DATE:__________________________ NURSING CARE PLAN ASSESSMENT NURSING DIAGNOSIS Acute urinary retention related to enlarged prostate as evidence by dribbling

of urine secondary to benign prostatic hypertrophy. Definition: Incomplete emptying of the bladder. SCIENTIFIC REFERENCE Benign Prostatic Hyperplasia characterized by progressive enlargement of the prostate gland (commonly seen in men older than 50 years old), causing varying degrees of urethral obstruction and restriction of urinary flow. GOAL/ OBJECTIVES That after 8 hours of comprehensive nursing intervention, patient will be able to; Void in sufficient amount, for at least 30-60 cc/hr with no palpable bladder distention. INTERVENTION RATIONALE EVALUATION

Subjective cues

Objective cues

Gagmay akong ihi, as verbalized by the patient. putol-putol ug ginagmay ang pag pangihi ni papa, as verbalized by the daughter.

Dribbling urine as verbalized by the daughter of the patient. Bladder distention.

Maintained accurate intake and output measurement. Drained accurately cystoclysis output from urobag every hour as ordered. Established catheter patency.

Loss of kidney function results in decrease fluid elimination and accumulation of toxic waste may progress to complete renal shutdown. To maintain free flowing drainage and fluid volume excess To prevent ascending urinary tract infection and maintaining free flow of the drain.

After 8 hours of comprehensive nursing intervention, patient was able to; Void sufficiently with a urinary output of 60-220 ml/hr.

Ensured the prevention of the backflow of the drain Collaborative: Underwent TURP procedure last September 26, 2011.

Source: Doenges, Marilynn E. ,et. al., Nursing Care Plans., 7th

Source: Doenges, Marilynn E. ,et. al., Nursing Care Plans., 7th Edition., 2006

Done to relieve urinary symptoms by removing a portion of the prostate gland immediately surrounding the

DATE:__________________________ Edition., 2006 urethra

DATE:__________________________ NURSING CARE PLAN ASSESSMENT NURSING DIAGNOSIS Deficient knowledge related to lack of specific to necessary information for client and SO to make informed choices regarding condition, treatment and lifestyle changes.. SCIENTIFIC REFERENCE Benign Prostatic Hyperplasia is characterized by progressive enlargement of the prostate gland (commonly seen in men older than 50 years old), causing varying degrees of urethral obstruction and restriction of urinary flow. GOAL/ OBJECTIVES That after 8 hours comprehensive nursing care patient and significant others will be able to; verbalize understanding of disease process/ prognosis and potential complications. INTERVENTION RATIONALE EVALUATION

Subjective cues Sige ug sinusitison akong papa nya tagaan namu siya ug Sinutab taga mutukar. Mao man ni siya nagkainingon ani tungod sa Sinutab, as verbalized by the daughter.

Objective cues

Reviewed disease process and clients information.

Patient and SO are asking questions regarding the causes of his condition. Statement of misconception. Inaccurate treatment of perceived condition.

Provides knowledge base from which client can make informed therapy choices. Helping client work through feeling can be vital to rehabilitation. May cause prostatic irritation with resulting congestion.

Encouraged verbalization of patients fears and concerns.

After 8 hours comprehensive nursing care patient and significant others was able to; verbalize understanding of disease process/ prognosis and potential complications.

Recommended avoiding spicy foods, coffee, alcohol, rapid intake of fluids. Instructed significant other/s to report any signs of unusualities (eg fever, chills, diminished urine output) to healthcare providers immediately.

Definition: Absence or deficiency of cognitive information related to specific topic. Source: Doenges, Marilynn E. ,et. al., Nursing Care Plans., 7th Edition., 2006

Prompt interventions may prevent more serious complications.

Source: Doenges, Marilynn E. ,et. al., Nursing

DATE:__________________________ Care Plans., 9th Edition., 2006 Dependent: Requested the ROD to explain to the patient the entire disease process and his condition. To provide accurate information regarding the condition.

