Steve Rogers, an 80-year-old man, was taken to the hospital by his daughter who 

stated that her father was

weak, vomited four times, and has pain in his belly. She is also informed that his appetite is poor and he is very
anxious. On assessment of the client, he is lethargic, states his pain is a 9 on a scale of 1-10. He vomited three
times, 100 milliliters each of greenish fluid, and passed approximately 150 milliliters of urine in the urinal. His
temperature is 38.2 C, pulse 80bpm, respiration 22cpm and blood pressure 140/80 mmHg.

CASE 1. STEVE ROGERS (7 columns)

CUES Nursing Background Planning Interventions Rationale Evaluation
Diagnosis knowledge
Subjective: Risk for Fluid volume Short term: 1.Monitor 1.Fluid loss After 24 hours
“She stated that deficient fluid deficit (also After of 24 active fluid loss from diarrhea patient have
her father felt volume related known as hours nursing from wound and/or achieved the
weak and has to process of hypovolemia) intervention the diarrhea and/or vomiting cause equal of intake
pain in his belly” ageing as describes the patient will vomiting; decreased fluid and output of
as verbalized by manifested by loss of have equal maintain volume and can fluid and his
the relative. patient extracellular intake and accurate input lead to appetite return
vomiting 100 fluid from the output of fluid and output dehydration. to normal.
ml of greenish body. There are as well his record.
fluids 3 times a number ways appetite will 2.Oral fluid Patient
Objective:
the body can return to 2.Persuade the replacement is demonstrates
BP 140/80mmHg
lose fluid. Some normal. patient to drink indicated for the lifestyle to
RR 22cpm
major causes of prescribed mild fluid changes to
HR 80bpm
deficient fluid Long term: amount of fluid deficit and is a progression of
T 38.2C
volume are Patient will cost-effective dehydration.
Lethargic
through demonstrate method for
3.Educate
gastrointestinal lifestyle replacement
Vomited greenish patient about
system: changes to treatment.
fluids possible cause
vomiting and avoid Older patients
and effect of
diarrhea. This is progression of have a
fluid losses or
particularly an dehydration. decreased sense
decreased fluid
issue with infant of thirst and
intake.
and elderly may need
patients. ongoing
Teach family
reminders to
members and
drink. Oral
patient how to
hydrating
monitor output
solutions (e.g.,
in the home.
Oresol,
Instruct them to
Gatorade) can
monitor both
be considered
intake and
as needed.
output.

STEVE ROGERS (5 column)

Assessment Diagnosis Planning Intervention evaluation
“She stated her father Acute Pain related to Short term: 1.Teach the use of After 8 hours, patient
has pain in belly and vomiting as After 8 hours of nonpharmacologic vomiting and abdominal
felt very anxious also manifested by patient nursing intervention techniques before, pain has reduced to 4/10
lost his appetite” rating pain 9 on 1-10 patient vomiting and after, and if possible, and his appetite returned to
verbalize by the also scale, active vomiting, abdominal pain will during painful normal.
relative reduce 4/10 as well activities; before pain
his appetite will return occurs or increases; Patient has been feeling
pain scale 9//10 and along with other more energetic than the
Patient will report pain relief measures past 24 hours
feeling less lethargic
within 24 hours. 2.Demonstrate and After 2 days, the patient has
BP 140/80mmHg
practice the relaxation no more pain and afebrile.
RR 22cpm
technique with patient
HR 80bpm
T 38.2 C Long term:
Lethargic After 1-2 days of
Vomited greenish nursing intervention
fluids. patient will be pain
free and afebrile
Scenario: Tony Stark is a 36-y/o police officer assigned to a high crime police precinct. One week ago he received a surface
bullet wound to his arm. Today he arrives at the outpatient clinic to have the wound redressed. While speaking with the nurse,
Mr. Stark mentions that he has been promoted to the rank of detective and has assumed new responsibilities. He states that since
his promotion, he has experienced increasing difficulty falling asleep and sometimes staying asleep. He expresses concern over
the danger of his occupation and his desire to do well in his new position. He complains of waking up feeling tired and irritable.
During interview the nurse notes that he is pale, drawn with dark circles under his eyes. Temp: 37.0 C Pulse: 80 bpm, Resp:
18cpm, BP: 140/90mmHg.

