Barbados Community College
Division of Health Sciences
Nursing Department
Bachelor Science Nursing: Year two group one
Identification #: 00000
Assignment: Medical Care Plan
Submitted to: Dr. Watson Miller
Date: 4th December, 2017
2
TABLE OF CONTENTS
COMPONENTS
PAGE #
Table of Contents
2
Biographical Data
3
Patient History
4
Review of Systems
8
Physical Assessment
11
Nursing Diagnosis (6)
16
Plan of Care
18
This plan of care is based on Mr. Purple Ville’ who was assessed on the 13th /11/2017.
3
Biographical Data
NAME: Mr. Purple Ville’
ADDRESS: August September Drive, St. Keisha.
TELEPHONE NUMBER #: (1246)-765-4321 (H)
SEX: Male
D.O.B: 27th January 1958
AGE: 59 years old
MARITAL STATUS: Single
EDUCATION: Secondary
OCCUPATION: Soil Technician
RELIGION: Roman Catholic
RACE: Black
NATIONALITY: Barbadian
NEXT OF KIN: Miss Pink Castle
RELATION: FIANCE’
TELEPHONE NUMBER # :( 246)-765-4321 (H)
HEALTHCARE PROVIDER: Dr. George
4
Patient History
DATE OF ADMISSION: 10th November 2017
TIME OF ADMISSION: 22:33hrs
HOSPITAL NUMBER: 000000
WARD: C5
BED NUMBER: 55
CONSULTANT: Dr. Jackman
ALLERGIES: Dimenhydrinate (Gravol ®)
PRESENTING COMPLAINT: Mr. Ville’ came to accident and emergency (A & E)
department seeking medical attention. He had been feeling short of breath and wheezing for 2
hours prior to his arrival and was experiencing chest tightness and burning epigastric pain for
about 1/52 and vomited multiple times this morning at least 6 episodes. He had a non- productive
cough 1/12.
ADMITTING DIAGNOSIS: INEFFECTIVE ENDOCARDITIS, SEVERE METABOLIC
ACIDOSIS 2˚ ORTHOPNEA.
FINAL DIAGNOSIS: SEPSIS 2◦ LOWER RESPIRATORY TRACT INFECTION, ACUTE
ON CHRONIC KIDNEY DISEASE
5
PAST MEDICAL HISTORY: Diagnosed with Diabetes Mellitus (DM) Type 2 at age 40,
Hypertension (HTN) at age 45, Asthma at the age of 30, Bladder CA, Kidney Problems at the
age of 53, Heart Failure at the age of 59.
PAST SURGICAL HISTORY: Total Knee Arthroplasty (2011), Radical Cystectomy (2013),
Ureterosigmoidostomy (2013), Incision & Drainage of Axilla Abscess X 2 (8/52 Ago).
FAMILY HISTORY: Mr. Ville’s mother is deceased, she suffered from Hypertension. Mr.
Ville’ does not have a relationship with his father and knew no family information.
SOCIAL HISTORY: Mr. Ville was born into a Christian household and attended an Anglican
Church. However he is now a Roman Catholic and does not attend church regularly. Mr. Ville
lives with his Fiancé Pink Castle in a one bedroom, wall apartment with all amenities (electricity,
running water, indoor toilet and shower) and 1 pet cat. He has four children: 1 boy and 3 girls
which he shares a good relationship with the youngest daughter. Mr. Ville works as a Soil
Technician (Grave Digger) for over 20 years, is presently still employed and enjoys his job.
Although work and payment is based on how many funerals are held at the church. He has an
inactive lifestyle, goes to work and home and does not exercise. He enjoys watching television
shows especially cartoons, and crossword puzzles. He used to meet past friends by a local bar on
evenings for an occasional alcoholic beverage and tobacco smoke. However he gave up those
habits about 6 years ago because of unloyal friends and goals of saving money.
PERCEPTION OF ILLNESS: Mr. Ville denies he has Chronic Kidney Disease but he knows
he is ill. He is depressed about his hospitalization, family and financial issues. He wishes to get
better as soon as possible, so he can go home, relax and watch cartoons and get back to his
“normal” life.
6
PERCEPTION OF HOSPITALIZATION: Mr. Ville dislikes to be hospitalized because he
doesn’t know if he will ever return home and has a fear of dying. Mr Ville states the doctors and
nurses have been assisting him as much as possible. However he does not like the fact of being
in a hospital and is ready to go home now.
PRESENT HISTORY: Mr. Ville was admitted to the ward accompanied by a nursing assistant
and orderly via a wheelchair. He was observed to be fully conscious, alert and oriented to x 3
(place, time, and person). He was noted to be experiencing dyspnea with expiratory wheezes
along with burning epigastric pain, radiating to the suprapubic region 7/10 on the pain scale 010. This pain was also added with vomiting at least 6 episodes of undigested food. Mr. Ville
stated that he also experience headaches, radiating pain from his left knee along the healed
surgical site to his ankle daily. Whenever he lays in the right lateral position he experiences
vomiting and a sharp pain throughout his entire right side from his ribs to his ankles. Vital signs
on admission were as follows – 38.5˚C (A), pulse 136 bpm, respiration 32 br/m, Blood pressure
95/55, SpO² 100% on the right middle finger, and random blood sugar (RBS) 12.1 mmol/L. The
following plan was implemented:

