NAME:_________________________________Year/Section:_________Date:___________

INDIVIDUAL ACTIVITY:
CASE STUDY:
A primary nurse is admitting Mr. Albert Smith, 66 years old, to a surgical unit
before surgery for prostate cancer. The primary health-care provider, Dr. Matthew
Espada tells the nurse that the patient was admitted early to ensure that the patient
is well hydrated and that electrolytes are within the expected range in preparation
for surgery. The nurse assesses the patient and collects the following information:
a. Skin is pale, dry, warm, intact, and tenting when pinched.
b. Capillary refill is delayed and nail beds are pale.
c. Vital signs are: apical pulse 95 beats/minute, respirations 23 breaths/minute
with a slight expiratory wheeze; temperature 97.8ºF using a temporal scanner
thermometer (infrared sensor), and blood pressure 160/86 mm Hg.
d. Vesicular breath sounds are present.
e. Hyperactive bowel sounds are present.
f. Slight abdominal distension is present over the suprapubic area.
g. Tympany is noted on percussion of the abdomen.
h. No lower extremity edema is present.
i. Speech is rapid and at times tremulous.
j. Patient appears clean and well groomed, with an absence of body and breath
odor.

When the nurse interviews the patient, the patient’s wife remains at the
bedside at the patient’s request. The nurse documents the following information
on the nursing admission history and physical examination.
The patient explained, “I’ve been taking Hytrin 2 mg at bedtime for the past
six months because I was getting up so many times at night to urinate. I started to
feel bloated and uncomfortable in the abdominal area several weeks ago and did
not feel that I completely emptied my bladder after urinating. I finally went to the
doctor, who ran tests and said I have prostate cancer.” The patient then explained
that his doctor then referred him to an urologist, who planned to do a total
prostatectomy in the morning. The patient stated, “Sometimes I need to go to the
bathroom and I don’t make it in time and I wet myself. It’s embarrassing and I feel
terrible. I’m afraid that I might become impotent and have incontinence after the
surgery, but I trust the urologist and recognized that the surgery is necessary.” The
patient asked many questions about what he can expect after surgery, which were
answered. He said, “Having cancer puts a big monkey wrench into my retirement
plans. I hope I’ll live long enough to do a little traveling.” The wife stated, “I don’t
care if we can’t travel. I don’t want him to die. Also, he forgot to tell you that he is
always tired because he keeps getting up at night to go to the bathroom.” During
the interview, the patient went to the bathroom and voided 200 mL of dark amber
urine. A urine specimen was sent to the laboratory for a urinalysis. After the
interview the nurse obtained a drug handbook and reviewed the side effects of
Hytrin.

i. Answer the following:

A. ASSESSMENT:
OBJECTIVE DATA: Identify the data that were collected using the following
assessment techniques:
 • Inspection
a.____________________________________________________________________
b. _____________________________________________________________________
c. _____________________________________________________________________
d. _____________________________________________________________________
e. _____________________________________________________________________
• Palpation
a.___________________________________________________________________
b.____________________________________________________________________
c.____________________________________________________________________
d.____________________________________________________________________
e.____________________________________________________________________
• Percussion
a.____________________________________________________________________
b.____________________________________________________________________
c.____________________________________________________________________
d.____________________________________________________________________
e.____________________________________________________________________
_
• Auscultation
a.____________________________________________________________________
b.___________________________________________________________________
c.____________________________________________________________________
d.___________________________________________________________________
e.____________________________________________________________________
• Other objective data:
a.___________________________________________________________________
b.___________________________________________________________________
c.____________________________________________________________________
d.___________________________________________________________________
e.____________________________________________________________________

SUBJECTIVE DATA:
Identify the subjective data collected by the nurse during the patient interview.
a.____________________________________________________________________
b.___________________________________________________________________
c.____________________________________________________________________
d.___________________________________________________________________
e.____________________________________________________________________

B. DIAGNOSIS: Identify the related to and defining characteristics, and secondary

to factors of the presented nursing diagnostic labels. (use NANDA nursing
handbook)
1. Risk for urinary retention
related to____________________________________________ __________________
as evidenced by ________________________________________________________
secondary to ___________________________________________________________
2. Fear of impotence and incontinence
related to____________________________________________ __________________
as evidenced by ________________________________________________________
 secondary to ___________________________________________________________
3. Disturbed sleep pattern
related to____________________________________________ __________________
as evidenced by ________________________________________________________
secondary to ___________________________________________________________
4. Situational low self-esteem
related to____________________________________________ __________________
as evidenced by ________________________________________________________
secondary to ___________________________________________________________
5. Urge incontinence
related to____________________________________________ __________________
as evidenced by ________________________________________________________
secondary to ___________________________________________________________

GROUP ACTIVITY:
II. CREATE 2 NURSING CARE PLANS (1 with actual diagnosis, 1 with potential/risk
diagnosis) BASED FROM THE SITUATION ABOVE:

CRITERIA:
Assessment (20%)
• Thorough and accurate assessment of the patient's physical, psychological,
social, and spiritual needs.
• Identification of relevant health history, risk factors, and pertinent data.
• Use of appropriate assessment tools and techniques.
Nursing Diagnosis (20%)
• Formulation of nursing diagnoses based on the assessment findings.
• Use of NANDA-I (North American Nursing Diagnosis Association International)
terminology.
• Prioritization of nursing diagnoses according to the patient's needs and acuity.
Planning/Goals and Desired Outcomes (20%)
• Clear and measurable goals/outcomes that are specific, achievable, realistic,
and time-bound (SMART).
• Alignment of goals with the identified nursing diagnoses.
• Involvement of the patient and family in setting goals when appropriate.
Interventions: (10%)
• Appropriate interventions based on the goals and nursing diagnosis.
• Evidence-based nursing interventions tailored to address the identified nursing
diagnoses and goals.
• Specific actions outlined for each nursing diagnosis, including nursing
assessments, treatments, and patient education.
• Consideration of interdisciplinary collaboration and delegation as needed.
Rationale (10%)
• Evidence-based rationale provided for each nursing intervention.
• Explanation of why each intervention is appropriate and how it addresses the
patient's needs.
• Integration of current research, best practices, and clinical guidelines.
Evaluation (20%)
• Ongoing evaluation of the patient's response to nursing interventions.
• Assessment of goal attainment and progress towards desired outcomes.
 NURSING CARE PLAN
Name: ________________________________ Room/Unit No. _____________________ Age: ________________
Attending Physician: ___________________________ Date: _______________

IMPLEMENTATION
ASSESSMENT DIAGNOSIS PLANNING EVALUATION
Intervention Rationale
Subjective Data:
At the end of my 8hr shift, 1. At the end of my 8hr shift,
the patient will be able to: the patient was be able
a. 2. to:
b. a.
c. 3 b.
d. c.
Objective Data: e. 4 d.
f. e.
g. f.
5 g.

10

Nurse/s on Duty (N.O.D): ________________________________