ASSESSMENT DIAGNOSI PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Deficient After 2-4 -determine ability -presence of Patient gradually

“Nakakatamad diversional hours of to participate in depression, problems develops substitute
dito activity nursing activities that are of motility may recreational
Sa ospital, related to intervention, available. interfere with desired activities.
walang UTI. patient will activity.
magawa...” as gradually -offer reading
verbalized by develop Materials or other -distraction provides __ goal met
the substitute substitute opportunity to perform __ partially met
Patient. recreational diversional desired activity in __ not met
activities. activities to assist different ways.
Objective: patient on caring
-slightly for herself.
inattentive
-weak and pale -encourage -for emotional support
in visitation
appearance
-lethargic -acknowledge -to establish
reality therapeutic
of situation and Relationship
feeling
of the client

-involve -to help identify and

occupational procure assistive
therapist as devices or gear
appropriate. specific activities to
individual situation.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Acute pain After 4 hours -assess pain, -provides information Patient’s pain
“Masakit ang during of nursing noting location, to aid in determining is relieved or
pag-ihi ko...” as urination intervention, intensity choice or controlled.
verbalized by related to patient will (scale of 0-10) effectiveness of
the patient. UTI verbalized that ,duration interventions
the pain is
Objective: relieved or -encourage increase -increased hydration __ goal met
-facial grimace controlled. fluid intake flushes bacteria and toxins __partially met
-restlessness __not met
-V/S taken as -investigate report of -urinary retention may
Follows: bladder fullness develop, causing tissue
T- ___ distension, and
PR- ___ potentiates risk for further
RR- ___ infection
BP- ___
-provide comfort -promotes relaxation,
measure like back rub, refocuses attention and
helping patient assume may enhance coping
position of comfort. abilities.
Suggest use of
relaxation techniques
and deep breathing
exercises.

-encourage use of sitz -promotes muscle

bath, warm soaks to the relaxation
perineum.

-administer antibacterial -reduces bacteria in the

as prescribed urinary tract
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Knowledge After 2 hours -Encourage to -Flushes bacteria out Patient is able
“anu-ano bang deficit of nursing increase fluid intake of urinary system to identify risk
dapat gawin related to intervention, factors that
para UTI patient will -Get enough vitamin -Vitamin C, or exacerbate the
maiwasan na identify C in diet, either ascorbic acid, makes disease process
UTI?” risk factors that through food or your urine acidic, or condition and
as verbalized exacerbate the supplements which discourages the modify her
by disease process growth of bacteria lifestyle
the patient. or condition and accordingly.
modify her -Urinate every two to -Keeping urine in your
Objective: lifestyle three hours. bladder for long
-request for accordingly. periods gives bacteria __goal met
information a place to grow. __partially met
-inaccurate __not met
follow-through -Keep the vagina are -To prevent
of instruction clean, including contamination of the
wiping from the front urinary tract
to back after a bowel
movement.

-Use tampons and -The pads can act as

change every three to a culture medium for
four hours, instead of fecal bacteria, which
sanitary pads may then be rubbed
against the urinary
outlet and invade the
bladder
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Increased After 1 hour -Give tepid sponge -To regulate body Patient’s VS
“Mainit ang temperature nursing bath. Do not use temperature. specifically the
pakiramdam ko” related to interventions, alcohol. Alcohol cools the temperature
as verbalized by growth of patient’s VS skin too rapidly temperature
the patient. microorganism specifically the causing shivering. decreased to
s in the blood temperature will normal range.
secondary to decrease to -Assess VS -To assess body
Objective: Urinary Tract normal range. specifically thermoregulation
-weak in Infection temperature after __goal met
appearance TSB __partially met
-skin warm to __not met
touch -Position patient -Allows patient’s
-warm breath comfortably in bed. self dependency
-irritable
-vital signs -Impart health -Prevent
taken as follows: knowledge about occurrence of
T-39.6 proper body and further
RR-26cpm hand hygiene. complications.
PR-74bpm
Bp-160/80 -Advise patient to - Additional fluids
mmHg increase oral fluid help prevent
intake. elevated
temperature
associated with
dehydration.

-Maintain bed rest. -Reduce

metabolic
demands/ oxygen
consumption
-Provide high-calorie -To meet
diet. increased
metabolic
-Monitored VS and demands.
recheck.
-To know the
effectiveness of
nursing
interventions
done and to know
the progress of
patient’s
condition.

-Administer -These drugs

medications as inhibit the
prescribed prostaglandin that
serve as
mediators of pain
and fever.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Impaired After 4 hours of -Determine -Used as a Patient will

“Parang laging urinary nursing patient’s previous baseline,to verbalize
puno yung elimination interventions, elimination pattern asses for understanding
pantog related patient will and compare with changes of the condition
ko...” as to UTI. verbalize current situation. and achieve
verbalized by understanding normal
the patient of the -Palpate bladder -To assess elimination
condition, retention pattern and
Objective: achieve normal demonstrate
-pale in elimination -Determine -To help ways on how to
appearance pattern or patient’s usual daily determine prevent
-looking weak participate in fluid intake level of reinfections
-retention measures to dehydration
correct the
defects and -Encourage fluid -To help __goal met
demonstrate intake up to 3000- maintain __partially met
ways on how to 4000mL/day renal function __not met
prevent
reinfections
-Instruct to void -To limit risk
immediately after of reinfection
intercourse, wipe
from front to back,
promptly treat
vaginal infections
and take shower
rather that tub baths