CASE STUDY ANALYSIS

A. Pre-operative Preparations

Cystoscopy is a procedure that

allows your doctor (urologist) to examine the
lining of your bladder and the tube that
carries urine out of your body (urethra) using
a cystoscope which is a thin tube with
camera and lens at the end (Bergen, 2019).
It is done to diagnose and treat bladder
disease and conditions and diagnose and enlarged prostate. Preparations for
cystoscopy includes taking antibiotics before and after the procedure if patient has
UTI or a weak immune system. Also, the doctor might ask for a urine sample before
the test. Before cystoscopy, the nurse will assist the patient in going to the bathroom
to empty his bladder and in changing into surgical gown. If the doctor plans to give
general anesthesia advise the patient to fast for several hours ahead of time and take
time to rest after the procedure. The nurse should provide health teachings regarding
potential risk and side effect after cystoscopy such as swollen urethra (urethritis),
infection in rare cases only, bleeding from urethra, which can appear bright pink in
urine and toilet paper, burning sensation upon urinating and more frequent urination
for the next day or two. Recommend patient to take a rest, drink lots fluid to flush
bladder and reduce irritation and hold a warm, moist washcloth over the opening to
your urethra to help relieve pain.

Transurethral Resection of the Bladder Tumor (TURBT) is an “incision-

less” surgery, usually the most common treatment for early-stage or superficial (non-
muscle invasive) bladder cancers. The goal is to take out the cancer cells and nearby
tissues down to the muscle layer of the bladder wall (American Cancer Society,
2019). The surgeon puts a thin rigid tube called a cystoscope into your urethra then
passes small instruments down the cystoscope to cut any tumors out of the bladder
lining. It is commonly done under general anesthesia, which means the patient is
asleep or in some cases under spinal anesthetic (epidural) where the patient cannot
feel anything below the waist. The treatment typically takes 15 to 90 minutes to finish.

Transurethral Incision of the Prostate (TUIP) is a minimally invasive

procedure used to treat patients with enlarged prostates, which are typically caused
by benign prostatic hyperplasia The goal of a TUIP is to relieve pressure on the
urethra to allow urine to flow from the bladder into the urethra and out of the body
(Mercy Health, 2020). The doctor will make two incisions into the prostate gland to
open the urinary channel and relieve pressure on the urethra, relaxing the opening to
the bladder and decreasing resistance to the flow of urine out of the bladder. No
tissue is removed. It is also done under either general or spinal anesthetic. If
successfully done, TUIP helps reduce urinary symptoms caused by benign prostatic
hyperplasia (BPH) including frequent and urgent need to urinate, difficulty starting
urination, slow or prolonged urination, increased frequency of urination at night and
urinary tract infections.

Preoperative preparations for both Transurethral Resection of the Bladder

Tumor (TURBT) and Transurethral Incision of the Prostate (TUIP) starts with a pre-
assessment clinic a week or two before the surgery where history taking takes place
 which includes medical history (previous surgery, serious illness or trauma), history
of familial diseases, allergies, support system, religious belief, lifestyle etc. Physical
assessment is also needed and done. On the day of your operation, the patient will
see the surgeon who will explain the procedure completely and thoroughly. It is
required to have an informed consent signed by the patient of legal age and mentally
capable or by the parent/guardian if the patient is minor, incompetent, unconscious.
This is to protect the patients from unsanctioned surgery and the surgeon from any
legal complications. Prior to the surgery, ensure that NPO is maintained, blood
ordered is available, dentures/false teeth and jewelries are removed and nails and
surgery site is cleaned. Since TURBT and TUIP may be done under general
anesthesia, a blood test, chest X-ray and ECG is necessary and instruct patient to
stop eating at least 6 hours beforehand and can only drink sips of water up to two
hours before. Several days before surgery, advise patient to stop taking medications
such as warfarin (Coumadin) or clopidogrel (Plavix) as per doctor’s order because it
can increase the risk of bleeding. The nurse is also likely to give an antibiotic to
prevent a urinary tract infection either before or after surgery. The nurse assists the
patient in full bath if able, going to the hospital chapel (if there is any), in changing
clothes into hospital gown and in transporting patient from room/ward to operating
room. It is also essential for nurses to obtain vital signs for baseline data and
reinforce teachings such as deep breathing & coughing exercises, leg exercises,
turning to sides, early ambulation, pain management, cognitive coping strategies.
Aside from that, preoperative checklist is done by nurses before endorsing the
patient to the operating nurse one hour prior to the surgery filled with patient’s
signature and vital signs data. The nurse should provide health teachings about
proper treatment and care after the surgery for possible side effects (blood in urine,
irritating urinary symptoms, difficulty holding urine, infections). Overall, preoperative
care involves preparation of the patient and patients’ family or significant others
physically, mentally, emotionally, and spiritually.

