NURSING DIAGNOSIS

N Title Topic
o
1. Activity intolerance Respiratory Rozita
2. Imbalanced nutrition Respiratory Rozita
3. Risk for imbalanced nutrition: Respiratory Rozita
4. Risk for impaired skin/tissue integrity Nutrition Nurul
5. Constipation GIT Nurul
6. Anxiety Respiratory Fathia
7. Deficient knowledge Nutrition Fathia
8. Ineffective breathing Psychological Fathia
9. Risk for infection Psychological Harsila
10 Acute pain Respiratory/pa Harsila
. in
11 Impaired physical mobility Infection Harsila
.
12 Risk for imbalanced fluid volume Pain Mas
.
13 Risk for electrolyte imbalance Mobility Mas
.
14 Risk for injury (fall) Infection Mas
.
15 Self-care deficit Respiratory Aqila
.
16 Disturbed sleep pattern Respiratory Aqila
.

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 GUIDELINE FOR INTEGRATED PLAN OF CARE

IMPAIRED GAS EXCHANGE RELATED TO NARROWING OR

OBSTRUCTION OF THE SMALL AIRWAYS

Objectives
The client will maintain adequate respiratory function as evidenced by:
1. Usual rate and depth of respiration
2. Decreased dyspnea
3. Usual or improved breath sounds
4. Usual mental status
5. Oximetry results within normal range for client
6. Arterial blood gas values within normal range for client

Intervention

1. Assess for signs and symptoms of impaired respiratory function.

RATIONALE : Early recognition of signs and symptoms of ineffective
breathing patterns allows for prompt intervention.

2. Asses for abnormal breathing example rapid, shallow respirations

Dyspnea, orthopnea (Use of accessory muscles when breathing)
RATIONALE :Rapid, shallow respirations do not provide adequate
ventilatory support. Difficulty with breathing and the need to sit up to
breathe, as well as use of accessory muscles, lead to client fatigue and
further decline in respiratory status.

3. Asses for abnormal breath sounds (e.g., wheezes, crackles)

RATIONALE :Changes in the characteristics of breath sounds may be
due to airway obstruction, mucus plugs, or retained secretions in
larger airways. Wheezing is associated with bronchospasms.

4. Encourage patient for cough effectiveness

RATIONALE :Muscle fatigue/weakness may impair effective clearance
of secretions.

5. Restlessness, irritability Confusion, somnolence

RATIONALE :Restlessness, irritability, and change in mental status or
level of consciousness indicate an oxygen deficiency and require
immediate treatment.

6. Central cyanosis (a late sign)

RATIONALE :The bluish discoloration of the skin and mucous
membranes occur in the presence of deoxygenated hemoglobin. This
occurs when arterial oxygen saturation falls below 85% to 90%.

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7. Place client in a semi-Fowler's position.
RATIONALE :Positioning in semi-Fowler's position promotes optimal gas
exchange by enabling chest expansion and diaphragm excursion.

8. Instruct client in breathing exercises focusing on hypoventilation,

breath holding after exhalation, and breathing through the nose.
RATIONALE :These techniques help clients decrease the need for beta 2
-agonists and inhaled corticosteroids.

9. Maintain activity restrictions and increase activity as allowed and

tolerated.
RATIONALE :Conservation of energy through activity restrictions allows
energy to be focused on deeper breathing.

10. Maintain client fluid intake of at least 2500 mL/day unless

contraindicated
RATIONALE :Maintaining adequate hydration decreases the viscosity of
secretions and improves ciliary action in removing secretions.

11. Assess arterial blood gas and pulse oximetry values and report
abnormal findings.
RATIONALE :Oximetry is a non-invasive method of measuring arterial
oxygen saturation. The results assist in evaluating respiratory status.
Decreasing PaO 2 and increasing CO 2 are indicators or respiratory
problems.
Allows for evaluation of client's current oxygenation status, so that
appropriate supplemental oxygen therapy can be implemented.

