>After 8 hours of
nursing interventions, the
patient will maintain
adequate fluid volume as
evidenced by good skin
turgor and balance intake
and output
NURSING INTERVENTION
Diagnostic:
>Monitor output carefully.
Note outputs of 100 to 200
mL/hour.
Evaluate capillary refill and
oral mucous membranes.
>Monitor electrolyte
>Monitor and recorded VS
Therapeutic:
>Encourage increased oral
intake based on individual
needs.
>Promote bed rest with
RATIONALE EVALUATION
OBJECTIVE FULLY MET…
>Rapid or sustained >client demonstrated the
diuresis could cause following:
client’s total fluid volume -increased fluid intake of
to become depleted and 300 cc per shift
-stated need of avoidance
in renal tubules. of intake of caffeinated
beverages
>Enables early detection of >If the client does not
and intervention for manifest signs and
systemic hypovolemia. symptoms of imbalanced
fluid volume
>As fluid is pulled from
extracellular spaces, OBJECTIVE PARTIALLY
sodium may follow the MET…
shift, causing >client was able to
hyponatremia. increased fluid intake of
300 cc per shift but still
>To obtain baseline data having imbalanced fluid
volume
OBJECTIVE NOT MET..
>Client may have restricted >if the patient did not
oral intake in an attempt to understand the health
control urinary symptoms, teachings, worsen the case
reducing homeostatic of the patient, still with
reserves and increasing risk having imbalanced fluid
of dehydration and volume.
hypovolemia.
>Decreases cardiac
workload, facilitating
head elevated. circulatory homeostasis.

>Replaces fluid and sodium

>Administer intravenous losses to prevent or correct
(IV) fluids—hypertonic hypovolemia following
saline as needed outpatient procedures.

>To avoid other fluid loses

>Provide proper through excessive
ventilation and cool sweating.
environment
>An antibiotic
>Medications given as kills/diminishes the
prescribed: Cefuroxime microorganisms causing
500mg 1 tab BID. the disease, thus,
preventing manifestation
to occur

EDUCATIVE: >To maintain hydration

>Instructed patient to status, thus, avoiding
increase fluid intake as dehydration
tolerated
>To prevent frequent
>Instructed to avoid urination
caffeinated drinks
>For hydration
>Encourage to eat foods
with high fluid content,
such as watermelon,
grapes