B. Focused Physical Priority Assessment

The purpose of focused assessments is to do a physical priority assessment in

response with the patient’s specific health issues and problems which is recognized
by the nurse as needing further assessment of a body system or systems. Patient
PAS has been diagnosed of urinary bladder malignancy, benign prostate
hyperplasia, Hypertensive cardiovascular diseases, diabetes mellitus type 2,
hypertension stage 2 – uncontrolled. Given his disease complications and based
from his assessment and history of present illness, the nurse should do a focused
physical priority assessment on genitourinary, respiratory, endocrine, and
cardiovascular systems.

a. Focused Genitourinary System Assessment

The gastrointestinal and genitourinary system is responsible for the

ingestion of food, the absorption of nutrients, and the elimination of waste
products. An assessment of gastrointestinal system includes inspecting
abdomen for distention, striae, scars, contour and symmetry, observing any
abdominal movements associated with respiration, pulsations or peristaltic
waves, auscultating and palpitating abdomen for bowel sounds in all four
quadrants. An assessment of the renal system includes all aspects of urinary
elimination. This includes objective data about urinary pattern, incontinence,
 frequency, urgency and dysuria, hydration status (fluid balance, balance,
weight), diet or fluid restrictions, skin condition (temperature, turgor and
moisture), urine output, urinalysis (pH, ketones, protein, blood, leukocytes,
specific gravity) and reviewing laboratory results (blood chemistry, urea,
creatinine, electrolytes and albumin). For subjective data, it covers patient’s
diet and exercise routine, patient’s family history of gastrointestinal and
genitourinary disease and asking patients regarding any symptoms about
gastrointestinal and genitourinary disease (characteristics of feces and urine,
pain upon urination). Aside from that, history taking for feeding patterns and
difficulties, elimination pattern (frequency, consistency, color, any bleeding)
and pain, cramping, nausea, vomiting (frequency, color, bleeding,
consistency), and previous GI interventions and concerns (stoma, bowel
obstruction etc.) is required.

b. Focused Endocrine System Assessment

Every cell in our body is influenced by our endocrine system. The

endocrine system acts to maintain equilibrium at the cellular level and is a
vital link in homeostasis. A focused endocrine system assessment needs
medical history about any experienced signs and symptoms of endocrine
diseases and disorders of the patient and the family as well. Signs and
symptoms of endocrine disease may include fatigue or lethargy, weight gain
or loss, dizziness, feelings of depression, irritability, or anxiety, pain,
decreased libido, nausea and vomiting, changes in urinary or bowel habits,
changes in vision, intolerance to heat or cold, or change in appetite. In
conducting a focused endocrine assessment on a patient both subjective and
objective data are important, and it comprises a thorough history of their chief
complaints, psychological status, present health status, current lifestyle,
laboratory test (blood tests, FBS, A1C), and physical assessment. Physical
exam may reveal heart murmur, cardiac irregularities, abnormal breath or
bowel sounds, changes in skin color or turgor, bruises or rashes, or enlarged
pancreas. Endocrine disorders and diseases usually manifest according to
which endocrine hormone is being overproduced and secreted, or under-
produced, at any given age (Jarvis, 2016).

c. Focused Cardiovascular/Peripheral Vascular System Assessment

The cardiovascular and peripheral vascular system affects the entire

body. Assessment of the cardiovascular system evaluates the adequacy of
cardiac output and includes both subjective and objective data. Same with
gastrointestinal and genitourinary systems history of patient’s diet, elimination
pattern and stress levels is asked, family history of cardiovascular diseases is
collected and signs, symptoms and complain about peripheral edema,
shortness of breath (dyspnea), and irregular pulse rate is inquired. A focused
cardiovascular/peripheral vascular system assessment involves inspection of
patient’s face lips and ears for cyanosis, chest for deformities, bilateral arm,
hands and legs, calf size and pain; examination of circulatory status and
hydration status (skin turgor, oral mucosa) of upper and lower extremities;
checking capillary refill time and nail beds, blood pressure, and for presence
of edema (central and/or peripheral). Auscultating apical pulse for one minute
and the chest for heart sounds and murmurs. Noting the rate and rhythm and
 comparing peripheral pulse and apical pulse for consistency (the rate and
rhythm should be similar). Palpating the radial, brachial, dorsalis pedis, and
posterior tibialis pulses for rate, rhythm and volume.
d. Focused Respiratory System Assessment