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ACTIVITY INTOLERANCE RELATED TO IMBALANCED OXYGEN SUPPLY
AND DEMAND

Objectives
1. Patient maintains activity level within capabilities, as evidence by
normal heart rate and blood pressure during activity, as well as
absence of shortness of breath, weakness, and fatigue.
2. Patient verbalizes and uses energy-conservation techniques

Interventions
1) Determined patient perceptions of causes of fatigue or activity
intolerance
RATIONALE :May be temporary or permanent, physical or physiological.
Assessment guide treatment.

2) Assess patient level of mobility

RATIONALE : Aids in defining what patient is capable of, which is
necessary before setting realistic goals.

3) Assess nutritional status

RATIONALE : Adequate energy reserved are required for activity.

4) Assess potential for physical injury with activity

RATIONALE : Injury may be related to fall or over exertion

5) Assess need for ambulation aids : bracing, cane, walker, equipment

modification for activities of daily living (ADLs)
RATIONALE : Some aids may require more energy expenditure (walking
with crutches) for patient who have reduced upper arm strength.
Adequate assessment of energy requirements is indicated

6) Monitor patient sleep pattern and amount of sleep achieved over past
few days
RATIONALE : Difficulties sleeping need to be address before activity
progression can be achieve

7) Observe and document response to activity

RATIONALE : Close monitoring serves as a guide for optimal
progression of activities, report any of the following : rapid pulse
>120bpm, palpitation, increase in systolic BP, dyspnea, labored
breathing, wheezing, weakness, fatigue, dizziness, pallor, and
diaphoresis

8) Establish guidelines and goals of activities with the patients

RATIONALE:Motivation is enhance if the patient participate in goal
setting. Depending on the etiologic factors of the activity intolerance

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 some patient may be able to live independently while other patient
with chronic debilitating disease may remain homebound

9) Encourage adequate rest period especially before meal, others

activities of daily living, exercise session, and ambulation. Refrain from
performing nonessential procedures
RATIONALE :To reduce cardiac workload. To promote rest. Patient with
limited activity tolerance need to prioritize task.

10) Teach energy conservation techniques

RATIONALE :They reduce oxygen consumption allowing more prolong
activities, e.g. sitting to do task, standing requires more work,
changing position often, because distributing work to different muscle
avoid fatigue

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IMBALANCED NUTRITIONS : LESS THAN BODY REQUIREMENTS DUE
TO DECREASE ORAL INTAKE RELATED TO DYSPNEA, WEAKNESS AND
FATIGUE

Expected outcome
Patient will maintain adequate nutrition status as evidence by :
1. Weight within normal range for patient
2. Normal BUN and serum Albumin level
3. Usual strength and activity tolerance

Interventions
1) Assess for and report sign and symptom of malnutrition : weight
significantly below patient usual weight or less than normal for patient
ages, height and body frame
RATIONALE :Early recognition of sign and symptom of malnutrition
allow for immediate Interventions

2) Assess for and report sign and symptom of malnutrition : Abnormal

BUN and low serum albumin, increase weakness and fatigue, sore,
inflamed oral mucous membranes and pale conjunctiva
RATIONALE : Inadequate nutritional intake may be exhibited by
significant weight loss or a weight that is less than normal, if a
significant amount of weight loss occurs in a short period of time, this
may be an indication of another disease process occurring.

3) Monitor percentage of meal and snack patient consumed. Report a

pattern of inadequate intake
RATIONALE : Monitoring patient intake help to identified when a patient
is at risk for inadequate nutrition

4) Perform actions to improve oral intake : implement measures to

improve respiratory status
RATIONALE : Intervention that relieve dyspnea allow the patient to eat
a meal without interruption or need to rest

5) Perform actions to improve oral intake : Schedule treatment that assist

in mobilizing mucous (e.g., aerosol treatment, postural drainage
therapy) at least 1 hour before or after meals
RATIONALE : Appropriate scheduling of treatments assist in decreasing
nausea.

