Cues Nursing Scientific Objectives Nursing Rationale Evaluation

Diagnosis Explanations Interventions

S 1. Due to After 3 hours of 1. Monitor vital signs - Loss of kidney -Does the patient
The patient may hyperplasia of nursing closely. function results able to
verbalized Impaired the prostate intervention Observe for in decreased manage the
difficulty in urinary gland the the hypertension, fluid elimination manifestations
urinating. elimination urethra is patient will be peripheral/dependent and of the disease;
related to being able to manage edema, changes in accumulation of a. nocturia
O increase blocked the mentation. Maintain toxic wastes b. dysuria
Patient may urethral causing manifestation accurate I&O. may progress to c.incontinence
manifest one or occlusion obstruction in of complete renal d.hesitancy to
more of the the flow of the disease. shutdown. urinate?
following: urine
- (+) nocturia that leads to
- (+) bothersome - *Increased
incontinence
LUTS, thus an
- (+) dysuria circulating
impairment in
-(+) facial grimaces fluid
the urinary
upon maintains
elimination.
urination 2. Encourage oral renal
- (+) edema fluids up to 3000 mL perfusion and
- pt may also be daily, within cardiac flushes
seen with an tolerance, if kidneys,
indwelling indicated. bladder, and
catheter
ureters of
connected with
“sediment
the urine bag.
and bacteria.”

Note: Initially, fluids

may be
restricted to
 prevent
bladder
distension
until adequate
urinary flow
is
reestablished.

- may minimize
3. Encourage patient to over distension
void every of the bladder.
2-4 hours and when
urge is noted.

- reduces risk
4. Encourage of ascending
meticulous catheter infection
and perineal care.
Cues Nursing Scientific Objectives Nursing Rationale Evaluation
Diagnosis Explanations Interventions
S 2. Activity is a After 3 hours of 1.Monitor vital signs. -to know the a. a. Does the pt
The patient may Activity natural nursing present status of able to
verbalize body intolerance process intervention the patient understand
malaise. related to and a vigorous the the health
body motion of patient will be 2. Encourage to - to optimize teachings
O malaise action. able to increase fluid intake hydration status given?
Patient may When one verbalize
manifest one or manifested understanding b. b. Does he able
more of the insufficient of 3. Encourage to eat - increase body to increase
following: physiologic the health foods rich in vitamin C resistance muscle
- (+) body and teachings given and intake of nutritious strength?
malaise psychologic to increase food.
- (+) facial functional muscle
grimaces changes he strength. 4. Encourage pt to -to promote
upon moving endure a perform PROM as proper blood
- (+) edema simple tolerated. circulation
task this
resulted 5. Encourage pt -to optimize
to activity to change position circulation to all
intolerance. every 2 hours. tissues and to
relieve pressure

6. Encourage pt to use - to prevent

appropriate assistive Injury.
devices.
Cues Nursing Scientific Objectives Nursing Rationale Evaluation
Diagnosis Explanations Interventions
S 3. The pt’s After an hour of 1. Monitor vital - Indicators of a. Does the
The patient may Risk for disease nurse patient signs for fever. sepsis requiring patient
verbalize body infection condition interaction he prompt understand
malaise. related to causes some patient will be evaluation and individual
periodic obstruction in able to intervention. causative/
O catheteriza the flow of verbalize risk factors?
Pt. may be seen tion . urine enabling understanding - to maintain
with an him to need on the health 2. Encourage renal function b. Does the
indwelling catheterization teachings given. increase fluid and prevent patient able
catheter to empty this intake development of to identify
connected with bladder. infection interventions
the urine bag Through this it to reduce/
- (+) nocturia enable - Prevents cross- prevent risk
- (+)body 3. Emphasize good hand contamination; of infection.
bacteria
malaise washing technique for reduces risk of
contained
- (+) all individuals coming in acquired
within the
hematuria contact with patient. infection
prostatic acini
- (+) febrile
to reach the
bladder thus - reduces risk of
4. Encourage meticulous ascending
increase the catheter and perineal
risk of urinary infection
care
infection .
- Prevents
5. Provide exposure to
sterile or freshly infectious
laundered linens/gowns. Organisms.

- Prevents cross-
6. Monitor/limit contamination from
visitors, if
necessary. visitors.
7. Administer
antibacterial as -Reduces
ordered. bacteria present
in urinary tract
and those
introduced by
drainage system.
Cues Nursing Scientific Objectives Nursing Rationale Evaluation
Diagnosis Explanations Interventions
S 4. Patients with After 3 hours of 1.Determine clients SO’s - address a. Does the pt
The patient may Sleep BPH often Nursing expectations of opportunity to able to relax and
verbalize pattern experience intervention the adequate sleep address gain enough
frequency in disturbance excessive patient will be misconceptions sleep?
urination at related to urination able to verbalize b. Does he still
night. urinary at night. This understanding 2. Encourage - napping in experience
incontinenc symptom of individual mid morning nap afternoon can nocturia?
O e. often indicates appropriate if one is required disrupt normal
Patient may that the intervention to sleep patterns
manifest one or bladder outlet promote sleep.
more of the is obstructed. 3. Provide quiet and - in preparation
following: And due to comfortable for sleep
- (+) dark this the environment
circles around patient sleep is
the eyes being affected 4. Limit fluid intake in - to reduce nighttime
- Appears weak because he is evening if nocturia is a elimination
and irritable often disturb problem.
- Restless with the urge
- Noted frequent to urinate at
yawning night.
- (+) nocturia
Cues Nursing Scientific Objectives Nursing Rationale Evaluation
Diagnosis Explanations Interventions
S 5. There is some After an hour of 1. Provide teachings - to diminish - Does the
The patient may Ineffective information nurse patient about BPH regarding client’s anxiety patient able to
verbalize therapeutic about the interaction the the disease process, how regarding the understand all
concerns regimen disease patient will be to prevent and alleviate process of his the information
regarding his related of the patient able to its complications. disease, the given?
condition to lack of that he does understand the effects of this
understand not course of his disease to his - Is there a
O ing of understand disease, lifestyle, and the significant
Patient may disease, that manifestations complications changes that
manifest one or manifestati leads to and medical that the disease occur on the
more of the ons, and ineffective treatments. could develop. patients
following: medical follow-up with knowledge
- Frequently treatment. the course of 2. Encourage - pt with BPH regarding;
asking therapy. fluid intake. tend to limit
question their fluids c. disease
about his intake to combat condition
condition, its manifestation d. diet
treatment needless did they e. treatment
and diet know that a f. medication
- With worried concentrated g. self-care
gaze urine exacerbate needs
- Minimal LUTS and
response upon increase risk of - Does the
assessment and UTI. patient able to
questioning
3. Explain medications; - to provide comply with the
how it works, its side knowledge about entire therapeutic
effects and precautions. the medications regimen given?
being given to
the patient