Assessment Subjective Data: napakasakit nito saka dito (pointing to his retroperitoneal and suprapubic area ), as verbalized by the

e patient. When patient was asked to rate the pain from 1-10 as 10 as the most painful, the patient answered, 10. P- bladder distention Q- stabbing pain R- retroperitoneal and suprapubic S- rate of 10severe T- intermittent

Nursing Diagnosis Acute pain r/t bladder distention secondary to enlarge prostate as manifested by complaints of discomfort caused by: Inability to void Palpable bladder No urine output Diaphores is

Scientific Explanation

Goal

Interventions

Rationale

Evaluation Goal was partially met as evidenced by: Decreased pain from 10 to 6 as 10 as the most painful. negative grimacing decrease irritability negative splinting behavior negative diaphoresis Long term goal: Still to be evaluated

Objective Vital Signs: T-37.1 C P- 92 bpm R- 24 cpm BP-160/100 mmHg Grimacing Irritable

Enlargement of the Short term: prostate Within 8 shift after doing all Compression of necessary nursing urethra interventions the pt will: Urinary retention Decrease pain from Bladder distention 10 to 6 as 10 as the Pain most painful. Vital signs except temp. will decrease at normal range negative grimacing decrease irritability negative splinting behavior Improve sleeping pattern negative diaphoresis Long term goal Within 1 weeks

Provide comfort measures like back rubbing, effleurage, quiet environment and change of position. Encourage patient to do deep breathing Advise patient to do divertional activities like listening to music and conversing to relatives. Encourage pt to maintain calm attitude. Provide well ventilated room

To promote relaxation and to eradicate stress and anxiety To promote relaxation and reduce muscle tension To divert the focus of the patient from the pain to other activities To decrease irritability and anxiety To provide comfort

To decrease BP Follow pts diet, which is low salt and low fat. To promote rest

Splinting behavior (+) Sleep disturbance Diaphoresis Lab. Results: CBC: WBC- 13.6 x10^9L URINALYSIS: Pus cells- 1015/HPF Color- Red Bacteria-few Rxn (pH)-5.0 SG-1.015 Protein-(+) Amorphous urates few Transparencyprecipitation of crystals, presence of blood cells, yeast and bacteria.

of rendering Observe proper proper nursing visit hours and intervention the give the pt pt will: enough time to (-) pain rest (-) Colaborative: irritability Good Schedule for sleeping suprapubic pattern cystostomy WBC-from Insert foley 13.6x10^9 catheter L to 4.510x10^9L Give Celecoxib 200 mg/tab Pus cellsBID as ordered from 1015/HPF to 0 Tamsulosin (Prozalax) 200 Bacteriamg/cap OD from few to none Amlodipine 100mg OD Transparen cy- from precipitatio n of crystals, presence of blood cells, yeast and bacteria to clear.

To confirm the diagnosis To relieve bladder distention To relieve pain Use to treat benign hyperplesia To treat hypertentio n