Strict I and O Charting

Urinalysis

Daily Weights

Monitor vital signs q2hrly

Oxygen Therapy

Blood Test

HTN, low sodium diet

Wound swab

Electrocardiogram (ECG)

Obtain Old notes

Chest X-ray (CXR)

Review of surgical site by previous
managing team
MEDICATIONS:
Zosyn® 2.25g IV tds (out of stock in hospital at moment)
Vancomycin 1g IV od
x 1⁄52
NaHCO3 100 meq IV q8hrly
Lasix® 40mg po bd
Albumin AlbuRx® 25, Albumin (Human) 25% 40 mg IV od
Sodium Bicarbonate 100 ml IV od (Buffer)
MEDICATIONS USED AT HOME:
 Metformin (Glucaphage ®)
 Valsartan (Diovan ®).
LABS
pH- 7.091
PO2- 36.2
Potassium - 2.6
Cor-Cal- 2.30 mmol
mmol
PCO2- 28 mmol
SpO2- 51.4%
Calcium 2.16
Cr-453
mmol
HCO3- 5.9
Sodium -140 mmol
CO2-28
Anion Gap -7.0 L
Hb- 9.1
Urea- 30.7 H mmol
Plt-332
Albumin- 33 g/L
WBC -29.0 ↑
Choride -119 H mmol
Magnesium- 0.59 L
Serum Creatinine- 453
mmol
μmol/L
LABS- hypokalemia (low potassium levels below 3.6 mmol), hypercholorenia (elevated chloride
levels above 107 mmol), normal anion gap, metabolic acidosis (pH levels below 7.35 and HCO3
levels below 22 mmol). ECG- Sinus tachycardia with frequent PVCs with PAC’s.
CXR- Bilateral pulmonary infiltrates ABG- Severe Metabolic Acidosis
8
Review of Systems
Respiratory System: Mr Ville had complained about being short of breath on admission.
However he is now able to state after his oxygen therapy his breathing is better. He stated he
remembers wheezing for about 2 hours and non- productive cough x 1⁄12 prior to admission.
He has no runny nose (rhinorrhea). In addition he is able to perform activities of daily living
without becoming short of breath.
Cardiovascular System: Mr Ville said his diagnosis of Hypertension in 1972 was
controlled through medication Valsartan (Diovan ®). When asked about the diagnosis of heart
failure, Mr Ville denied and stated, “My heart is just fine.” He also said he never had a heart
attack. He has family history of Hypertension.
Gastrointestinal System: Client is experiencing burning epigastric pain 7 on the pain scale
0-10. He states he unable to eat most days without vomiting. Usually this occurs either right after
eating or a few hours later or if he eats too fast. However he stated that he has the urge to pass
feces which are usually watery. He also states he dislikes macaroni pie and cou-cou and prefers
rice and ground provisions cook up with chicken feet and chicken meat.
Urinary System: Mr Ville said since he had his Bladder removed (Radical cystectomy) he is
very sad because sometimes mostly on nights he is unsure when he wishes to miturate and uses
adult pull up pampers to avoid any bed wetting incidents. Mr. Ville did not mention about CA of
the Bladder.
9
Reproductive System: Mr. Ville was a bit reserved about his sexuality but he answered the
questions very quickly and concise. He said he has 4 children (1 boy and 3 girls) from 2 different
women. His prostate was removed in his Radical cystectomy (2013). Since then his life has not
been the same especially in the area of penis. His erections are not consistent and sometimes he
does not even study it (penis); but when asked his last sexual encounter was he excitedly
answered last week with his Fiancé (means of protection used-none). He further said he never
had a sexually transmitted disease.
Musculoskeletal System: Client states his range of motion is good. Although somedays he
is has lower back pain 6 on the pain scale 0-10 and cannot lay on his right side as sometimes it
he makes him vomit. He is presently experiencing joint stiffness in his left leg radiating to his
ankle and a sharp pain 7 on the pain scale 0-10 to his left calf usually during the night and which
sometimes radiate to his right leg to his right ankle. He also stated he has pins in his left knee
after his Total knee arthroplasty (2011). When asked about daily living activities, Mr. Ville states
he is able to perform those activities without assistance.
Integrementory System: Mr. Ville said he fell off a bicycle at age 50 (9 years ago) and
struck his head and has a 2 cm indented scar to the left of the body place midline. He has
alopecia (balding) to the crown of the head. He said he has a surgical incision under his left arm
due to the surgical drainage of abscess (boils) he got from deodorant and it is itching (pruritus)
very badly and has the urge to scratch it but he did not want to irritate it. He further states he has
NO rashes, pressure sores, abnormal skin colour (e.g.- vitiligo, ecchymosis), dryness, excessive
sweating (diaphoresis), abnormal nail growth (e.g. clubbing of fingers), swelling (edema),
redness (erythema).
10
Neurological System: The client was oriented x3 (place, time and person) and stated where
he was (hospital), what time it is and who he is. His sleep patterns are usually late to bed at
nights like 10/11 pm and early to rise at either 530/6am.
He stated his sense of smell, touch are in well function. However he sometimes cannot taste his
food and it seems not to be to his liking. He further explained sometimes he has problems with
his hearing and would not hear persons sometimes when they call his name. His vision is