6) Perform actions to improve oral intake : Provide oral hygiene before

meal

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 RATIONALE : Oral hygiene moistens the mouth, which make it easier to
chew and swallow, it also remove unpleasant taste, which often
improve the taste of food and fluids

7) Perform actions to improve oral intake : Assist the patient who is

dyspnea in selecting food that require little or no chewing
RATIONALE : Because a person cannot swallow and breath at the same
time, relieve of dyspnea increases the likelihood of maintaining a good
oral intake. Food that require little or no chewing are easier to eat and
help to maintain a patient nutritional status

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RISK FOR IMBALANCED NUTRITION : LESS THAN BODY
REQUIREMENTS DUE TO DECREASE ORAL INTAKE RELATED TO
DYSPNEA, WEAKNESS AND FATIGUE

Expected outcome
Patient and care giver verbalizers and demonstrate selection of food or meal
that achieve a normal weight

Interventions
1) Document actual weight, do not estimate
RATIONALE : Patient may be unaware of their actual weight or weight
loss due to estimating Weight

2) Obtain nutritional history, include family, significant others or care

giver in assessment
RATIONALE : Patient perception of actual intake may differ.

3) Monitor or explore attitude towards eating and food and monitor

environment in which eating occurs
RATIONALE : Many psychological psychosocial and cultural factors
determine the type, amount, and appropriateness of food consume.
Fewer families today have a meal together

4) Determine etiological factors for reduce nutritional intake

RATIONALE: Proper assessment guides interventions

5) Establish appropriate short and long range goals

RATIONALE :Depending on the etiologic factors of the problems,
improvement in nutritional status may take a long time. Without
realistic short term goals to provide tangible rewards, patient may lose
interest in a dressing this problem

6) Perform actions to improve oral intake : implement measures to

improve respiratory status
RATIONALE :Intervention that relieve dyspnea allow the patient to eat a
meal without interruption or need to rest

7) Perform actions to improve oral intake : Schedule treatment that assist

in mobilizing mucous (e.g., aerosol treatment, postural drainage
therapy) at least 1 hour before or after meals

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 RATIONALE :Appropriate scheduling of treatments assist in decreasing
nausea.

8) Perform actions to improve oral intake : Provide oral hygiene before

meal
RATIONALE : Oral hygiene moistens the mouth, which make it easier to
chew and swallow, it also remove unpleasant taste, which often
improve the taste of food and fluids

9) Perform actions to improve oral intake : Assist the patient who is

dyspnea in selecting food that require little or no chewing
RATIONALE : Because a person cannot swallow and breath at the same
time, relieve of dyspnea increases the likelihood of maintaining a good
oral intake. Food that require little or no chewing are easier to eat and
help to maintain a patient nutritional status

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RISK FOR INJURY (FALL) RELATED TO LOOSE STOOL (DIARRHEA)

Expected outcome
Patient will not develop any injury (fall) during care and diarrhea will reduce,
patient will pass soft formed stool no more than 3 times per day

Intervention
1- Assess for abdominal pain, cramping, frequency, urgency, loose or liquid
stool, hyperactive bowel Sensation.

(i) Culture stool

RATIONALE : To identify causative organism

(ii) Inquire about the following. Tolerance to milk and others dairy product,
medication patient is or has been taking, idiosyncratic food intolerances,
method of food preparation, level of activity and current stressors.
RATIONALE : Patient with lactose intolerance have insufficient lactase, the
enzyme that digest lactose, laxative and antibiotic may cause diarrhea, c-diff
can colonize the intestine following antibiotics use, c-diff is a common cause
of nosocomial diarrhea in health care facilities, spicy, fatty or high
carbohydrate food may cause diarrhea, fried food or contaminated with
bacteria during preparation may cause diarrhea and some individuals
respond to stress with hyperactivity of the GI tract.

2- Assess the risk of fall developing during patient stay.

RATIONALE : Patient may sustain and injury from a fall due to weakness and
susceptibility and environmental hazard.

3- Measure patient level of consciousness and orientation to people, place

and time.
RATIONALE : Diminished mental status, confusion, delirium, dementia,
infection can be a factor to increase risk of fall.