TONY STARK (7 COLUMN)

Assessment N. Diagnosis Background Planning Intervention Rationale Evaluation
Knowledge
Subjective: Anxiety related Generalized After 8 hours - Establish a - To establish After 8 hours
“Since the to threat of anxiety of nursing therapeutic the trust and of nursing
promotion I current status disorder is intervention, relationship, show interest. Intervention,
experienced as evidenced characterized the patient will conveying - To avoid the patient is
difficulties by waking up by excessive feel relaxed empathy and confusions. - feeling better
falling asleep feeling tired worry about a and the level of positive To identify and relaxed
and sometimes and irritable, number of anxiety will regards. physical and reduced
staying asleep” difficulty different reduce and - Acknowledge response. - the level of
as verbalized falling asleep events, decrease in to a anxiety fear. May help the anxiety and
by the patient. and stay associated with manageable - Encourage client relax and feel Easily to
asleep. heightened level. the client to feel better fall asleep.
He also tension. A express
expresses the person with feelings.
danger of his generalized - Monitor Vital
of his anxiety signs
occupation. disorder may - Provide
also feel comfort
irritable and - Instructor
Objective:
have physical assess to deep
T 37.0 C
symptoms such breathing and
HR 80bpm
as restlessness, relaxation.
RR 18cpm
feeling easily
BP
tired and
140/90mmHg
having tense
Pale skin
muscles.
Drawn dark
circles

Tony Stark (5 column)

Assessment N. Diagnosis Planning Intervention Evaluation
Subjective: Hypertension related to Patient will maintain Provide calm, restful Maintained the blood
“He states that since lack of sleep as BP within individually surroundings, and pressure at less than
his promotion, he has manifested by acceptable range. minimize 140/90 mmHg with
experienced increasing 140/90mmHg environmental activity lifestyle modifications,
difficulty falling asleep Patient will participate and noise. medications, or both.
and sometimes staying in activities that will
asleep” prevent stress (stress Instruct in relaxation
management, balanced techniques, guided
activities and rest imagery, and
Objective:
plan). distractions.
T 37.0 C
HR 80bpm Monitor response to
RR 18cpm medications to control
BP 140/90mmHg blood pressure.
Pale skin
Drawn dark circles Provide comfort
measures (back and
 neck massage, the
elevation of head).

CASE 1. STEVE ROGERS (7 columns)

CUES Nursing Background Planning Interventions Rationale Evaluation
Diagnosis knowledge
Subjective: Risk for Fluid volume Short term: 1.Monitor 1.Fluid loss After 24 hours
“She stated that deficient fluid deficit (also After of 24 active fluid loss from diarrhea patient have
her father felt volume related known as hours nursing from wound and/or achieved the
weak and has to process of hypovolemia) intervention the diarrhea and/or vomiting cause equal of intake
pain in his belly” ageing as describes the patient will vomiting; decreased fluid and output of
as verbalized by manifested by loss of have equal maintain volume and can fluid and his
the relative. patient extracellular intake and accurate input lead to appetite return
vomiting 100 fluid from the output of fluid and output dehydration. to normal.
ml of greenish body. There are as well his record.
fluids 3 times a number ways appetite will 2.Oral fluid Patient
Objective:
the body can return to 2.Persuade the replacement is demonstrates
BP 140/80mmHg
lose fluid. Some normal. patient to drink indicated for the lifestyle to
RR 22cpm
major causes of prescribed mild fluid changes to
HR 80bpm
deficient fluid Long term: amount of fluid deficit and is a progression of
T 38.2C
volume are Patient will cost-effective dehydration.
Lethargic
through demonstrate method for
3.Educate
gastrointestinal lifestyle replacement
Vomited greenish patient about
system: changes to treatment.
fluids possible cause
vomiting and avoid Older patients
and effect of
diarrhea. This is progression of have a
fluid losses or
particularly an dehydration. decreased sense
decreased fluid
issue with infant of thirst and
intake.
and elderly may need
patients. ongoing
4.Teach family
reminders to
members and
drink. Oral
patient how to
hydrating
monitor output
solutions (e.g.,
in the home.
Oresol,
Instruct them to
Gatorade) can
monitor both
be considered
intake and
as needed.
output.

3.Enough
knowledge aids
the patient to
take part in his
or her plan of
care.

4.An accurate
measure of
fluid intake and
output is an
important
indicator of
patient’s fluid
status.