impaired and wear glasses but does not have to wear them everywhere and most uses them to
read. Mr. Ville also stated when he has a very high fever he tends to have tremors of his hands.
Endocrine: Mr. Ville’s face showed signs of disbelief, sadness and confusion. When asked
about his Diabetes Mellitus he said “ yes they told me years ago I have Diabetes…..but I do not
eat sweet things so…and my mother never had it so ….i doubt I have it…but I take the
medication Metformin (Glucaphage ®) when I remember .
11
Physical Assessment
The 59 year old male was taken over 16th /11/2017 at 14:00 hours lying in left lateral position in
bed. Alert and oriented x 3: person, place & time. IV access insitu in left dorsal of hand with end
stopper. Client has a clean dressing under left axilla region. Oxygen Therapy via nasal prongs at
2 litres per minute discontinued. Strict I & O charting and daily weighs continues. Patient
continues to diet poorly. Fluids are limited to 1 liter per day. Client was willing to sit up and
complete a physical assessment. Vitals taken and recorded as: Temperature- 37° Celsius, Pulse94 bpm, Respirations- 23br/m, Blood Pressure-111/63 mmHg, SpO2- 95%.
HEAD
Hair: On inspection hair is curly, black, low hair cut with greying patches with alopecia on the
crown of the head.
Scalp: Clean, free of dandruff. On palpation no lumps, swelling or breakage in the skin. A 2cm
scar noted on forehead. Patient stated he fell off a bicycle about 9years ago. Temporal pulse felt.
FACE
On inspection face structure symmetrical, no rashes, no acne noted. On palpation no abnormal
lumps noted, facial sinus not swollen.
Eyebrows: unevenly shaped & sparse.
Eyes: Mr. Ville’s eyes were clean and no signs of pain seen. Iris- On inspection colour dark
brown, symmetrical. No discharge noted. Sclera- almost white, symmetrical. Mucus
membranes pink and moist. Pupils- symmetrical, PERRLA to penlight noted. Visual acuitywears glasses for reading (no Snellen’s Chart- CN11). Eye movement- convergence &
12
divergence noted. Eyelashes: symmetrical, black, short and evenly distributed. Eyelids:
voluntary blinking (CN1V) noted.
Nose: On inspection the skin is intact and similar to the colour of the face. The nares are clean,
and clear. Cilia noted at entrance of nostrils.
Nose bridge is centre of the face, good sense of
smell (CN 1) assessed. No lesions, no tenderness, erythema, discharge. Sinuses: non tender or
edema noted.
Ears: Symmetrical: the top of the ears are aligned with the outer canter of the eyes. Colour is
consistent with face. They are bean shaped. Pinna of ear is clean, no excess cerumen or discharge
noted. On Observation client appears to be have a right ear hearing deficit which was manifested
by the asking some questions on the right side (which he would ask me to repeat the question)
and on the left side (he answered the questions without asking for them to be repeated). There
was no tuning fork to facilitate the Weber or Rinne tests.
Mouth: On inspection lips appeared symmetrical and brown in colour. Mucous membranes
appear slightly dry. Inspection of buccal cavity: eight (8) Teeth appear to be missing. No
implants or cavities noted. Gums were connected to the teeth and slight black discoloration
noted. Slight yellow discoloration of teeth noted. Client also wears top plate dentures but they
are at home. Tongue is pink and moist and free of lesions, cuts, bruises and pigmentation. It was
centered and large in size and no growths noted. Tonsils not present. Movement of uvula noted
and there is no signs of being inflamed.
13
NECK: On inspection Mr. Ville’s neck showed no signs of discoloration, edema, rash, or
masses. Ranges of Motion exercises performed (flexion, extension, rotation) were easily done
without discomfort. Trachea central and no jugular vein distention noted. On palpation thyroid
glands not enlarged. Lymph nodes not felt. Carotid pulse palpated and regular rhythm noted.
SHOULDERS: symmetrical, no lesions, scars, rashes noted. Active ROM exercises (supination,
pronation.
UPPER EXTREMITIES: On inspection upper extremities symmetrical. IV insuti in dorsal of
left arm. Joints moveable and flexible. Full range of movement noted. Wound Dressing under
left arm (axilla), mild exudate noted, MRSA +, 1 wound 7cm in length , 2 wound 3-4 cm in
length (according to notes as I was not allowed to handle the MRSA wound). Pain in area of
wound under left arm 8/10 on pain scale 0-10. On palpation capillary refill noted less than 3
seconds. Bones intact no fractures noted. Brachial and radial pulse felt.
CHEST/ THORACIC CAVITY: On inspection No tripod position, chest symmetrical in size.
short black and grey hair sparsely distributed. No use of accessory muscles. The rise and fall of
the chest noted along with the bilateral chest expansions observed. No lesions, Scars, or bruises
noted. Tactile Fremitus- slight vibrations felt. On percussion dullness noted. On palpation
tenderness over kidneys noted. Skin Turgor decreased.
Lungs: On auscultation no abnormal breath sounds noted. Heart: Apical Pulse located and
assessed (Regular). No abnormal heart sounds heard.