4- Age related physical changes.

RATIONALE : Older people with weak muscle are most likely to fall than those
who maintain their muscle strength as well as endurance. These changes
include change in sentence of gravity, unsteady gait, decrease muscle
strength, and delayed response and reaction time.

5- Assess need for use for mobility assisted device

RATIONALE : In proper use and maintenance of mobility aids such as cane,
walkers and wheelchair increase the patient risk of fall.

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RISK FOR ELECTROLYTE IMBALANCE,HYPOKALEMIA AND
HYPONATREMIA RELATED TO LOSS OF ELECTROLYTE IN BEDRIDDEN
PATIENT WITH NASOGASTRIC TUBE

Expected outcome
The patient will not experience hypokalemia or hyponatremia as evidence by
absence of cardiac dysrhythmias, twitching, muscle weakness, dizziness,
headache, nausea, and BUN, serum electrolyte and blood gases within
normal range.

Intervention
1- Assess for and report, sign and symptom of fluid volume deficit,
hypokalemia and hyponatremia, disorientation and drowsiness.
RATIONALE :Sign of electrolyte imbalance is disorientation, stupor, rapid,
deep respiration, cardiac dysrhythmias, low pH, irritability and anxiousness.

2- Implement additional measures to prevent or treat electrolytes imbalances

(i) Administered electrolytes replacement e.g. : potassium, normal saline if
ordered.
(ii) Give feeding as instructed with the measure amount as prescribed by
dietitian and doctor, avoid food and fluids that may cause diarrhea.
(iii) Administered antidiarrheal agent if ordered
RATIONALE : To correct electrolyte imbalances by adding supplemental
electrolytes and reducing risk for excessive electrolyte loss.

3- Assess fluid in the body, edematous upper and lower limbs. Looks for sign
of swollen areas, weight gain, cough, engorge neck vein, and increase pulse
rate.
RATIONALE : Electrolytes imbalance such as this may stem from kidney,
heart or liver failure, along
with failure in regulatory mechanism.

4- Monitor strict intake and output

RATIONALE : To determine excessive fluid and electrolyte loss from urine,
defecation and perspiration. Document and inform the physician.

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RISK FOR IMBALANCED FLUID VOLUME RELATED TO
PHYSIOLOGICAL/SURGICAL PAIN DUE TO INADEQUATE FLUID INTAKE

Expected outcome
Patient experiences adequate fluid volume and electrolyte balance as
evidence by urine output more >30mls/hour, normotensive blood pressure,
heart rate 100bpm, consistency of weight and normal skin turgor.

Intervention
1- Obtain patient history to ascertain the probable cause of the fluid
disturbance
RATIONALE :To help guide intervention, to exclude acute trauma bleeding,
reduce fluid intake from changes, large amount of drainage post-surgery or
persistence diarrhea.

2- Assess patient weight daily and consistently with same scale and
preferably at the same time of day.
RATIONALE :To facilitate accurate measurement and follow trend

3- Evaluate fluid status in relation to dietary intake. Determine if patient has

been on a fluid restriction.
RATIONALE :To determine amount of fluid that enters the body through
drinking, water in food.

4- Monitor and document vital sign

RATIONALE :Sinus tachycardia may occur in hypovolemia to maintain an
effective cardiac output. Usually pulse is weak and irregular. Hypotension is
evidence in hypovolemia. Febrile states decrease body fluid through
perspiration and increase respiration.

5- Assess colour and amount of urine. Report urine output less than
30mls/hour for 2 consecutive hours.
RATIONALE : Concentrated urine denotes fluid deficit

6- Assess skin turgor and mucous membrane for sign of dehydration

RATIONALE :The skin in elderly patient loses its elasticity therefore skin
turgor should be assessed. Longitudinal furrow maybe noted along the
tongue

7- Encourage patient to drink prescribe fluid amount

RATIONALE :Oral fluid replacement is indicated for mild fluid deficit. Patient
that have decrease sense of thirst may need ongoing reminders to drink.