DATE:__________________________ NURSING CARE PLAN ASSESSMENT NURSING DIAGNOSIS Activity intolerance related to functional changes accompanying aging secondary to Benign Prostatic Hyperplasia. Definition: Insufficient physiological energy to endure or complete required or desired daily activities. SCIENTIFIC REFERENCE Benign Prostatic Hyperplasia in characterized by progressive enlargement of the prostate gland (commonly seen in men older than 50 years old), causing varying degrees of urethral obstruction and restriction of urinary flow. GOAL/ OBJECTIVES That 8 hours of comprehensive nursing care patient will be able to; participate in exercise and social activities to the extent possible. INTERVENTION RATIONALE EVALUATION

Subjective cues

Objective cues 68 y.o Unable to tolerate prolonged sitting and standing Reports of fatigue or weakness upon exertion of activities Exertional discomfort Inability to maintain usual routine Lethargic

Clustered nursing care and adjust activities within limits of tolerance

Sige rakog higda, as verbalized by the patient.

To provide adequate rest periods and prevent overexertion. To increase stamina and enhance ability to participate in activity. Enhance ability to participate in activity to improve strength. Helps identify or monitor degree of fatigue and potential for complications. To help improve his quality life.

Encouraged patient to become involved in simple exercise such as walking and assist with ADLS. Adjust activities, reduce intensity level or discontinued as needed. Monitor response to activity including BP, pulse, respiratory rate, skin color and behavior. Establish realistic goals for improving patients activity

That 8 hours of comprehensive nursing care patient was able to participate in simple exercise to the extent possible.

kinahanglan jud niya ug kuyog kung magbakonbakon ug mubalik ra pud ug higda dayon kay daling kapuyon as verba;lized by the daughter.

That after 1 week of comprehensive nursing care patient will be able to; tolerate prolong sitting and standing

That after 1 week of comprehensive nursing care patient will be able to; tolerate prolong sitting and standing and perform basic ADLS.

Source: Doenges, Marilynn E. ,et. al., Nursing Care Plans., 9th Edition., 2006

Source: Doenges, Marilynn E. ,et. al., Nursing Care Plans., 7th Edition., 2006

DATE:__________________________ level, considering his physical limitations and energy level.

DATE:__________________________ NURSING CARE PLAN ASSESSMENT NURSING DIAGNOSIS Risk for infection related to urine stasis as evidenced by decreased urine output secondary to Benign Prostatic Hyperplasia. Definition: At increased risk of being invaded by pathogenic organisms. SCIENTIFIC REFERENCE Benign Prostatic Hyperplasia in characterized by progressive enlargement of the prostate gland (commonly seen in men older than 50 years old), causing varying degrees of urethral obstruction and restriction of urinary flow that will cause urine stasis which can contribute to bacterial growth. GOAL/ OBJECTIVES That after 8 hours of comprehensive nursing care patient will be able to; Be free from infection; and identify interventions to prevent/ reduce risk of infection. Long Term: Patients significant others will know the ways to prevent ascending infection and observe proper aseptic technique. INTERVENTION RATIONALE EVALUATION

Subjective cues

Objective cues With cystoclysis attached to uroguard draining blood tinged urine

Monitored vital signs for fever.

Indicators of sepsis requiring prompt evaluation and intervention. Reduces risk of cross contamination. Prevents exposure to infectious organism. To prevent contamination that would promote further complication.

Observed careful handling of patient and thorough hand washing. Provided clean and freshly laundered bed linens/ gowns. Instructed patients SO to wash hands frequently before handling patient and making sure the environment is always clean. Ensured the placement of the urobag.

After 8 hours of comprehensive nursing care management patient was; free from any signs of infection; and the SO was able to identify interventions to prevent/ reduce risk of infection.

Source: Doenges, Marilynn E. ,et. Al., Nursing Care Plans., 9th Edition., 2006

Source: Doenges, Marilynn E. ,et. Al., Nursing Care Plans., 7th Edition., 2006

To prevent ascending UTI and maintaining the flow of the drain. Reduces bacterial

Promoted

DATE:__________________________ meticulous perianal care. colonization.

Dependent: Administered Vigocid 2.25 g IVTT every 8 hours. To treat existing infection and prevent any further infection.

DATE:__________________________ NURSING CARE PLAN ASSESSMENT NURSING DIAGNOSIS Sleep pattern disturbance related to medical regimen as evidence by vital signs monitoring every hour secondary to essential hypertension. Definition: Time limited disruption of sleep amount and quality. SCIENTIFIC REFERENCE Clients with sleeping problems have difficulty falling asleep or difficulty staying asleep. Various factors may be involved. These include frequent changes in sleep time, changes in sleep environment, physical discomfort or pain, or anxiety about actual or anticipated loss. GOAL/ OBJECTIVES After 8 hours of nurse-patient interventions the patient will be able to: >verbalize understanding of sleep disturbance >identify individually appropriate interventions to promote sleep Long Term: Patient will be able to sleep during uninterrupted night time and wakes up during day time. INTERVENTION RATIONALE EVALUATION

Subjective cues dili ko katulog magbii as verbalized by the patient.

