Nursing

Cues Nursing Diagnosis Inference Objective Rationale Evaluation

Intervention

Objective Short Term Goal Independent

◈ Impaired Urinary ◈After 4 hours of
◈ c IVF of D5LR 1L Elimination r/t oral Oral fluid/solid ◈ After 4 hours of ◈ Assessed patency ◈ Provides basis for nursing
@ 30 gtts/min fluid/solid restriction nursing of foley catheter. further assessment intervention, the
restriction & intervention, & action. goal is met through
sensory motor normal urine exhibition of
◈ pale in impairment Dehydration elimination and adequate urinary
appearance ◈ Used asepsis and ◈ Prevents or
output will be hand hygiene in reduces risk of output and patent
maintained. providing care and contamination of drainage system.
◈ weak looking Less urinary output
manipulating the foley catheter.
urinary drainage
◈ on NPO system.

◈ c abdominal Reference: ◈ Assessed color, ◈ Provides

dressing, dry & Understanding volume, odor and information about
intact Pathophysiology, components of adequacy of urine
Huether
urine. output, condition
◈ (+) anesthetic and patency of foley
effect on pelvic & catheter and debris
lower extremities in urine.

Dependent
◈ c foley catheter
draining to ◈ Administered IV ◈ By regulating the
yellowish urine, > fluids such as PNSS amount of sodium,
30 mL/hr on fast drip as the kidney can
prescribed. regulate the volume
of body fluids.