The respiratory system allows us to breathe. The lungs bring oxygen

into our bodies (called inspiration, or inhalation) and send carbon dioxide out
(called expiration, or exhalation). A focused respiratory system assessment
includes conducting an interview related to history of respiratory disease,
smoking and environmental exposures. Medical history is taken upon
assessment such as family’s history of pulmonary diseases and onset plus
duration of signs and symptoms (cough, shortness of breath) and triggers
(dust, pollen, smoking, aerosol). This is to determine the severity of
respiratory conditions. Assessment of objective data involves: inspection for
the use of accessory muscles and work of breathing, configuration and
symmetry of the chest, respirations for rate (1 minute), depth, and rhythm
pattern, skin color of lips, face, hands, and feet, audible sounds such as
vocalization, wheeze, stridor, grunt, cough (productive/paroxysmal), and O2
saturation using a pulse oximeter; listening for absence/equality of breath
sounds and auscultating (anterior and posterior) lungs for breath sounds and
adventitious sounds; and palpating bilateral symmetry of chest expansion,
skin condition (temperature, turgor and moisture), capillary refill
(central/peripheral), Fremitus (tactile), and subcutaneous emphysema.

C. Laboratory Finding and Interpretations

Laboratory Test Laboratory Results Reference

RBC 2.92 L 3.69 – 5.90 x10E12/L
Hemoglobin 8.30 g/dl 13.50 – 17.50 g/dL
Hematocrit 33.40 % 41.00 – 53.00%
WBC 9.33 L 4.50 – 11.00 x10E9/L
Platelet Count 320 L 150.00 – 390.00 x10E9/L
Bleeding Time Minutes – 2; Seconds - 20 less than 10 min
Clotting Time Minutes – 4; Seconds – 2-8 minutes
29
Cholesterol 5.72 mmol/L 3.88-5.15 mmol/L
Triglycerides 1.89 mmol/L 1.69 mmol/L
HDL .77 mmol/L 1.04 mmol/L
LDL 4.23 mmol/L 3.36 mmol/L
Uric Acid 583 umol/L 200–430 µmol/l (men)
Minimal Fibrosis, Both Bony structures appear
Chest X-ray Lung Apices with residual white on the film. Hollow
Atherosclerotic Aorta structures containing
mostly air, appear dark.
Glycosylated hemoglobin 7.9% 5.7% - 6.4%
Concentric left ventricular The ventricular wall is
hypertrophy with thickest near the cardiac
Color flow doppler study segmental wall motion base and thins to 1–2
abnormality. mm at the apex.
Segmental wall motion is
kinetic.
 Ultrasound of the prostate Weight of the prostate is Average weight of 11
20 grams, with 35 cm3 in grams (1-16 grams), with
size. 20 cm3 in size