14
ABDOMEN: Client is placed in the Supine position. On inspection abdomen noted to be slightly
distended in the lower quadrants. Midline Scar from just above the umbilicus to the shaft of the
penis (25 cm) in diameter seen. Scar is black in colour. On auscultation frequent bowel sounds
were heard in all 4 quadrants. On light palpation abdomen is non-tender. However patient stated
he is experiencing burning epigastric pain 7 on the pain scale 0-10.
GENITALS: Client refused to participate in this examination.
LOWER EXTREMITIES: On inspection lower extremities appear symmetrical. Scars noted
on anterior left leg from a previous fall accident. 5 cm surgical scar noted on left knee. Joint
stiffness and pain 5 on the pain scale 0-10 to left knee noted.
Pulses regular and 3+ felt in
popliteal, dorsal pedis and posterior tibial. Capillary refills within less than 3 seconds. Sense of
feeling noted by grooving finger along the bottom of feet. Client stated sharp pain 7 on the pain
scale 0-10 on palpitation of the left ankle. The reaction to the both feet were moderate.
Back: On inspection no abnormal curvatures noted in spinal process. Scapula aligned and
symmetrical. Hips aligned and symmetrical. Buttocks not examined as client refused to
participate. On palpation normal curvature of spine felt and the skin is cool to touch. Burning
Pain to lower back 5 on the pain scale 0-10.
15
Nursing Diagnosis
1. Risk for Infection
2. Acute Pain
3. Deficit Fluid Volume
4. Imbalance Nutrition Less Than Body Requirements
5. Disturbed Body Image
6. Deficit Knowledge
Plan of Care
Assessment
Findings
Nursing
Diagnosis
Patient
Goal
Intervention &
Rationale
Expected
Outcome
Implementation
Evaluation
MRSA+ surgical
wound under left
axilla.
Risk for Infection
related to surgical
and invasive
procedure
manifested by
MRSA + surgical
wound under left
axilla.
Patient will
be infection
free within
5/7.
Monitor the presence of
infection.
Rationale- To document
the changes in infection
process or if the
infection becomes
worst.
Patient remains
infection free
after discharge.
1510hrs:
Demonstrated the
proper hand washing
technique using the
hand washing chart
and singing the happy
birthday song twice
(for least 20 seconds)
to reduce the amount
of bacteria on hands.
I further encouraged
the patient to avoid
sharing personal
items such as towels,
roll-on, etc. Also to
cover his mouth with
tissue or cough into
his clothing or elbow
if tissue is not
available.
Goal not
met however
the patient is
able to
effectively
demonstrate
hygiene
practices
such as hand
washing, and
handling
coughing in a
hygiene
manner to
reduce the
spread of
microorganis
m.
Diagnosis of Sepsis
and lower
respiratory tract
infection.
Monitor patient’s Vital
signs q4hrly:
Temperature, Pulse, and
Blood Pressure.
Rationale- An increase
in Blood Pressure,
Pulse, and temperature
is present in a patient
with an infection.
Encourage client to cover
mouth and nose with
tissue during coughs.
Rationale- This
prevents the spread of
infection.
Monitor Lab results
especially WBC count
Rationale- elevated
Patient is able to
demonstrate the
most important
technique in
promoting
hygiene (Hand
washing.)
.
17
WBC indicates sign of
infection.
Wear PPE such as gloves
as necessary when
performing wound
dressing.
Rationale- The use of
PPE eliminates the
spread of
microorganisms and
breaks the chain of
infection.
Dispose of soiled gauze
from dressings in an
appropriate manner.
Rationale- Reduces the
spread of
microorganisms,
contamination and
cross infection.
Administer medications
as prescribed such as
tazobactam
(Zosyn®), vancomycin
(Vancocin®).
Rationale- Zosyn® is
used reduce the
development of drugresistant bacteria and
Vancocin® is a
18
glycopeptide antibiotic
that is primarily active
against gram-positive
bacteria, including
methicillin-resistant
Staphylococcus aureus
(MRSA)
19
Assessment
Findings
Nursing
Diagnosis
Patient
Goal
Intervention &
Rationale
Expected
Outcome
Persistent vomiting
of undigested food
Deficit Fluid
Volume related to
Electrolyte and acid
base imbalances
manifested by
persistent vomiting
of undigested food,
weakness, dry
mucous
membranes,
negative fluid
balance.
Patient will be
normovolemic
within 8
hours.
Limit fluid volume intake
as prescribed 500-600 mls
per day.
Rationale- Fluid
restriction is done to
prevent the excess
buildup of fluids in the
body.
Patient is able
to maintain
normal fluid
balance as
tolerated by the
kidney and
cardiac
function.
Strict Fluid volume Intake
& Output charting.
Rationale: To maintain
the amount of fluids loss
or retained such as
wound drainage,
vomiting, diarrhea etc.
to assist in ongoing data.
Patient’s B/P
and pulse are
within normal
ranges for his
condition:
120/80 mmHg,
60-100 bpm.
Weakness
Dry mucous
membranes
Tachycardia
Decreased skin
turgor
Negative fluid
balance
Monitor patient’s weight
daily.
Rationale- To determine
fluid retention or fluid
loss.
Monitor patient’s Vital
signs q4hrly:
Temperature, Pulse,
Respiration, and Blood
Patient’s
abdomen is not
distended.
Patient’s Lab
values will be
within normal
range: K+ (3.14.4 mmol),
Chloride (98-
Implementation



