- Acute Pain related to distended bladder and renal colic as evidenced by complaints of bladder or rectal spasm and Facial grimacing
- Disturbed Sleep Pattern related to Increased frequency of urination as evidenced by Insomnia and Frequent urination
- Risk for Deficient Fluid Volume related to Post obstructive diuresis and Insufficient fluid intake as evidenced by dehydration and inadequate urine output
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: -Verbal reports from the patient -Expressions of pain, such as crying -Unpleasant feeling Objective data: -Significant changes in vital signs -Changes in appetite or eating patterns -Changes in sleep patterns | Acute Pain related to Distended bladder and renal colic as evidenced by complaints of bladder or rectal spasm and Facial grimacing | Patient will verbalize relief from bladder or urinary tract pain. Patient will demonstrate interventions to ease discomfort. | 1. Encourage sitz baths and warm soaks. Soothe perineal discomfort with a warm sitz bath for 20 minutes several times per day to relax the prostate and surrounding muscles. 2. Secure the catheter. Securing the urinary catheter correctly to the client’s thigh prevents pain from an injury in the penile-scrotal junction and pulling on the bladder when turning or ambulating. 3. Relieve bladder spasms. Administer antispasmodics as prescribed to minimize bladder spasms brought on by catheter sensitivity. 4. Promote prostate massage. Prostate massage can relieve excess fluids that build up in the prostate and reduce the inflammation and pressure causing the pain. The patient can be instructed on how to do this themselves. 5. Relieve pain with medications. Narcotics may be given following surgical procedures to relieve acute pain. | Patient verbalized relief from bladder or urinary tract pain. Patient demonstrated interventions to ease discomfort. |
| Subjective data: -Verbal reports from the patient about sleeplessness Objective data: – Frequent Urination – Insomnia -Changes in sleep patterns | Disturbed Sleep Pattern related to Increased frequency of urination as evidenced by Insomnia and Frequent urination | Patient will be able to verbalize restful sleep. Patient will demonstrate a calm and well-rested appearance. Patient will receive at least 8 hours of sleep nightly. | 1. Encourage limiting fluid intake before bed. Limit fluid intake 2-4 hours before bedtime, as advised. Instruct the patient to drink plenty of fluids during the day (particularly water) to prevent dehydration. Emphasize limiting their intake of alcohol and caffeine (soda, tea, and coffee), which causes diuresis. 2. Administer desmopressin as prescribed. Desmopressin, a synthetic form of vasopressin, is used to replenish decreased levels of the hormone. It manages excessive thirst and prevents dehydration, and urine production, especially at night, limiting nocturia. 3. Shrink the prostate. 5-alpha reductase inhibitors like finasteride shrink the prostate and prevent hormonal changes that cause prostate growth which can reduce symptoms of BPH. 4. Provide compression stockings. During the day, keep the legs elevated or apply a pair of compression stockings to promote fluid circulation to lessen the need to urinate at night. | Patient verbalized about restful sleep. Patient demonstrated a calm and well-rested appearance. Patient received at least 8 hours of sleep nightly. |
| Subjective data: -Verbal reports from the patient about Poor urine elimination Objective data: – Inadequate fluid intake – dehydration -poor skin turgor | Risk for Deficient Fluid Volume related to Post obstructive diuresis and Insufficient fluid intake as evidenced by dehydration and inadequate urine output | Patient will maintain a urine output of 0.5mL/kg/hr. Patient will remain free from any signs of dehydration, such as altered mental status, poor skin turgor, and alterations in vital signs. | 1. Decompress the bladder. Insertion of a urinary catheter allows for complete and immediate drainage of the bladder without increased complications. Post-obstructive diuresis normally resolves within 24 hours, but the nurse must monitor closely for dehydration, electrolyte imbalances, and shock. 2. Closely monitor lab values, urine samples, and vital signs. Patients should have their electrolyte and renal function reassessed at least every 12 hours. A urine sample can assess for urinary sodium, potassium, and osmolality. Monitor vital signs for alterations indicative of hypovolemia. 3. Encourage fluid replacement. Patients who are alert and oriented should be encouraged to replace lost fluids orally. Cognitively impaired patients may receive IV fluids. Excessive fluid intake should be avoided as this can exacerbate diuresis. 4. Continuously monitor the urine output. Urine output exceeding 200 mL per hour for 2 consecutive hours can help diagnose post-obstructive diuresis and requires close monitoring. When POD has resolved, the patient’s 24-hour urine output will be less than 3L. | Patient maintained adequate urine output Patient remained free from signs of dehydration, such as altered mental status, poor skin turgor, and alterations in vital signs. |