Interpretation:
A low level of hemoglobin in the blood relates directly to a low level of oxygen. Based
from the laboratory findings, patient PAS has low RBC, hematocrit and hemoglobin levels.
Low hemoglobin levels usually indicate that a person has anemia it is linked with a disease
or condition that causes your body to have too few red blood cells. In addition, low
hematocrit levels may be a sign of bone marrow diseases, hemolytic anemia and kidney
failure. In the case of Patient PAS, it is associated with his Urinary Bladder Malignancy and
Benign Prostatic Hyperplasia. Since kidney disorders and cancer can affect the body’s ability
to produce red blood cells.
Patient PAS has high cholesterol and HDL levels and low LDL levels which indicates
that fatty deposits are developing in his blood vessels that can eventually lead to heart attack
and stroke if these fatty deposits break and form a clot. Although high cholesterol levels can
be inherited, based from the patient’s record, it is clearly because of his sedentary lifestyle
and diet and non-compliance to medications.
High uric acid level or hyperuricemia is a sign that patient PAS may have gout. A
gout is a form of arthritis where crystals from uric acid form in your joints and cause intense
pain. This is supported by his assessment data where it is documented that he experiences
pain and has swelling in his lower extremities. It is also linked with his bladder cancer where
he undergoes chemotherapy treatments and these treatments kill a lot of cells in his body,
which can raise the level of uric acid leaving high levels of purines inside his body.
The chest X-ray results shows that patient PAS has pulmonary fibrosis. His lung
tissues are damaged and scarred making it more difficult for the lungs to work properly and
to function twice as needed. Along with minimal fibrosis, patient PAS also has
atherosclerosis in both lungs which is caused by his high cholesterol and HDL levels
resulting in build-up of fats in the artery walls. Shortness of breath, wheezing and dyspnea
upon exertion are all symptoms of both illness which is manifested by the patient as well. Yet
Again, this is because he is a smoker and lives a sedentary lifestyle with poor diet choices.
Patient PAS is already diagnosed with Type 2 Diabetes Mellitus, it is understandable
that he has high glycosylated hemoglobin (HbA1c) level. This condition leads him to have
cardiovascular problems and kidney disease. As shown in his color flow doppler study
results, while treating his long-term hypertension to decrease the risk of stroke, renal failure,
and myocardial infarction, patient PAS developed a left ventricular hypertrophy with
segmental wall motion abnormality; as a result of controlling arterial pressure, sodium
restriction, and weight.
The results of the ultrasound of his prostate reveals that his prostate is bigger in size
and weight and so he is diagnosed with benign prostatic hyperplasia or prostate
enlargement. This is cause and a complication of his urinary bladder malignancy which is
evidenced by his increase in urine frequency of at least 10-15 times a day. Other laboratory
findings/results of patient PAS like WBC, platelet count, bleeding and clotting time fall within
normal range values which implies that he has no current infection, no bleeding problems
and clotting disorder.
 D. Pathophysiology

Urinary Bladder Malignancy; Benign

Prostatic Hyperplasia; Hypertensive Predisposing Factors:
Cardiovascular Disease; Diabetes Age
Precipitating Factors:
Mellitus Type 2, Hypertension stage 2 Gender
Lifestyle and Diet
– Uncontrolled Heredity
Heart Disease Risks Factors
Race
Sexual Activity
Socioeconomic Status
Smoking  
Over-activity of Sympathetic
 
  Nervous System
 

Heart Rate &

Production of catecholamine Insulin Resistance Exhaustion of beta cells
Vascular Dysfunction

Secretion of Insulin

Renin Angiotensin I
Absorption of
Glucose
glucose by the cell
Arteriolar
Angiotensin II
Vasoconstriction
Vascular Cell Starvation
Changes
Peripheral Vascular Adrenal Cortex
Resistance Stimulation II
Stimulation of
Atherosclerosis hunger mechanism
Hypertension via hypothalamus
Cardiomyopathy Aldosterone