14:00hrs:
Temperature37° Celsius,
Pulse- 94
bpm,
Respirations23br/m,
Blood
Pressure111/63
mmHg,
SpO2- 95%
on room air.
1425hrs: Post
Lunch Blood
Glucose:
11.8 mmol
1435hrs: IV
access insitu
in left dorsal
of hand with
end stopper
placed (to be
reviewed by
doctor).
Evaluation
Goal not met.
Patient
continues to
be unstable at
the end of the
shift.
20
Pressure.
Rationale- To obtain
baseline data and
monitor any changes in
vital signs which can
indicate signs for further
medical intervention.
Auscultate the chestlungs.
Rationale- To assess if
there is any fluid
buildup in the pleural
space, or lungs and if
any adventitious breath
sounds such as crackles,
wheezing, bruits,
rhonchi etc.
107 mmol),
and Serum
Creatinine (60110 umol).

15:25hrs:
Assisted
patient to the
bathroom.
Patient
passed 5 cm
of Black,
Type 2 stool
on the Bristol
Stool Chart.
Recorded on
Intake and
output chart.

1535hrs:
vital signs
assess and
recorded as
follows:
Temp: 36.5˚
C, Pulse: 84
bpm,
Respiration:
20 br/m, B/P:
114/60
mmHg.

