Assessment

Subjective:
Masakit kapag
umiihi ako pero
nawawala din
naman
pagkatapos
Objective:
(+) Dysuria
(+) Facial grimace
(+) pain upon
palpation on the
suprapubic are
(+) pain on the flank
area
Pain Scale:
7/10 (where 0 is
absence of pain and
10 is severe pain)

Nursing Diagnosis
Acute Pain related
to the presence of
calculi in the
bladder

Short Term Goal

Within the shift,
the patient will
verbalize a
decrease in pain
from 7/10 to 5/10

Long Term Goal

Intervention
Within the
Determined the
hospitalization
location, duration,
period, the patient
intensity (1-10
will verbalize
scale) and radiation
absence of pain Assisted patient with
ambulation
Advised patient to
find position of
comfort
Advised patient to
report episodes of
pain

Rationale
Aids to evaluate site
of obstruction and
progress of calculi
movement
This prevents urinary
stasis and aids in
prevention of further
stone formation
Proper positioning
may help decrease
pain felt
Awareness of the
caregiver to the pain
felt will guide her to
Provided health
the intervention that
teachings on:
done
Deep breathing Promotes relaxation,
exercises
reduces muscle
Applying warm
tension, enhances
compress
coping and
redirects attention
Administered
and helps in muscle
analgesics as
relaxation
prescribed by the
Analgesics will help
physician
lessen pain felt

Evaluation
Goal Met

Assessment

Nursing Diagnosis

Short Term Goal

Long Term Goal

Intervention

Rationale

Evaluation

Subjective:
Hindi ako nakatae
ng apat na araw
simula nung
naospital ako.
Hindi ko makalabas
dahil sa catherter na
yan
Objective:
>IVF hooked PNSS,
1L KVO at left
metacarpal cephalic
vein
>(-) BM for 4 days
>(+) distended
abdomen (all
quadrants)

Constipation
related to
decreased
peristalsis
secondary to
decreased physical
activity

Within the shift

the patient will
able to defecate.

Within the
hospitalization
period the patient
will be able to
facilitate the
maintenance of
elimination

>Assessed general
health status of the
patient
>reviewed Review
your client's dietary
regimen and note if
the diet is deficient in
fiber and
encouraged to have a
balanced diet that
rich in fiber and bulk
forming food.
>encouraged increase
intake of fluid
>Encouraged to
ambulate everyday
>provided health
teaching:
1. the importance of
fiber and bulk
forming food in diet
2. drinking of warm
glass of water before
breakfast
3. importance of not
delaying defecation

>Find other problems

aside form
constipation
>Fiber and bulk
forming food helps
food to move through
your digestive tract
more quickly for
healthy elimination.
>Increase in OFI will
able to help and
promote passage of
stool.
>Ambulation will
increase peristaltic
activity inside the
intestine
>fiber and bulk
forming food help
elimination process
>Warm water before
breakfast will
stimulate major
peristaltic movement
in Large intestine
>Delaying of urge in
defecation will cause
constipation

Goal not met

-patient was
not able to
defecate.