Hunger
Na Reabsorption
Hypertension Blood Pressure
Polyphagia
H2O Reabsorption

Hyperglycemia
Blood Volume Plasma Volcano
(ECF)
 E. Nursing Care Plan

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Impaired urinary Short Term: Independent: After nursing
elimination related to interventions, goal met.
Verbal report on
mechanical obstruction;
After 6 hours of nursing 1. Encourage patient  May minimize urinary Patient voided in
inability to empty interventions, patient will to void every 2–4 retention and
enlarged prostate as sufficient amount,
bladder completely and be able to: hr and when urge overdistension of the
evidenced by frequency demonstrated postvoid
feeling like the need to is noted. bladder.
and urgency to empty  Void in sufficient residuals and managed
empty bladder always.
bladder amounts with no the manifestation of the
2. Ask patient about  High urethral
Objective: palpable bladder disease process.
stress pressure inhibits
distension. incontinence when
 Urinary bladder emptying or
 Demonstrate moving, sneezing,
frequency and can inhibit voiding
postvoid coughing,
urgency at least until abdominal
residuals of less laughing, lifting
10 – 15 times pressure increases
than 50 mL, with objects.
per day. enough for urine to
absence of
 Difficulty in be involuntarily lost.
dribbling/overflow 3. Observe urinary
sleeping  Useful in evaluating
. stream, noting
especially at degree of obstruction
night. Long Term: size and force. and choice of
 (+) Hematuria intervention.
After 8 days of nursing 4. Have patient  Urinary retention
 (+) Dysuria
interventions patient will document time increases pressure
 Facial grimaces be able to manage the and amount of within the ureters
upon urinating manifestation of the each voiding. Note and kidneys, which
 (+) Edema disease. diminished urinary may cause renal
output. Measure insufficiency. Any
specific gravity as deficit in blood flow
indicated to the kidney impairs
its ability to filter and
concentrate
substances.
5. Percuss and  A distended bladder
palpate can be felt in the
suprapubic area. suprapubic area.
 6. Encourage oral
fluids up to 3000  Increased circulating
mL daily, within fluid maintains renal
cardiac tolerance, perfusion and flushes
if indicated. kidneys, bladder, and
ureters of “sediment
and bacteria.” Note:
Initially, fluids may be
restricted to prevent
bladder distension
until adequate
urinary flow is
reestablished.
7. Monitor vital signs
closely. Observe
 Loss of kidney
for hypertension,
function results in
peripheral and
decreased fluid
dependent
elimination and
edema, changes
accumulation of toxic
in mentation.
wastes; may
Weigh daily.
progress to complete
Maintain accurate
renal shutdown.
I&O.
8. Check catheter
often (every 15
 For patency and
minutes for the
urine color. To
first 2 to 3 hours).
maintain returns that
Keep the catheter
are clear and light
open.
pink.
Collaborative:
1. Administer alpha-
adrenergic
 Studies indicate that
antagonists:
these drugs may be
tamsulosin
as effective as
(Flomax), prazosin
Proscar for outflow
(Minipress),
obstruction and may
 terazosin (Hytrin),
doxazosin have fewer side
mesylate effects regarding
(Cardura); per sexual function.
doctor’s order.
2. Administer rectal
suppositories (B &
O) as prescribed.  Suppositories are
absorbed easily
through mucosa into
bladder tissue to
produce muscle
relaxation and relieve
spasms.
3. Adminiter
antibiotics and
 Given to combat
antibacterials per
infection. May be
doctor’s order.
used
prophylactically.
CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
Subjective: Acute pain related to Short Term: Independent: After nursing
surgery procedure of the interventions, goal
Verbal report of pain
bladder as evidenced by
After 6 hours of nursing 1. Determine pain  Information provides met. Patient reported
especially when interventions, patient will history (location of baseline data to
guarding behavior maximal pain relief
urinating in surgery be able to: pain, frequency, evaluate and control,
site. duration, and effectiveness of
 Report maximal demonstrated use of
intensity using interventions. Pain of
Objective: pain relief/control relaxation skills and
numeric rating scale more than 6 mos.
with minimal diversional activities,
 Pain scale of (0–10 scale), or duration constitutes
interference with followed prescribe
6/10 verbal rating scale chronic pain, which
ADLs. program and patient
 (+) guarding (“no pain” to may affect
 Demonstrate use free of any pain and
behavior “excruciating pain”) therapeutic choices.
of relaxation skills discomfort.
 (+) hematuria and relief measures Recurrent episodes of
and diversional used. Believe acute pain can occur
 Transurethral activities as patient’s report. within chronic pain,
Resection of indicated for
the Bladder requiring increased
individual level of intervention.
Tumor situation
(TURBT)  Follow prescribed
surgery done pharmalogical  Pain may occur near
2. Determine timing or
yesterday program the end of the dose
precipitants of
interval, indicating
Long Term: “breakthrough” pain
need for higher dose
when using around-
After 5 days of nursing or shorter dose
the-clock agents,
interventions patient will interval.
whether oral, IV, or
be free from any pain patch medications.
and discomfort
 A wide range of
3. Evaluate and be discomforts are
aware of painful common (incisional
effects of therapies pain, burning skin,
(surgery, radiation, low back pain,
chemotherapy, headaches),
biotherapy). depending on the
procedure and agent
being used.
 Promotes relaxation
4. Provide and helps refocus
nonpharmacological attention.
comfort measures
(massage,
repositioning,
backrub) and
diversional activities
(music, television)  Enables patient to
5. Encourage use of participate actively in
stress management nondrug treatment of
skills or pain and enhances
complementary sense of control.
therapies (relaxation
techniques,
visualization, guided
imagery,
biofeedback,
laughter, music,
 aromatherapy, and
therapeutic touch).
6. Provide cutaneous  May decrease
stimulation (heat or inflammation, muscle
cold, massage). spasms, reducing
associated pain.