1800hrs:
Lasix 40mg
po bd given
as
prescribed.
Assess Patient’s skin
turgor and mucous
membranes.
Rationale- for signs of
dehydration.
Give medications Lasix®
(Diuretic) as prescribed.
Rationale- Lasix ® is
used to increase the
elimination of sodium
and chloride by
primarily preventing
reabsorption of sodium
21
and chloride.
Administer IV Fluids as
prescribed such as
Colloids (Albumin Human
25%)
Rationale- Fluid therapy
is most effective early in
the course of severe
sepsis because as the
condition worsens, there
is greater
dysfunction at the
cellular level.

1930hrs:
Temperature
assessed and
recorded:
37.8˚C.

1955hrs:
Vital signs
assessed and
recorded as
follows:
Temp:
36.9˚C,
Pulse:
90bpm, Res:
20br/m, B/P:
140/86
mmHg.
Nurse in
charge
informed.
Tepid
sponging
and tremors
continued.

1956hrs:
Unable to
reach on call
doctor.
Monitor Lab values such
as Hct/RBC count;
BUN/Cr.
Rationale- Moderate
elevations of BUN reflect
dehydration; high
values of BUN/Cr may
indicate renal
dysfunction/
failure.
Educate patient through a
teaching plan about the
benefits of diet
modification and lifestyle
changes needed to prevent
further complications;
such as; low sodium, low
22
protein diet and
introducing light exercises
as tolerated by the cardiac
and kidney function.
Rationale- To assist in
meeting the diet needs of
the client and improving
present health status.

2000hrs:
Patient
vomited
20mls of
undigested
food, and
clear
mucous.
Patient to perform oral
hygiene after each meal.
Rationale- to promote
his appetite and provide
comfort.

2010hrs:
Patient
assisted to
the bathroom
and passed
25 mls of
Type 7 stool
on the Bristol
Stool Chart.

2015hrs:
Patient
assisted back
to bed and
hygiene
needs were
met.

2030hrs:
Vital Signs
assessed and
recorded as
follows:
Temp:
23

35.4˚C,
Pulse:
80bpm, Res:
19br/m, B/P:
110/70
mmHg.
2045hrs:
Patient is
resting
comfortably
in the Semi
Fowler’s
Position.
24
Assessment
Findings
Nursing
Diagnosis
Patient
Goal
Intervention &
Rationale
Expected
Outcome
Patient complains
of pain about the
body :
Burning Pain to
lower back 5 on the
pain scale 0-10.
Acute Pain related
to systemic
infection
manifested by
patient
verbalization of
pain, Temp: 38.8˚C,
Pulse: 110bpm,
Res: 23br/m, B/P:
145/70 mmHg.
Patient will
verbalize a
decrease in
pain at 4 or
less using the
pain scale 010 within 2
hour.
Assess the Patient’s pain
q4hrly using the Pain
scale 0-10 and QRST
(Quality eg; burning,
sharp), Radiating (pain
moving to another
location), Severity (using
the pain scale 0-10), Time
(duration of the pain if
continuously), Location,
Onset of pain (gradual or
sudden), Relieving
factors.
Rationale- Assessing the
pain provides direction
in how to manage the
pain and make any
adjustments to pain
treatment.
Patient is pain
free.
sharp pain 7 on the
pain scale 0-10 on
palpitation of the
left ankle.
burning epigastric
pain 7 on the pain
scale 0-10.
Joint stiffness
Temp: 38.8˚C,
Pulse: 110bpm,
Res: 23br/m, B/P:
145/70 mmHg.
Monitor patient’s Vital
signs q4hrly:
Temperature, Pulse,
Respiration, and Blood
Pressure.
Rationale- An increase
in Blood Pressure, Pulse,
and temperature may be
present in a patient with
acute pain.
Patient is able
to perform
relaxation
exercises as
needed of
onset of pain.
Implementation

16:00hrs:
Positioned
patient in
Semi
Fowler’s
position.

1650 hrs:
patient
observed to
have
vigorous
tremors of
the hands,
excessive
diaphoresis
and
complains of
sharp and
burning pains
about the
body. Nurse
in charge
informed.
1651 hrs:
Temp
assessed and
recorded:
38˚C.
1652 hrs:
Tepid
Patient is able
to determine
when to use
Hot or Cold
Compresses to
reduce pain
and
discomfort.


