Assessment | Nursing Diagnosis | Inference | Planning | Intervention | Rationale | Evaluation | Subjective:“Nahihirapan akong umihi”Objective:•Bladder Distention•Small, frequent voiding or absence of urine output | Urinary Retention related to mechanical obstruction; enlarged prostate | BPH is the enlargement of the prostate gland thus causing mechanical obstruction in the passageway of urine. | * * •After 8 hours of NI client be able to void in sufficient amounts with no palpable bladder distension. * •Demonstrate techniques/ behaviors to alleviate/ prevent retention | •Encourage patient to void every 2–4 hr and when urge is noted.• Ask patient about stress incontinence when moving, sneezing, coughing, laughing, lifting objects.•Have patient document time and amount of each voiding. Note diminished urinary output. Measure specific gravity as indicated.•Percuss/palpate suprapubic area.• Encourage oral fluids up to 3000 mL daily, within cardiac tolerance, if indicated.• Monitor vital signs closely. Observe for hypertension, peripheral/dependent edema, changes in mentation. Weigh daily. Maintain accurate I&O.• Provide/encourage meticulous catheter and perineal care.• Recommend sitz bath as indicated.• Catheterize for residual urine and leave indwelling catheter as indicated. | • May minimize urinary retention/overdistension of the bladder.• High urethral pressure inhibits bladder emptying or can inhibit voiding until abdominal pressure increases enough for urine to be involuntarily lost.•Urinary retention increases pressure within the ureters and kidneys, which may cause renal insufficiency. Any deficit in blood flow to the kidney impairs its ability to filter and concentrate substances.• A distended bladder can be felt in the suprapubic area.• Increased circulating fluid maintains renal perfusion and flushes kidneys, bladder, and ureters of “sediment and bacteria.” Note: Initially, fluids
Assessment | Nursing Diagnosis | Inference | Planning | Intervention | Rationale | Evaluation | Subjective:“Nahihirapan akong umihi”Objective:•Bladder Distention•Small, frequent voiding or absence of urine output | Urinary Retention related to mechanical obstruction; enlarged prostate | BPH is the enlargement of the prostate gland thus causing mechanical obstruction in the passageway of urine. | * * •After 8 hours of NI client be able to void in sufficient amounts with no palpable bladder distension. * •Demonstrate techniques/ behaviors to alleviate/ prevent retention | •Encourage patient to void every 2–4 hr and when urge is noted.• Ask patient about stress incontinence when moving, sneezing, coughing, laughing, lifting objects.•Have patient document time and amount of each voiding. Note diminished urinary output. Measure specific gravity as indicated.•Percuss/palpate suprapubic area.• Encourage oral fluids up to 3000 mL daily, within cardiac tolerance, if indicated.• Monitor vital signs closely. Observe for hypertension, peripheral/dependent edema, changes in mentation. Weigh daily. Maintain accurate I&O.• Provide/encourage meticulous catheter and perineal care.• Recommend sitz bath as indicated.• Catheterize for residual urine and leave indwelling catheter as indicated. | • May minimize urinary retention/overdistension of the bladder.• High urethral pressure inhibits bladder emptying or can inhibit voiding until abdominal pressure increases enough for urine to be involuntarily lost.•Urinary retention increases pressure within the ureters and kidneys, which may cause renal insufficiency. Any deficit in blood flow to the kidney impairs its ability to filter and concentrate substances.• A distended bladder can be felt in the suprapubic area.• Increased circulating fluid maintains renal perfusion and flushes kidneys, bladder, and ureters of “sediment and bacteria.” Note: Initially, fluids