Objective cues Dark circles noted around the eyes Appears weak Noted frequent yawning

Noted waking and sleeping hours. Discussed or implemented effective age appropriate bed time rituals such as going to bed at same time each night, drinking warm milk and switching on dim lights. Limited intake of chocolate and caffeinated drinks.

To assess patients sleeping pattern Enhance clients ability to fall asleep, reinforce that bed is a place to sleep

After 8 hours of nurse-patient interventions the patient was able to verbalize that the interventions done here in the hospital are important.

di mani siya matulog ug gabie, sa buntag man ni siya matulog, as verbalized by the daughter.

Asleep during the day until 2pm Monitor vital sign such as BP, TPR every hour

To assist patient to establish optimal sleep or rest patterns

Source: Doenges, Marilynn E. ,et. al., Nursing Care Plans., 9th Edition., 2006

Encouraged to avoid afternoon naps.

Source: (Kozier, et. al. Fundamentals of Nursing, 7th ed. page 1122).

Napping in the afternoon can disrupt normal sleep pattern To promote minimal interruption and enhance sleep or

Clustered fast and organized care and visited at intervals; observed silence at

DATE:__________________________ all times during patients visit, close the door slowly. rest

DATE:__________________________ ASSESSMENT NURSING DIAGNOSIS SCIENTIFIC REFERENCE GOAL/ OBJECTIVES INTERVENTION RATIONALE EVALUATION

Subjective cues

Objective cues

DATE:__________________________ ASSESSMENT Subjective Kanus-a ni tangtangon ang mga tubo sa askon ihi? as verbalized by patient. Objective Insomnia NURSING DIAGNOSIS SCIENTIFIC REFERENCE Vague and easy feeling of discomfort or dread accompanied by an autonomic response: a feeling of apprehension caused by anticipation of danger. It is an altering signal that warns of impending danger and enables the individual to take measures to deal with threat. Source: (Kozier, et. al. Fundamentals of Nursing, GOAL/ OBJECTIVES After 8 hours of nurse-patient interaction the patient will be able to: >appear relax and report that anxiety is reduced After 2 days: >verbalized awareness of feelings of anxiety >use resources or support system effectively >identify healthy ways to deal with and express anxiety

INTERVENTION Established a therapeutic relationship conveying empathy and conditional positive regard. Encouraged verbalization of feelings and discomforts. Instructed to have breathing exercises and provided comfort measures such as calm environment, well lit room and television. Provided accurate information about the Identify healthy ways to deal with and express anxiety Dependent: Let the ROD explain to the patient the disease process and

RATIONALE It will encourage client to acknowledge and to express feelings To assist client to identify feelings and begin to deal with problems. Promotes relaxation and diverts the attention of the client

EVALUATION After 8 hours of nurse-patient interaction the patient was relaxed and showed a good response by participating well during procedures

Mild Anxiety related to Sleep change in disturbances health status secondary to Worried the disease process Expressed concerns Definition: about Vague changes. uneasy feeling of discomfort or dread accompanied by an autonomic response Source: Doenges, Marilynn E. ,et. al., Nursing Care Plans., 9th Edition., 2006

Helps client identify what is reality based.

To be aware of the disease process and the

DATE:__________________________ 7th ed. page 1122). his condition. possible changes in health status.

DATE:__________________________ ASSESSMENT NURSING Subjective Objective DIAGNOSIS Dili kaayo ko ganahan mukaon karon as verbalized by the patient with loss of appetite food served not taken reported altered taste sensation lack of interest in food Imbalanced Nutrition: less than body requirements related to loss of appetite. Definition: Intake of nutrients insufficient to meet metabolic needs.

SCIENTIFIC REFERENCE Intake of nutrients insufficient to meet metabolic needs. Adequate nutrition is necessary to meet the bodies demands nutritional status can be affected by disease or injury states; physical factors; social factors; psychological factors. During times of illness adequate nutrition place an important role in healing and recovery.