7. Evaluate pain relief  Goal is maximum

and control at pain control with
regular intervals. minimum interference
Adjust medication with ADLs.
regimen, as
necessary.
8. Discuss use of  May provide
additional alternative reduction or relief of
or complementary pain without drug-
therapies related side effects.
(acupuncture and
acupressure).
Collaborative:
1. Administer opioids:
codeine, morphine  A wide range of
per doctor’s order. analgesics and
associated agents
may be employed
around the clock to
manage pain.
2. Administer
acetaminophen  Effective for localized
(Tylenol); and and generalized
nonsteroidal anti- moderate to severe
inflammatory drugs pain, with long-acting
(NSAIDs), including and controlled-
aspirin, ibuprofen release forms
(Motrin, Advil) as available.
prescribed.
3. Administer
 corticosteroids:  May be effective in
dexamethasone controlling pain
(Decadron) as associated with
prescribed inflammatory process
(metastatic bone
.
pain, acute spinal
cord compression
and neuropathic
pain).

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Decrease cardiac output Short Term: Independent: After nursing
related to decreased interventions, goal
“I feel dizzy
venous return
After 6 hours of nursing 1. Monitor BP every 1-2  Changes in BP may met. Patient have no
sometimes”, as interventions, patient hours, or every indicate changes in elevation in blood
verbalized by the will be able to: 5minutes during patient status pressure and
patient. active titration of requiring prompt
 have no maintained blood
vasoactive drugs. attention.
Objective: elevation in pressure within
2. Suggest frequent  It may decrease
blood pressure acceptable limits,
 Lethargic position changes. peripheral venous
above normal participated in
 Prolonged pooling that may be activities that reduce
limits and will
capillary refill potentiated by stress and cardiac
maintain blood
(3 seconds) vasodilators and workload.
pressure within
 Vital signs prolonged sitting or Demonstrated stable
acceptable
taken as standing. cardiac rhythm and
limits
follow:  Caffeine is a cardiac rate within patient’s
 participate in 3. Encourage patient to
stimulant and may normal range.
 T: 36.3 activities that decrease intake of
adversely affect
 P: 82 will prevent caffeine, cola and
cardiac function.
 R: 28 stress (stress chocolates.
4. Observe skin color,  Peripheral
 BP: management,
temperature, capillary vasoconstriction may
150/100 balanced
refill time and result in pale, cool,
 O2: 96% activities and
diaphoresis. clammy skin, with
rest plan).
prolonged capillary
 participate in
refill time due to
activities that
cardiac dysfunction
reduce
 BP/cardiac
workload.
Long Term:
After one week of
nursing interventions,
patient will demonstrate
stable cardiac rhythm
and rate within patient’s
normal range.
Collaborative:
and decreased
cardiac output.
 May indicate heart
5. Note dependent and failure, renal or
general edema. vascular impairment.
 Helps lessen
6. Provide calm, restful sympathetic
surroundings, stimulation; promotes
minimize relaxation.
environmental activity
and noise. Limit the
number of visitors and
length of stay.
7. Instruct client & family  Restrictions can
on fluid and diet assist with decrease
requirements and in fluid retention and
restrictions of sodium hypertension, thereby
improving cardiac
output.
8. Emphasize and  Promotes knowledge
instruct client and and compliance with
family on medications, the drug regimen.
side effects,
contraindications and
signs to report.
1. Administer loop
diuretics: furosemide  These drugs produce
(Lasix); ethacrynic marked diuresis by
acid (Edecrin); inhibiting resorption of
bumetanide (Bumex), sodium and chloride
torsemide (Demadex) and are effective
as per doctor’s order. antihypertensives,
especially in patients
2. Administer adrenergic who are resistant to
 neuron blockers: thiazides or have
guanadrel (Hylorel); renal impairment.
guanethidine
(Ismelin); reserpine  Reduce arterial and
(Serpalan) as venous constriction
indicated. activity at the
sympathetic nerve
endings.

