College of Nursing-A Nursing Care of Adult I Nursing

(NURS 321)
Nursing Care Plan
Spring 2020
Guidelines for Focused Bedside Nursing Care Plan Based on Nursing Process
Purpose: The purpose of the nursing care plan is to:
Provide you as a student with learning experience to integrate theoretical concepts and
scientific principles when utilizing the nursing process in generalized patient care
Help you as a student to develop and implement a comprehensive plan of bed side
nursing care for an assigned patient based on his/her needs.

Name of Student: Clinical Area:

Latifah Almanea
Student ID: 411230573 Evaluator:
Man surgery
Date: / co /020dB
2019 Total Mark: ( / 6)
13

NURSING ADMISSION DATA BASE (5%)

Patient’s initial: ...................................... Age: ...............
74 Sex: ....................
Mr Ahmed Male
Spoken language: .....................................................................................
Arabic Date
of Admission: ..........................Via:
3Oct2021 ................................................ Source of
Data: ........................................................................................
Bestcare Patient
Education: ………………………………………………………. Condition
on arrival: Wheelchair.............. Walking............ Stretcher..........
Reasons for Hospitalization: ......................................................

Confirmed Diagnosis: ..........................................................……..

Benignprostatichyperplasia
Past medical history: .........................................................................................
..............................................................................................................................
Hypertension urineretension
Past surgical history: .........................................................................................
..............................................................................................................................
Prostatectomy prostaticbiopsy
Family history (Genogram): …………………………………………
(Please draw it in the box below)

yo
Hypertension
Anned
Hypertension
or

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 College of Nursing-A
Nursing Care of Adult I (NURS 321)
NURSING CARE PLAN
Spring 2020

Narrative: (Brief description of patient’s case – Endorsement)

______________________________________________________________________
Mr Ahmed in the seventh suffer fromenlargeprostate
______________________________________________________________________
urinary retention and a bacterial infection inThe urinarytract Also
______________________________________________________________________
he had prostatectomy
______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

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 FOCUSED NURSING CARE PLAN BASED ON NURSING PROCESS

Assessment Planning
Nursing Patient Goals Expected Nursing Interventions Rationale Evaluation
Subjective Data Objective Data Outcomes (Actions)
Diagnosis
Criteria

inanitixtourinateswenigos your urinaryretention bladder Elimenateau

empties antibiotics givetocomba Bladderis
completely
abdomen relatedtoinability
lower
completely
theurinefrom antibacterials infection
Bladders.anness
ofbladderi contract empty
bladders
feelingineneed alsoEnlargedprostate catheter maintaindrainage providefree
after
gourinate evidenced by tubingacatheter drainageoturine
urination
finishing inabilitytoempty kinkfree
bladdercompietix

Nurse Labs
References: ……………………………………………………………………………………………
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 FOCUSED NURSING CARE PLAN BASED ON NURSING PROCESS

Assessment Planning
Nursing Patient Goals Expected Nursing Interventions Rationale Evaluation
Subjective Data Objective Data Outcomes (Actions)
Diagnosis
Criteria

Acutepain facial maintainpatient toPrevent Thepain

expressions reduseanepain
Acutepainrelated painriive Postoperative
ivabdominal tobladderdistensionScalesfrons comfort
complicationsScalesis
andurinaryinfection102
stius

Assesspainvoting toenoice
Locationintensity aneffectiveness
cscaieos.o.io interventions

References: ……………………………………………………………………………………………
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 FOCUSED NURSING CARE PLAN BASED ON NURSING PROCESS

Assessment Planning
Nursing Patient Goals Expected Nursing Interventions Rationale Evaluation
Subjective Data Objective Data Outcomes (Actions)
Diagnosis
Criteria

Decreasein Riskfordeficient maintainadeauate output

monitor cars.am Rapido
s ustained
drainage
Abnormal no nr diuresis
could
patient
c ause
fluidvolumeinclude hydration ofdeficient noteoutputofloozoompatientsara stininrisk
fluidintake weakness postonstructive
fluidvolume pernr fluidvolumeto
rapid
diuresisfrom become
depleted
drainageofacnronica limitssodium
overdistenaeabladder reabsorption
inrenaitunnies

Nurse's lab's
References: ……………………………………………………………………………………………
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 Student Clinical Portfolio: Nursing Care of Adults I (NURS 321)

MEDICATION PROFILE

Student name:____________________
LatifahAlmanea

Allergies: (1)

Item Medication 1 Medication 2 Medication 3 Medication 4

Drugs and
Classification (1) Tamsulosin piperacillin Amlodipine

selective a receptorkillsbacteriaby inninitscaicianion

For this Patient antagonisttuataras inhibitingthesynthesisinfluxacrosscel
preferentialselectivity ofbacteriacenwan membranes
Action/indication (1) Foranreceptorinane
prostatversustnealB
inbloodvessels
Dose / Route /
Frequency (1) 0.4mg oral 3375g Iv long oral
Avoidusingwitnotnerreaction
Historyofallergic Hypersensitivity
a blockers iopiperacinin
Contraindications (1) toamoaipine

sleepiness swellingoedema
Diarrhea
Expected side effects Difficultyfallingasleep pulmonaryedema
Headache
(2) weakness constipation fatigue
Backpain palpitation
painintneface Nausea nausea
monitorforsignsof match forseizures AssessHeart
orthostaticHypotensionmonitor Reportanxrnx.mn
Nursing Implications signsof
monitorpatientson pseudomembranous disturbancesoranx
symptomsofincreased
(2) warfarintherapy colitisincluding diarrhea
abdominalpain fever arrhythmiasincluding
closely Pusornucusinstoois Chest pain
shortness
ofbreath

References: _________________________________________
Medicinenet

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 Student Clinical Portfolio: Nursing Care of Adults I (NURS 321)

Diagnostic Evaluation (5 Marks)

(Lab Results, MRI, CT, ECG, etc…)

Test Performed Normal Value Patient Value Interpretations & Nursing Care
Date
(1 Mark) (1 Mark) (1 Mark) (2 Marks)

uricAcid 250 750mg 181 207 Lowgassessineviansignus

Neotroman 17.5 135 19.01 High
120 Low monitorinevianisions I
Hgb 138 17291L pulseoximeterreadingsclosely
NBC 4.5 ho o 22.10 High Assessforinfection
mangenatrisonsintakeby
Encouragepatienttoincreasedietaryintake
Phosphorus 2.5 4sugar 0.85 ofphosphorus.rieneood

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