8- Teach intervention to prevent future episode of inadequate intake. Inform

patient or caregiver of important of maintaining prescribe fluid intake.

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RATIONALE :Patient need to understand the important of drinking extra fluid
to maintain fluid balance.

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 IMPAIRED TISSUE INTEGRITY RELATED TO INFECTION.

Expected outcome
- Patient reports any altered sensation or pain at site of tissue
impairment.
- Patient demonstrates understanding of plan to heal tissue and prevent
injury
- Patient describes measures to protect and heal the tissue, including
wound care.
- Patient wound decreases in size and has increased granulation tissue.

Intervention

1. Monitor site of impaired tissue integrity for color changes, redness,

swelling, warmth, pain, or other sign of infection.
RATIONALE : Systemic inspection can identify impending problems
early.

2. Provide tissue care as needed

RATIONALE :Each type of wound is treated based on its etiology. Skin
wounds maybe covered with wet or dry dressing.

3. Keep a sterile dressing technique during wound care.

RATIONALE :This technique reduces the risk of infection.

4. Monitor patients continence status and minimize exposure of skin

impairment site and other areas to moisture from incontinence,
perspiration or wound drainage.
RATIONALE :This is to prevent exposure to chemicals in urine and stool
that can strip or erode the skin.

5. Administer antibiotics as ordered.

RATIONALE :Wound infection may be managed well and more
efficiently with topical agents, although intravenous antibiotics may be
indicated.

6. Tell patient to avoid rubbing and scratching. Provide gloves or clip the
nails if necessary.
RATIONALE :Rubbing and scratching can cause further injury and delay
healing.

7. Encourage a diet that meets nutritionals needs.

RATIONALE :A high protein, high calories diet may be needed to
promote healing.

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8. Monitor for proper placement of tubes, catheter, and other devices.
Assess skin and tissue affected by the tape that secures these devices.
Check every 2hours.
RATIONALE :Mechanical damage to skin and tissues as a result of
pressure, friction, or shear is often associated with external devise.

9. For patients with limited mobility, use a risk assessment tool to

systemically assess immobility-related factors.
RATIONALE :This is to identify patients at risk for immobility-related
skin breakdown.

10. Do not position patient on site of impaired tissue integrity,

reposition patient at least 2hourly.
RATIONALE :To reduces shear and friction.

11. Educate patient about nutrition, hydration to maintain tissue

integrity.
RATIONALE :The patient needs proper knowledge on his condition to
prevent further tissue injury

12. Encourage use pillows, foam wedges and pressure reducing

devices
RATIONALE : To prevent pressure injury

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DIARRHEA RELATED TO ENTERIC INFECTIONS : VIRAL, BACTERIAL OR
PARASITIC

Expected outcome
- Patient explains cause of diarrhea and rationale for treatment.
- Patient consumes at least 1500-2000ml of clear liquids within 24h
periods.
- Patient maintain good skin turgor and weight at usual level.
- Patient report less diarrhea within 36h
- Patient defecates formed, soft stool every day to every third day.
- Patient maintains a rectal area free of irritation
- Patient states relief from cramping and less or no diarrhea.
- Patient has negative stool cultures.

Intervention

1. Weigh patient daily and note decreased weight

RATIONALE : An accurate daily weight is an important indicator of
fluids balance in the body.

2. Have patient keep a diary that includes the any abnormalities during
bowel motion.
RATIONALE :Evaluation of defecation pattern will help direct treatment.

3. Avoid using medications that slow peristalsis.

RATIONALE :The increase in gut motility helps eliminate the causative
factor ,and use of anti-diarrhea medication could result in toxic mega
colon.

4. Give anti-diarrhea drug as order.

RATIONALE :Most anti-diarrhea drug suppress gastrointestinal motility,
thus allow for more fluid absorption. Supplement beneficial bacteria
(probiotic) or yogurt may reduce symptoms by reestablishing normal
flora in the intestine.