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Risk for infection related Short Term: Independent: After nursing
to high glucose level, interventions, goal
“My wounds are not
decreased leukocyte
After 8 hours of nursing 1. Monitor vital signs  To achieve baseline met. Patient can
healing” as verbalized interventions, patient will data
function. identify interventions
by the patient. be able to: 2. Observe for the  Patients with DM may to prevent or reduce
signs of infection be admitted with
Objective:  Identify risk infection and
and inflammation: infection, which could
interventions to demonstrated
 Flushed fever, flushed have precipitated the
prevent or reduce techniques and
appearance appearance, wound ketoacidotic state.
risk of infection. lifestyle changes to
 Wound drainage, purulent They may also
 Demonstrate prevent development
drainage sputum, cloudy develop nosocomial
techniques, of infection.
 Vital signs urine. infection.
lifestyle changes
taken as to prevent
follow: 3. Teach and promote  Reduces risk of
development of good hand hygiene. cross-contamination.
 T: 36.3 infection.
 P: 82 4. Maintain asepsis  Increased glucose in
 R: 28 during IV insertion, the blood creates an
 BP: administration of excellent medium for
150/100 medications, and bacteria to thrive.
 O2: 96% providing wound or
site care. Rotate IV
sites as indicated.
5. Provide catheter or  Minimizes the risk of
perineal care. UTI. A comatose
 patient may be at
particular risk if
urinary retention
occurred before
hospitalization.
6. Provide meticulous  Peripheral circulation
skin care: gently may be ineffective or
massage bony impaired, placing the
areas, keep skin dry. patient at increased
Keep linens dry and risk for skin
wrinkle-free. breakdown and
infection.
7. Place in semi-  Facilitates lung
Fowler’s position. expansion; reduces
risk of aspiration.
8. Encourage
 Decreases
adequate dietary
susceptibility to
and fluid intake
infection. Increased
(approximately 3000
urinary flow prevents
mL/day if not
stasis and aids in
contraindicated by
maintaining urine
cardiac or renal
pH/acidity, reducing
dysfunction),
bacteria growth and
including 8 oz of
flushing organisms
cranberry juice per
out of system.
day as appropriate.
Collaborative:
1. Administer
antibiotics as  Early treatment may
appropriate. help prevent sepsis.
 CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
Subjective: Impaired gas exchange Short Term: Independent: After nursing
related to airway and interventions, goal
“I have trouble
alveoli thickening and
After 8 hours of nursing 1. Monitor respiratory  There will be an met. Patient
breathing”, as interventions, patient will and heart rate for increase in the
inflammation as maintained optimal
verbalized by the be able to: any changes. respiratory and heart
evidenced by dyspnea gas exchange and
patient. rate as a way of
 Will maintain oxygen saturation of
compensation for early 96% or higher, and
Objective: optimal gas
hypoxia. ABG’s are within
exchange as
 (+) dyspnea  Abnormalities may normal range.
evidenced by 2. Assess for changes
upon exertion indicate respiratory Achieved relaxed
oxygen saturation in respiratory status
 (+) wheezing compromise, breathing and
of 90% or greater, such as cyanosis,
breath sound hypercarbia, or baseline of heart
arterial blood pallor, changes in
 Smoker for 67 hypoxia. rate.
gasses (ABGs) the level of
years within the client’s consciousness,
 Vital signs usual range, labored breathing
taken as relaxed breathing, and tachypnea.
follow: and baseline 3. Monitor  Increasing levels can
 T: 36.3 heart rate transcutaneous indicate the
 P: 82 carbon dioxide as progression of acute
 R: 28 ordered. infection and pending
 BP: respiratory failure.
150/100 4. Monitor arterial  Increasing Paco2 and
 O2: 96% blood gasses and decreasing Pao2 are
oxygen saturation as signs of respiratory
indicated failure.
 5. Provide for  Activity increases
adequate rest oxygen needs and
between activities should be paced
during the day, with appropriately to avoid
a minimal nighttime fatigue.
interruption in sleep.

6. Place the client in a

semi-Fowler’s  Semi-Fowler position
position. promotes lung
expansion and
decreases airway
collapse, dyspnea, and
breath work through
Collaborative: gravity.

1. Administer oxygen
therapy as indicated.
 Supplemental oxygen
(Avoid giving high
maintains adequate
oxygen
concentration in oxygenation,
decreases the work of
clients with chronic
carbon dioxide breathing and calorie
expenditure, and
retention).
relieves dyspnea,
increasing the level of
2. Collaborate with
respiratory care comfort.
personnel in the  Bilevel positive airway
monitoring and pressure is a
administration of noninvasive ventilation
noninvasive for assistance with
ventilation as nighttime ventilatory
indicated. needs.
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