REASON FOR Bladder Cancer

ADMISSION
3 PRIORITY 1. UTI related to catheter insertion as evidenced by elevated temperature.
DIAGNOSIS
Max 25 words 2. Impaired urinary elimination related to diminished bladder capacity as evidenced by
per diagnosis bladder distention

3.Acute Pain related to surgical procedure as evidenced by guarding behaviour

PATIENT DATA
DIET Regular, Fluid- Honey thicken fluid
Hygiene/ADL – independent, partial Partial assist X2. Mobility devices used-
assist, total care Cane. Bed bath, Peri care and mouth care
Mobility/activity-bedrest, w/c, walker, Transferred to chair and then to commode for
mobility lift, fall risk washroom. Transferred to bed after that.
Output – continent, foley, drains, n/g, CBI-until urine runs clear. Urine vol-2000 ml
ostomy @0900. Last BM @ 01100
Code status Full
Treatments – dressing, O2, wounds No wounds, no dressings
IV therapy – solution, rate, lok Saline lock flushed @0900. Later peripheral
IV inserted. Iv solution –Lactated Ringers for
30 min Rate-125 ml/hr
Vital – frequency Q4h
PATIENT VITALS T-37.4, BP-107/65, O2-96%, HR-88, RR-18, MAP-80
ASSESSMENTS
RESPIRATORY Breath sounds clear bilaterally, no adventitious sounds
Findings from
CARDIOVASCULAR Normal rhythm, no chest pain, no shortness of breath
your patient
assessment at
clinical GASTROINTESTINAL Abdomen is flat, symmetrical. No swelling, bowel sounds
in all four quadrants.
GENITOURINARY Skin intact, clean and dry. Urine pink, no odour
MUSCULOSKELETAL Full range of motion
INTEGUMENTARY Skin- warm, dry and intact, no redness or edema
NEUROLOGICAL Alert and orientatedX3. Calm, no agitation

PRIORITY Priority assessment Interventions Rationale

ASSESSMENT, Pain assessment- Pain management is priority.
INTERVENTIO 1. Pain OPQRSTU Unmanaged pain can lead to
N AND 2. Infection Administer pain meds adverse physical and
RATIONALE psychological outcomes and can
Maximum 25 Monitor VS and for delay discharge.
words per section signs of infection
Administer antibiotics Infection after a surgical procedure
as per orders. is common and if it’s not treated
on time it can lead to more serious
consequences like organ failure
 and even death
ABNORMAL LAB TEST CURRENT PREVIOUS NORMAL WHY IS VALUE
LAB VALUES RANGE ABNORMAL
Hemoglobin 121 g/L 130-180 g/L Due to the blood
loss associated with
surgery
Creatinine 137 umol/L 58-110 Due to post renal
umol/L function
complications after
surgery
Sodium 131 mmol/L 135-145 Due to surgical
mmol/L stress promoting
water retention
Hematocrit 0.367 L/L 0.390-0.540 Due to the blood
L/L loss associated with
surgery

ABNORMAL DIAGNOSITIC TEST Explanation of test How does this relate to

DIAGNOSITIC your patient
TEST

Not applicable-
Patient didn’t had
any recent
diagnostic tests

MEDICATION – maximum 25 words per section; include all routine and PRN medications; add as
many rows needed

Medication classification Common Common Common Nursing Patient Why is the patient
name, dose, use of side effects assessments teaching taking this med
generic/trade route, medication
names frequency
 Amlodipine/ Calcium Oral To treat Swelling of Assess HR, Take This patient has
Narvasc channel route, high Blood hands, feet, ECG, Heart medication coronary heart
blockers tablet pressure ankles, sounds, and around disease and this
once a headache, chest pain. same time medication helps to
day-5 mg nausea, Shortness of every day. manage it
stomach pain breath Follow low
sodium diet
as
prescribed
by doctor

Bisoprolol/ Selective Oral To treat Headache, Monitor Take This patient has
Monocor beta-clocker route, high Blood dizziness BP,ECG medication coronary heart
tablet pressure Weakness pulse, jugular around disease and this
once a Nausea or venous same time medication helps to
day-5 mg vomiting distention, every day manage cardiac
Muscle or dyspnea issues and
joint pain myocardial
infarction
Dutasteride/ 5-alpha Oral Used to Inability to Assess Avoid To reduce the time
Avodart reductase Capsule treat have or bladder taking postoperative
inhibitors 0.5 mg enlarged maintain volume, medication bladder irrigation
once a day prostate erection output, for erectile and duration of
gland Decrease in dysuria dysfunction indwelling
sex drive catheterization
Ejaculation
disorder
Mirabergron/ beta-3 Oral It is used to Headache, Monitor Do not To Improve
Myrbetriq adrenergic route, ER manage of dizziness, dry urinary crush, break symptoms for
agonist tablet overactive mouth, output, or chew urinary frequency,
once a bladder constipation, Monitor for tablet urgency and
day-25 mg difficulty signs and incontinence
emptying the symptoms of
bladder medication
Spironolactone/ aldosterone Oral It prevents Vomiting. Assess BP, Avoid To controls edema,
Aldactone receptor route, the body Diarrhea, Assess renal potassium- heart failure,
antagonist, tablet from enlarged or function. containing hyperaldosteronism
potassium- once a absorbing painful Intake and salt
sparing day-25 mg too much breasts, output. substitute.
Diuretics salt. It irregular Follow
caused menstrual doctors
kidney to periods order for
eliminate the amount
unneeded of
water. potassium
rich food