ASSESSMENT Subjective Data: "My husband has been struggling urinating for 3 days and every time he pees its very minimal" as verbalized by the wife Objective Data: V/S BP:140/100 RR:24 CR:117 TEMP:37.1C SPO2: 98% LAB RESULT: ● Dark yellow urine color • Shortness of breath (SOB) • (+) bipedal edema DIAGNOSIS Impaired urinary elimination related to decreased urine output INFERENCE PLANNING Short Term: After 2-3 hours of nursing interventions: -The patient will be able to demonstrate improvement in urine elimination. -The patient will be able to maintain the normal limits of vital signs. -The patient will be able to demonstrate improvement of breathing pattern Long Term: After 2-3 days of nursing interventions: -The patient will achieve the normal urine elimination pattern INTERVENTION EVALUATION

ASSESSMENT Subjective Data: "My husband has been struggling urinating for 3 days and every time he pees its very minimal" as verbalized by the wife Objective Data: V/S BP:140/100 RR:24 CR:117 TEMP:37.1C SPO2: 98% LAB RESULT: ● Dark yellow urine color • Shortness of breath (SOB) • (+) bipedal edema DIAGNOSIS Impaired urinary elimination related to decreased urine output INFERENCE PLANNING Short Term: After 2-3 hours of nursing interventions: -The patient will be able to demonstrate improvement in urine elimination. -The patient will be able to maintain the normal limits of vital signs. -The patient will be able to demonstrate improvement of breathing pattern Long Term: After 2-3 days of nursing interventions: -The patient will achieve the normal urine elimination pattern INTERVENTION EVALUATION

Essentials Health Info Management Principles/Practices

4th Edition

ISBN:9780357191651

Author:Bowie

Publisher:Bowie

Chapter6: Patient Record Documentation Guidelines: Inpatient, Outpatient, And Physician Office

Section6.5: Physician Office Record

Problem 4E

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