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NCP Gbs

The patient was experiencing impaired urinary elimination secondary to Guillain-Barré syndrome. The nursing assessment found urinary retention, paralysis, difficulty communicating the need to urinate, and nocturia. The nursing diagnosis was impaired urinary elimination. Short term goals within 24 hours were for the patient to establish a routine elimination pattern and for the significant other to understand the patient's condition and prevent infection. Interventions included monitoring intake/output, educating the significant other, and inserting a catheter if needed. The goal was met as evidenced by the patient and significant other establishing an elimination routine and understanding causative factors and prevention techniques.

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1K views2 pages

NCP Gbs

The patient was experiencing impaired urinary elimination secondary to Guillain-Barré syndrome. The nursing assessment found urinary retention, paralysis, difficulty communicating the need to urinate, and nocturia. The nursing diagnosis was impaired urinary elimination. Short term goals within 24 hours were for the patient to establish a routine elimination pattern and for the significant other to understand the patient's condition and prevent infection. Interventions included monitoring intake/output, educating the significant other, and inserting a catheter if needed. The goal was met as evidenced by the patient and significant other establishing an elimination routine and understanding causative factors and prevention techniques.

Uploaded by

Jaylord Verazon
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Assessment Nursing Scientific Goals and Nursing Intervention Rationale Evaluation

Diagnosis Explanation Objectives


Subjective Impaired A quarter of the SHORT TERM INDEPENDENT SHORT TERM
“Hindi po siya Urinary patients with After 24 hours of  Assess progressive Provides data on the effect
After 24 hours of
umiihi ng kusa Elimination Guillain-Barré nursing degree of paralysis of motor dysfunction that nursing intervention,
dahil po sa related to syndrome tend to intervention the and effect on travels upward from the goal was met, as
kondisyon niya neuromuscular have micturitional patient/significant urinary elimination extremities evidenced by:
at minsan po impairment disturbance. The other will:  The patient was
nakakaihi secondary to patients studied had  Establish able to establish
nalang po siya Guillain Barre evacuation and routine urinary  Monitor intake and Provides monitoring of routine urinary
sa kanyang syndrome storage disorders, as elimination output every 4 to 8 I&O ration and presence elimination
sapin tuwing well as bladder patterns hours and palpate of urinary retention or patterns
gabi” as areflexia and  The SO will bladder every 2 infection as paralysis  The SO was able
verbalized by disturbed bladder verbalize hours. Also assess progresses to verbalize
the significant sensation indicative understanding for cloudy, foul understanding of
others of peripheral types of the patient’s smelling urine the patient’s
of parasympathetic condition condition
and somatic nerve  The SO will  The SO was able
Objective dysfunction. identify the  Educate the Supports urinary to identify the
 Urinary Decreased bladder specific significant others in elimination and return to specific
retention volume with bladder causative the program to baseline pattern without causative factors
 Urinary overactivity but no factors that restore urinary retention and possible that contributed
 Paralysis evidence of CNS contributed to function urinary bladder infection to the patient’s
 Immobility involvement was the patient’s condition
 Difficulty also found, evidence condition  The SO was able
communica that bladder  The SO will  Instruct the Maintain I&O balance and to demonstrate
ting when overactivity also demonstrate significant others to adequate intake to behaviors and
to urinate occurs in peripheral behaviors and maintain fluid promote urinary output techniques to
 Nocturia nerve lesions with techniques to intake and monitor prevent urinary
probable pelvic prevent urinary output in infection in the
nerve irritation. infection in the connection to patient
patient intake
Reference:  The SO will
Sakakibara, R., manage care of
Hattori, T., urinary  Assist client in Promotes urine
Kuwabara, S., catheter urinary elimination elimination and return to a
Yamanishi, T., & rehabilitation normal pattern as soon as
Yasuda, K. (1997). program and possible
Micturitional perform Crede’s
disturbance in maneuver in a
patients with gentle manner if
Guillain-Barré indicated
syndrome. Journal
of neurology,
neurosurgery, and  Instruct the Avoids complication of
psychiatry, 63(5), significant others to neuromuscular
649–653. report any impairment of disease and
https://doi.org/10.11 reduction or effect on urinary bladder
36/jnnp.63.5.649 absence of urinary function
elimination

 Emphasize to the SO To reduce the risk of


the importance of infection and skin
keeping the area breakdown
clean and dry

DEPENDENT
 Insert an indwelling Relieves bladder
urinary Cather to distention and urinary
maintain as retention of the client
prescribed by the
doctor to maintain
elimination

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