GOAL/ INTERVENTION OBJECTIVES After 8 hours of nursing intervention, the patient will have an increase in appetite and will consume the food provided to him Noted total daily intake, patterns and times of eating. RATIONALE To reveal changes that should be made in clients dietary intake To stimulate appetite EVALUATION After 8 hours of comprehensive nursing interventions, the patient was able to have an increase in appetite, consumed the food provided to him.

Encouraged patient to choose foods that are appealing to him Promoted pleasant, relaxing environment, including socialization Minimized unpleasant odors and sights Encouraged to wash mouth before and after meals.

To enhance intake

May have a negative effect on appetite. Eliminating unpleasant taste may enhance appetite. Hesitation to eat may be result of fear that food will cause exacerbation of symptoms

Source: Doenges, Marilynn E. ,et. al., Nursing Care Plans., 9th Edition., 2006

Encouraged patient to verbalize feelings concerning resumption of diet.

DATE:__________________________ ASSESSMENT Subjective Gi operahan ko unya gi butangan ko ug tubo para sa paglimpyo sa akong dugo ug para sa akong ihi, as verbalized by the patient. Objective presence of surgical incision at the right femoral area for Hemodiaysis with intact ; dry dressing with cystoclysis incision at right suprapubic area attached to uroguard draining bloodtinged urine NURSING DIAGNOSIS Impaired skin integrity related to a break of continuity of the skin secondary to AV shunt incision and cystoclysis. SCIENTIFIC REFERENCE Benign Prostatic Hyperplasia in characterized by progressive enlargement of the prostate gland (commonly seen in men older than 50 years old), causing varying degrees of urethral obstruction and restriction of urinary flow that will cause urine stasis which can contribute to bacterial growth. GOAL/ OBJECTIV ES After 1 whole shift (8 hours) of nursing interventio n the patient will be able to maintain dry intact dressing and prevent itchiness.

INTERVENTION

RATIONALE

EVALUATION

Assessed the skin of patient and noted for skin turgor and color

establishes a comparative baseline for a timely intervention To assess for signs of infection Moisture may contribute to skin maceration and itching Removes waste products from skin while preventing skin dryness. May decrease skin irritation and need for scratching To prevent occurrence of ulcers. Prevents skin excoriation and infection from scratching.

Inspect incision sites for any signs of infection. Encouraged patient and SO to keep a wellventilated room.

Definition: Altered epidermis or dermis. Source: Doenges, Marilynn E. ,et. al., Nursing Care Plans., 9th Edition., 2006

Provide frequent skin care and to avoid soaps and alcohol-based lotions

After 1 whole shift (8 hours) of nursing intervention, the patient still has intact Right femoral catheter, clean and dry dressing.

Recommended to patient and SO to avoid harsh detergents.

Encouraged ambulation as tolerated

Advised patient and SO to keep fingernails short and smooth.

DATE:__________________________ ASSESSMENT NURSING DIAGNOSIS Impaired physical mobility related to presence of blood in the urine secondary to cystoclysis. SCIENTIFIC REFERENCE Benign Prostatic Hyperplasia characterized by progressive enlargement of the prostate gland (commonly seen in men older than 50 years old), causing varying degrees of urethral obstruction and restriction of urinary flow. GOAL/ OBJECTIVES That after 8 hours of nursing intervention, patient will be able to understand the medical management and to know that blood in the urine is normal. INTERVENTION RATIONALE EVALUATION

Subjective cues Sige Rako anig higda, as verbalized by the patient

Objective cues On bed always With ongoing cyctoclysis of PNSS 1L attached to uroguard Blood-tinged urine noted on the uroguard upon moving

Independent: Explained that presence of blood in the urine is temporary and normal due to operation, (CTURP) Encouraged to perform ROM exercises. To relieved patients anxiety and know the post-op consideration of C-TURP. To help patient realized and understand that activities are encouraged. Prevents incidence of skin and respiratory complication. Refocuses attention, enhances diets sense of control and self worth.

After 8 hours of nursing intervention patient was able to ambulate with assistance to and from the comfort room.

Repositioned periodically and encouraged coughing and deep breathing exercises. Encouraged participation in divertional activities (wathching television)

Source: Doenges, Marilynn E. ,et. al., Nursing Care Plans., 9th Edition., 2006

DATE:__________________________