Evaluation
Goal
Partially
met: Patient
stated pain
decreased to
5/10 on the
pain scale 010 after the 2
hours. He was
able to return
demonstration
of guided
imagery
.
Nursing care
continues to
ensure the
patient is pain
free.
25
Position patient in Left
Lateral position.
Rationale- To promote
patient comfort.
Provide analgesic
medications (Panadol®)
as prescribed.
Rationale- To relief pain
or reduce pain.
Discuss and allow patient
to return demonstration of
relaxation techniques such
as deep breathing
exercises (pursed lip
breathing), guided
imagery (this is usually
done after pursed lip
breathing; you picture
yourself in a calm and
peaceful location
surrounded by all the
things you enjoy.
Rationale- This
encourages the patient to
decrease anxiety and
promotes a calm and
relaxing effect to be
introduced.
Provide Hot or Cold
compresses as necessary.



sponging
done.
1710 hrs:
Nurse in
charge
unable to
reach on call
doctor.
1725hrs:
Vital Signs
assessed and
recorded:
Temp:
38.8˚C,
Pulse:
110bpm,
Res: 23br/m,
B/P: 145/70
mmHg.
1728hrs: Dr.
Jackman
informed and
verbal order
of STAT
dose of 1g
Panadol ®
prescribed.
1730hrs: STAT
dose of 1g Panadol
® po with a Sip of
water given to the
patient under the
26
Rationale- Heat
decreases pain
through increasing blood
flow to the area and thus
reduction of pain is
accomplished. Cold
lessens pain,
inflammation,
and muscle spasticity by
decreasing the release of
pain-inducing chemicals
and regulating the
conduction of pain
impulses. The two can be
used either one after the
other. Eg cold compress
before hot compress.
Assist patient with
hygiene needs (Bath).
Rationale- Bathing can
assist in pain
management by
relieving some
discomfort and provide
relaxation.
supervision of
Registered Nurse.
Patient participated
in discussion about
guided imagery.
Client was unable to
think of any happy
memories at present
moment. However
He stated “He would
love to be at home in
his bed and watching
cartoons.” Which I
expressed to him as
a good image to
reminisce in that
statement to assist in
decreasing
discomfort, anxiety
and pain.
27
Assessment
Findings
Patient complains
of Nausea,
Vomiting
Nursing
Diagnosis
Imbalance
Nutrition: Less
than body
requirements
Patient dieting
related to
poorly (not meeting increased
his food intake
metabolism
daily requirements). manifested by
nausea,
Dry mucous
vomiting,
membranes
alteration in taste
sensations
Alteration in taste
sensation.
Patient
Goal
Intervention &
Rationale
Expected
Outcome
Implementation Evaluation
Patient will be
able to
consume all of
his supper by
the end of the
shift.
Assess the client’s weight
and height to calculate the
BMI
Rationale- to be used as
baseline data and
reference.
Patient is
knowledgeable
about the
importance of
diet and nutrition
in promoting a
speedy recovery.
1815hrs: Patient
tolerated supper
well: 2 wholewheat slices of
bread, grated carrot
and ½ can of tuna,
250ml tea, 100ml
of orange juice.
Thereafter patient
performed oral
hygiene.
Weigh client weekly at
specific time.
Rationale- This gives
information to if the
patient is losing
weigh/fluid or gaining
weigh/fluid.
Assess client’s eating
habits including food
portion sizes,
consumption, food
preferences.
Rationale- This provides
baseline data for
nutritional intervention.
Educate client about the
benefits of having a
balanced diet which
includes fruits such as
apples and green leafy
vegetables, and on time.
Patient is able to
state foods
which are
healthy and can
be put in place of
processed food
and snacks.
Goal met:
Patient
tolerated
supper well
by
consuming
100% of his
meal.
28
Rationale- to promote a
healthy lifestyle.
.
Frequent oral care.
Rationale- Promotes
appetite.
Make meals look
attractive and presentable.
Rationale- By making
the meals attractive the
patient is able to enjoy
their meals more and
have an appetite.
Refer to the dietician
Rationale- to ensure
proper diet planning is
given to the client.
29
Assessment
Findings
Nursing
Diagnosis
Patient
Goal
Intervention &
Rationale
Expected
Outcome
Implementation
Evaluation
Multiple surgeries
especially Radical
cystectomy (2013),
Ureterosigmoidosto
my (2013).
Disturbed Body
Image related to
changes in
appearance 2˚ loss
of body part
manifested by
patient’s
verbalizations “I
don’t even study
that(Penis) no more
it don’t do what it
used to do as
much…plus…. I
have to pass water
through my
bottom.” (erectile
dysfunction) and
the refusal to
participate in
gentilia
examination during
physical
assessment.
Patient will be
able to
effectively
cope with his
body changes
by 1/52.
Acknowledge the
patient’s feelings of grief,
sadness, frustration and
anger.
Rationale- By
acknowledging the
