pected Outcome S>hindi ako gaanong umiihi, mga 2-3 beses lang kada araw O>150cc urine collected

for 8 hours >with a yellow to brownish colored urine > no crystals or blood observed > goes to comfort room twice per shift

Diagnosis: Impaired urinary elimination related to decreased renal perfusion secondary to

Within 6 hours of appropriate nursing intervention the patient will be able to have a urine output of 30-50 cc per hour or void in normal amounts and usual pattern.

> Monitor intake and output and characteristic of urine R: provide information about the kidney function and presence of complication.

> Encourage increase fluid intake. R: to increase hydration to flushed bacteria.

> Investigate reports of bladder fullness or palpate suprapubic distension. R: the urinary retention may develop causing tissue

After 6 hours of appropriate nursing intervention the patient will be able to have a normal urine output and void in a normal amounts as evidenced by 30-50cc level per hour.

nephrolithiasis

Scientific Explanation: Obstruction of the urinary stones(calculi) in the urinary tract causes urinary retention. Over distension of the bladder causes poor contractivity of the detrusor muscle, further imparting urination. And urinary retention causes overflow voiding or incontinence. distension and potentiates risk of infection.

> Document any stone expelled and send laboratory for analysis. R: retrieval of calculi allows identification of type of stones and influences choice of therapy. Assessment Planning Interventions

xpected Outcome S>Paano ba nagkakaroon ng bato O>Asking questions about his health problem >Requested for a list of contraindicated foods

>Unfamiliar with the things that contributes to his health problem like eating salty foods

Diagnosis: Knowledge deficit r/t lack of information regarding current health condition. Scientific Explanation:

Within 2 hrs. of proper nursing intervention, the patient will be able to verbalize understanding of his disease process and potential complications.

>review disease process and future expectations R: provides knowledge base from on which patient can make and formed choices >encourage patient to notice dry mouth and excessive diaphoresis and to increase fluid intake whether or not feeling thirsty R: increased fluid losses/dehydration require additional intake beyond usual daily needs >encourage patient to eat * low purine diet (example:

After 2 hrs. of proper using intervention, the patient is able to verbalized understanding of his disease process and potential complication

Lack of cognitive information or psychomotor skills required for health promotion, recovery and maintenance.

lean meat, legumes) R: decreases oral intake of uric acid precursors that leads to formation of uric acid calculi. *low calcium diet (limited milk, cheese, green leafy vegetables) R: reduces calcium oxalate stone formation *low oxalate diet (restrict chocolate, caffeine) R: reduce calcium oxalate stone formation >discuss medication regimen R: drugs will be given to acidify or alkalize urine

Assessment Planning Interventions

xpected Outcome S>tatlong araw na akong di nakakapagbawas

O>weak in appearance >restless >irritable >abdominal tenderness >discomfort

Diagnosis: Constipation r/t insufficient physical activity

Scientific Explanation: Decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and passage of excessively hard, dry stool.

Within 2-4 hrs of proper nursing intervention, the patient will demonstrate behaviors to relieved constipation

>Monitor intake and output >Auscultate for bowel sounds >Instruct client to increase fluid intake from 4-6 glasses 68 glasses per day >instruct client to eat foods that are high in fiber such as oranges, pineapple >Encourage client to increase mobility or exercise such as walking >Administer laxative medications (Dulcolax)

After 2-4 hrs. of proper nursing intervention, the patient will demonstrate behaviors to relieved constipation as evidenced by feeling of relieved and urge to defecate

Assessment Planning Interventions

xpected Outcome S > parang puputok na ang pantog ko.

O> bladder distension > small frequent voiding > urine output of 150cc within 8 hrs

Diagnosis: Chronic urinary retention related to pain felt during urination secondary to obstruction of the urinary tract.

Scientific Explanation: Urine retention occurs because the cl;ient experiences pain during urination, he is unable to excrete all the urine in his bladder.

Within 4-8 hrs of proper nursing interventions the patient will be able to void in sufficient amounts with no palpable bladder distention

>evaluate hydration status >pour warm water over perineum to stimulate reflex arc >encouraged client to report problems immediately >measure amount of voided residual >determine frequency of voiding >encourage patient to use valsalva maneuver if appropriate

After 4-8 hrs, of proper nursing interventions, the patient will be able to void in sufficient amounts (260 cc in 8 hrs.) with no palpable bladder status

Assessment Planning Interventions Expected Outcome S > Hinang-hina ako

O> grade 3 pitting edema on of hands and feet > intake of six glasses of water a day > 500cc urine output in 24 hours. > increase respiratory rate 25cpm.

Diagnosis: Fluid volume excess r/t to compromise renal function.

Scientific Explanation: Due to impairment of the renal function fluid retention occur that lead to excessive fluid in the body.

Within the 8 hours shift of proper nursing intervention the patient will stabilize fluid volume as evidence by balance intake/ output.

>Note intake and output. R: to have a baseline data of fluid intake and output.

> Review intake of sodium and protein. R: to know if foods taken aggravate the condition.

> Note pattern and amount of urination. R: to have a measurement of fluid output.

> Observe skin and mucus membrane. R: to assess for decubitus or ulceration.

> Restrict sodium fluid intake as indicated.

R: to avoid further fluid retention.

>Assist patient when changing position. R: to reduce pressure tissue pressure.

After 8 hours shift of proper nursing intervention the patient will stabilize fluid volume as evidence by balance intake/ output.