5. Record number and consistency of stools per day, use fecal

incontinence collector to measurement of output.
RATIONALE :Documentation of output provides a baseline and helps
direct replacement fluid therapy.

6. Evaluate dehydration by observing skin turgor. Watch the excessive

thirst, fever, dizziness, palpitation, bloody stool, hypotension.

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 RATIONALE :Severe diarrhea can cause deficient fluid volume with
extreme weakness and critically ill may lead to death.

7. Encourage fluid intake 1.5L 2L, consider nutritional support.

RATIONALE :Increase fluid intake replace fluid loss in the liquid stool.

8. Provide perianal care after each bowel movement

RATIONALE :Mild cleansing of the perianal skin after each bowel
movement will prevent excoriation, barrier creams can be used to
protect the skin.

9. Encourage patient to eat small, frequent meals and to consume foods

that normally cause constipation and are easy to digest.
RATIONALE :Bland, starchy food are initially recommended when
starting to eat solid food again.

10. Educate patient about to avoid spicy, fatty foods, alcohol, and
caffeine. Broil, bake, or boil food, avoid frying. Avoid food that
disagreeable.
RATIONALE :These dietary changes can slow the passage of stool
through the colon and reduce eliminate diarrhea.

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Self-care deficit impaired ability to perform or complete activities of daily
living for oneself, such as feeding , dressing, bathing, and toileting

Expected outcome
- Patient identifies useful resources in optimizing the autonomy and
independence
- Patient demonstrate lifestyle changes to meet self-care needs
- Patient recognizes individual weakness or needs
- Patient safely executes self-care activities to utmost capability.

Nursing Intervention

1. Establish short-term goals with the patient

Rational : Helping the patient with setting realistic goals will reduce
frustration

2. Guide the patient in accepting the needed amount of dependence.

Rational : Patient may require help in determining the safe limits of
trying to be independent versus asking for assistance when necessary

3. Present positive reinforcement for all activities attempted , note partial

achievement
Rational : External resources of positive reinforcement may promote
ongoing efforts. Patient often have difficulty seeing progress.

4. Boost maximum independence.

Rational :The goals of rehabilitation is one of achieving the highest level
of independence possible.

5. Allow patient to feed himself or herself as soon as possible (using the

unaffected
hand, if appropriate). Assists with setup as needed
Rational : It is possible that the dominant hand will also be affected hand
if there is upper extremity involvement.

6. Place the patient in a comfortable positioning for feeding

Rational : Proper positioning can make the task easier while also
reducing the risk for aspiration

7. Assure that the consistency of diet is suitable for the patient ability to
chew and swallow, as assessed by the speech therapist.
Rational : Thickened semisolid foods such as pudding and hot cereal are
most easily swallowed and less likely to be aspirated

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8. Provide privacy during dressing
Rational :The need for privacy is fundamental for most patients. Patients
may take longer to dress and may be fearful of breaches in privacy.

9. Use appropriate assistive devices for dressing as assessed by the nurse

and occupational therapist.
Rational : The use of buttonhook or loop-and-pile closures on clothes
may make it possible for a patient to continue independence in this self-
care activity.

10 For moderate assistance, the caregiver places arms beneath both

. patients armpits with the caregivers hands on the patients back
Rational : This method forces the patient to maintain his or her weight
forward.

11 For patient needing maximal assistance, use a gait belt

.
Rational : This method maximizes patient support while protecting the
care provider from injury.

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Disturbed sleep pattern related to decreased physical activity, fear,
anxiety, inability to assume usual sleep position, frequent assessments,
unfamiliar environment, and discomfort resulting from current illness/injury

Expected outcome

- Statements of feeling well rested

- Usual mental status
- Absence of frequent yawning and dark circles under eyes.
- Falls asleep without difficulty
- Wake up less frequently during night

Nursing Intervention

1. Assess sleep pattern disturbances that are associated with the

environment.
Rational : High percentage of sleep disturbances can affect the recovery
of the patient.

