Nursing Process Case Study: Communication
The Case:
(Read the assigned article prior to completing this case study assignment)
You are the nurse caring for Andrew (he/him) on the second day of his hospitalization.
Before coming into the room for handoff, the night nurse tells you they did not feel
comfortable taking care of a transmasculine patient and they hope Andrew couldn’t feel
their discomfort. The nurse states Andrew has been withdrawn.
You introduce yourself and do bedside handoff with the previous nurse. The nurse tells
you Andrew has been responding well to the antibiotic therapy. His vital signs on the
previous shift were: Temperature 98.1 F, heart rate 70 bpm, respirations 16 breaths per
minute, blood pressure 110/60, and pulse oximetry 100% on room air. He has been
taking pain medication and states his pain is under control. The nurse finishes report
and quickly leaves the room.
You ask Andrew if you can start your assessment and he agrees.
During your assessment you note that Andrew is restless, and his heart rate is elevated
at 112 bpm. He is afebrile. You ask Andrew how he is feeling.
He states “I am feeling better physically but I feel uneasy. I am having trouble
concentrating and I just feel tense all the time since I have gotten here. I am having
trouble sleeping. My pain is under control, but I just can’t get comfortable.”
You say to Andrew, “So you are saying you feel uncomfortable and uneasy here in the
hospital. Can you tell me more about these feelings?”
Andrew states, “I don’t understand how I got a urinary tract infection. I thought I was
doing everything right. I know I should be seeing my doctor every year, but I really don’t
like going to the doctor because I don’t trust that they know how to care for me.”
Create an appropriate plan of care for Andrew based on this morning’s assessment.
Develop two nursing diagnosis and identify the priority diagnosis.
Identify the Cues in this Case Study:
- “feel tense”, uneasy, and uncomforable
- having trouble sleeping
Nursing Diagnosis
(PES Format)
Problem:
anxiety
Goal & outcome criteria
Interventions & rationales
Evaluation method
Goal:
- reduce anxiety/ patient will
not be anxious
The nurse will:
- educate on proper hand
hygiene
- educate on wearing cotton
underwear, avoiding tightfitting clothing, and
changing out of sweaty
clothing
- educate on perineal care
1. patient list 3 risks factos
for UTI transmission
2. patient state he will wipe
front to back.
3. patient states anxiety is
decreased
Etiology (cause):
r/t distrtrust on healthcare porvider
Symptoms (Defining
Characteristics):
- elevated heart rate
- burning on urination
- “feel tense”, uneasy, and
uncomforable
- having trouble sleeping
Outcome Criteria:
- patient will report absence
or reudction of pain
- patient will list 3 actions to
prevent UTI
Nursing Diagnosis
(PES Format)
Problem:
Goal & outcome criteria
Goal:
Etiology (cause):
Outcome Criteria:
Symptoms (Defining
Characteristics):
Interventions & rationales
The nurse will:
Evaluation method