Nursing Diagnosis 1.
Impaired Urinary Elimination related to postoperative cystostomy
Goal :
No interference elimination urinary elimination pattern
Nursing Interventions :
1) Monitoring of urine output and characteristics.
Rational: Detecting bladder elimination disorders at an early stage.
2) Maintain a constant bladder irrigation for 24 hours.
Rationale: Prevents blood clots obstruct the flow of urine.
3) Maintain the catheter with irrigation.
Rationale: Prevents blood clots clogging the catheter.
4) Pursue fluid intake (2500-3000).
Rational: Smooth flow of urine.
5) Once the catheter is removed, continue to monitor the symptoms of impaired bladder elimination patterns
Rational: Detecting early bladder elimination disorders.
Nursing Diagnosis 2.
Impaired sense of comfort: Pain related to postoperative cystostomy.
Goal:
Patient said, feeling more comfortable.
Nursing Interventions :
1) Extension to the patient not to urinate all around the catheter.
Rational: Reduce the possibility spasmus.
2) Monitoring of patients at regular intervals for 24 hours, to recognize early symptoms of bladder spasmus.
Rationale: Determining the presence spasmus bladder so that medications can be given.
3) Providing ordered drugs (analgesic, antispasmodic).
Rationale: Symptoms disappeared.
4) Tell the patient that the intensity and frequency will be reduced within 24 hours to 28 hours.
Rational: Inform patients that the discomfort is only temporary.
Nursing Diagnosis 3.
Risk for infection, hemorrhage related to surgery.
Goal:
No infection, bleeding is minimal.
Nursing Interventions :
1) Monitoring of vital signs, reported symptoms of shock and fever.
Rationale: Prevents before the shock.
2) Monitoring of fresh red blood urine color, not dark red just a few hours after surgery.
Rational: The color changed from red fresh urine becomes dark red on days 2 and 3 after surgery.
3) Guidance to patients in order to prevent the Valsalva maneuver.
Rational: Can be irritating, prostate bleeding in early postoperative period due to the pressure.
4) Prevent the use of a rectal thermometer, rectal examination at least 1 week.
Rational: It can cause bleeding.
5) Maintain aseptic technique of urine drainage systems, irrigation, if necessary alone.
Rationale: Minimizing the risk of entry of germs that can cause infection.
6) Pursue intake that much.
Rational: May decrease the risk of infection.
Nursing Implementation for Urethral Stricture
Implementation is the embodiment of the nursing intervention, which includes the actions planned by the nurse. In implementing the nursing process should be collaboration with other health team, family and clients with the clients, which include three things: Implement nursing actions by observing the code of ethics with standard practices and resources available.
Identify the client's response.
Documenting / evaluating the implementation of nursing actions and patient response.
Factors to consider:
Client's needs.
The basis of the action.
Individual capabilities and expertise / skills of nurses.
The sources of his own family and clients.
Nursing Evaluation for Urethral Stricture
Evaluation is a measurement of the success of nursing intervention in meeting client needs. Evaluation phase is the key to success in using the nursing process. Postoperative Evaluation of clients with urethral strictures, which fitted with a catheter still be performed based on the criteria previously set goals and nursing care is successful if the criteria in the evaluation of visible achievement of the goals of care provided.
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Impaired Urinary Elimination related to postoperative cystostomy
Goal :
No interference elimination urinary elimination pattern
Nursing Interventions :
1) Monitoring of urine output and characteristics.
Rational: Detecting bladder elimination disorders at an early stage.
2) Maintain a constant bladder irrigation for 24 hours.
Rationale: Prevents blood clots obstruct the flow of urine.
3) Maintain the catheter with irrigation.
Rationale: Prevents blood clots clogging the catheter.
4) Pursue fluid intake (2500-3000).
Rational: Smooth flow of urine.
5) Once the catheter is removed, continue to monitor the symptoms of impaired bladder elimination patterns
Rational: Detecting early bladder elimination disorders.
Nursing Diagnosis 2.
Impaired sense of comfort: Pain related to postoperative cystostomy.
Goal:
Patient said, feeling more comfortable.
Nursing Interventions :
1) Extension to the patient not to urinate all around the catheter.
Rational: Reduce the possibility spasmus.
2) Monitoring of patients at regular intervals for 24 hours, to recognize early symptoms of bladder spasmus.
Rationale: Determining the presence spasmus bladder so that medications can be given.
3) Providing ordered drugs (analgesic, antispasmodic).
Rationale: Symptoms disappeared.
4) Tell the patient that the intensity and frequency will be reduced within 24 hours to 28 hours.
Rational: Inform patients that the discomfort is only temporary.
Nursing Diagnosis 3.
Risk for infection, hemorrhage related to surgery.
Goal:
No infection, bleeding is minimal.
Nursing Interventions :
1) Monitoring of vital signs, reported symptoms of shock and fever.
Rationale: Prevents before the shock.
2) Monitoring of fresh red blood urine color, not dark red just a few hours after surgery.
Rational: The color changed from red fresh urine becomes dark red on days 2 and 3 after surgery.
3) Guidance to patients in order to prevent the Valsalva maneuver.
Rational: Can be irritating, prostate bleeding in early postoperative period due to the pressure.
4) Prevent the use of a rectal thermometer, rectal examination at least 1 week.
Rational: It can cause bleeding.
5) Maintain aseptic technique of urine drainage systems, irrigation, if necessary alone.
Rationale: Minimizing the risk of entry of germs that can cause infection.
6) Pursue intake that much.
Rational: May decrease the risk of infection.
Nursing Implementation for Urethral Stricture
Implementation is the embodiment of the nursing intervention, which includes the actions planned by the nurse. In implementing the nursing process should be collaboration with other health team, family and clients with the clients, which include three things: Implement nursing actions by observing the code of ethics with standard practices and resources available.
Identify the client's response.
Documenting / evaluating the implementation of nursing actions and patient response.
Factors to consider:
Client's needs.
The basis of the action.
Individual capabilities and expertise / skills of nurses.
The sources of his own family and clients.
Nursing Evaluation for Urethral Stricture
Evaluation is a measurement of the success of nursing intervention in meeting client needs. Evaluation phase is the key to success in using the nursing process. Postoperative Evaluation of clients with urethral strictures, which fitted with a catheter still be performed based on the criteria previously set goals and nursing care is successful if the criteria in the evaluation of visible achievement of the goals of care provided.