2. Observe and obtain feedbacks regarding on the usual sleeping pattern,

bedtime routine and the usual number of hours of sleep and rest.
Rational : To determine usual sleeping pattern and to compare if there
are any improvements on the sleeping pattern of the patient

3. Do as much nursing care as possible without waking up the client and do

as much as possible while the client is still awake.
Rational : To avoid disturbances during sleep, and also to maximize the
sleep and the rest of the client.

4. Explained necessity of disturbances for monitoring vital sign and care

when hospitalized.
Rational : For the client to have an understanding of the importance of
care being done to her and to minimize the complaints.

5. Recommend limiting of caffeine / alcohol use and eating of chocolate

prior to sleep
Rational : This contains ingredients that decreases the ability to fall
asleep

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Activity Intolerance due to disease process

Expected outcome

Nursing Intervention

1. Assess patient's level of mobility.

Rationale: This aids in defining what patient is capable of, which is necessary
before setting realistic goals.

2. Assess nutritional status.

Rationale: Adequate energy reserves are required for activity.

3. Assess potential for physical injury with activity.

Rationale: Injury may be related to falls or overexertion.

4. Assess need for ambulation aids: bracing, cane, walker, equipment

modification for activities of daily living (ADLs).
Rationale: Some aids may require more energy expenditure for patients who
have reduced upper arm strength (e.g., walking with crutches). Adequate
assessment of energy requirements is indicated.

6. Determine patient's perception of causes of fatigue or activity intolerance.

Rationale: These may be temporary or permanent, physical or psychological.
Assessment guides treatment. Monitor patient's sleep pattern and amount of
sleep achieved over past few days. Difficulties sleeping need to
be addressed before activity progression can be achieved.

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Knowledge deficit related to lack of information about the disease
process and self-care.

Expected outcome

Patients can express their knowledge and skills of the management of

early treatment of hypertension.

Reported the use of drugs according to medical advice.

Patients are met in terms of information about hypertension.

Nursing Intervention

1. Describe the nature of the disease and the purpose of the procedure
and the treatment of hypertension.

2. Explain the importance of a peaceful environment and therapeutics,

and management of stressors.

3. Discuss the importance of maintaining a stable weight.

4. Discuss the need for low-calorie diet, low in sodium to order.

5. Discuss the importance of avoiding fatigue in the activity.

6. Explain the need to avoid constipation in the bowel movement.

7. Explain penetingnya maintain proper fluid intake, amount allowed,

restrictions such as caffeinated coffee, tea and alcohol.

8. Discuss the symptoms of relapse or progression of complications

reported to the doctor: headache, dizziness, fainting, nausea and
vomiting.

9. Talk about drugs: the name, dosage, time of administration, purpose

and side effects or toxic effects.

10. Explain the need to avoid drug-free, without a doctor's

examination

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Acute Pain related to inflammation and infection of the urethra, bladder and other urinary
tract structures.

Expected outcome
No pain when urinating, no pain in the pelvic percussion.

Nursing Intervention

1. Monitor urine output to changes in color, odor and voiding patterns, input and output
every 8 hours and monitor the results of urinalysis repeated.
Rational: To identify indications of progress or deviations from the expected results

2. Record the location, the length of the intensity scale (1-10) the spread of pain.
Rational: Help evaluate the place of obstruction and cause pain.

3. Provide convenient measures, such as back rubs, environment, rest ;

Rationale : increase relaxation, decrease muscle tension.

4. Help or encourage the use of breath -focused.

Rational : help redirect the attention and for muscle relaxation.

5. Give perineal care.

Rational : to prevent contamination of the urethra.

6. If indwelling catheter, catheter care given 2 times per day.

Rationale : The catheter provides a way for bacteria to enter the bladder and urinary tract
rise to collaboration

7. Give analgesics according to program requirements and evaluation of its success.

Rationale: analgesics block pain trajectory, thereby reducing pain.

8. Give antibiotics. Create a wide variety of preparations drink, including fresh water. Giving
water to 2400 ml / day.
Rationale: The result of the output of urine facilitate frequent urination and help flush
channel urination

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