patients feeling either
negative or positive
gives the patient the
opportunity to feel as
though someone is
willing to listen and
cares about him.
Patient is able
to describe the
stages of grief.
1430hrs: Patient
engaged in a
discussion about his
past hospitalizations
and the goals he
would like to put in
place after he leaves
the hospital this
time. I educated the
patient about being
able to express
himself when he is
feeling upset or
unclear to what is
going on; the stages
of grief and
incorporating social
activities into his
lifestyle such as
exercise.
Goal not
met:
Patient
verbalized his
feelings
further about
his bladder
removal
surgery and
his penis
erectile
dysfunction.
However he is
not interested
in accepting
he is grieving
the loss of his
body part and
wishes to not
study it
anymore. It is
what it is.
Patient’s
verbalizations “I
don’t even study
that (Penis) no
more it don’t do
what it used to do
as much…plus…. I
have to pass water
through my
bottom.”
Refusal to
participate in
gentilia
examination during
physical
assessment.
Verbalization of
denying illness (He
didn’t have Bladder
Cancer) His
Bladder was just
removed.
Assist patient with
activities to uplift his
overall mood such as
having a journal, exercise
such as walking, riding
bicycle, swimming,
music therapy etc.
Rationale- Through
these activities the
patient convert his
negative energy to
positive energy which
will boost his mood to a
level of contentment.
Discuss with the patient
the grieving process (The
Patient is able
to understand
what he is
going through
is a part of the
grieving
process and it
is considered
normal in
certain
situations such
as his.
Patient is able
to journal his
feelings.
Patient is apart
of a social
support group
which caters to
persons who
have had a
body part
removed or
self-esteem
management
30
five stages of grief:
Denial, Anger,
Bargaining, Depression
and Acceptance).
Rationale- Discussing
the different stages of
grief provides the
patient with the much
needed information to
understand what stage
he is in and how to get
to the end stage of
acceptance. Some
person stay in one of
the five stages longer
than some and some
never reach acceptance
upon death.
Refer patient to
counseling, social
services, as needed.
Rationale- Through the
referral of these
specialists. The patient
is able to connect with
himself once more as he
did before and is able to
live a happier life.
classes.
31
Assessment
Findings
Nursing
Diagnosis
Patient Goal
Intervention &
Rationale
Expected
Outcome
Implementation Evaluation
Patient’s
verbalization of
denying his
diagnosis.
Deficit Knowledge
related to new
medical condition
manifested by
Patient’s
verbalization of
denying his
diagnosis.
Patient will be
knowledgeable
of the disease
processes,
causes, risk
factors and
complications
within 1 hour.
Assess the patient’s
readiness to learn,
previous knowledge,
medication management,
community resources
and.
Rationale- Learning
takes place when the
patient is ready to
participate in learning.
It also gives baseline
data to build on what
he knows already or
where the teaching
should begin.
Patient is able
to state the
disease
processes,
causes, risk
factors and
complications.
1625hrs:
Discussion with
patient about his
health status and
present condition.
Patient continues to
deny his condition
but he knows he is
ill. He further
stated, “He prefers
to let his Fiancé to
speak to the doctors
and nurses as she
explains
information to him
good.” He asked for
reference materials
and stated he will
go to his polyclinic
for more
information when
he is better.
Include family in
discussions and teaching
session as needed.
Rationale- This provide
s the patient with the
much need support to
promote recovery.
Plan multiple, short and
concise teaching sessions
with visual aids.
Rationale- Providing
multiply, short and
concise sessions allows
the patient to grasp the
Patient
verbalizes his
concerns about
his condition an
asked for more
information and
reference
materials.
Patient has the
ability to deal
with health
situation and
remain in
control of life.
Goal met:
Patient
expressed he
would like
reference
materials and
someone to
explain to his
Fiancé about
his condition
so she can
assist him
when he is at
home.
32
information better than
1 long, informative
session.
Assist the patient in goal
setting and
implementation into his
daily life.
Rationale- Assisting in
goal setting encourages
patient participation in
learning and executing
plans of achieving goals.
Educate and refer patient
to Community resources
such as Polyclinics,
Barbados Cancer Society
etc.
Rationale- through
these referrals the
patient is able to
educate his self more
about his conditions.
.