Nursing Care Plan for Prostate Adenocarcinoma: A Case Study | Assignments Earth science

NURSING CARE PLAN 1

ASSESSMENT NURSING DIAGNOSIS CLIENT GOAL OUTCOME

CRITERIA

`NURSING INTERVENTIONS RATIONALE ACTUAL EVALUATION

SUBJECTIVE CUES

“Makulbaan man ko sa

akong umaabot na

operasyon ma’am oi.

Hadlok ko ba unsa pa

kahay mahitabo nako.” as

verbalized by the patient.

OBJECTIVE CUES:

Restlessness

Poor eye contact

Hand tremors and

facial tension noted

Increased in

perspiration

Cold hands and

fingers observed

Vital Signs:

oT = 36.5 C

oPR= 80 bpm

oRR = 20 cpm

oBP = 110/80 mmHg

oSPO2= 98%

Moderate Anxiety related to

upcoming Transurethral

Resection of the Prostate

(TURP) Secondary to Prostate

Adenocarcinoma

SCIENTIFIC BASIS:

If the tumor has caused a

blockage around the prostate

area, the only treatment for this

situation is an invasive surgery

and it is totally normal to feel

anxious before surgery. Even if

operations can restore your

health or even save lives, most

people feel uncomfortable about

“going under the knife” because

it can be hard not to worry about

the operation and remember

important things that are told

about the operation, such as the

advice about how to prepare for

it or about recovering

afterwards.

REFERENCE:

Doenges, M. E., Moorhouse, M. F., & Murr, A.

C. (2017). Nurse's Pocket Guide.

Philadelphia: F.A. DAVIS COMPANY.]

Short Term:

After 3 hours of nursing

interventions, the client

will be able to appear

relaxed and aware of

feelings.

Specifically, the client

will be able to:

Verbalize

awareness of

feeling of

anxiety.

Appear at ease

and more

relaxed.

Report reduction

of anxiety.

Independent:

1. Monitored vital signs.

2. Established a therapeutic

relationship and remained

aware of own feelings.

3. Informed client and SO of the

nurse’s intraoperative

advocate role.

4. Allowed patient to talk about

anxious feelings and examine

anxiety, provoking situations if

they are identifiable.

5. Acknowledged normalcy of

fear.

6. Encouraged the client to

acknowledge and express

feelings.

7. Provided an active-listen

attitude during conversation of

feelings.

8. Accepted the client as is.

1. To identify physical responses

associated with both medical

and emotional conditions.

2. To avoid transmission of

anxiety.

3. May minimize urinary retention

and overdistention of the

bladder.

4. Talking about anxiety,

producing situations, and

anxious feeling can help the

patient perceive the situation

realistically and recognize

factors leading to the anxious

feeling.

5. Opens door for discussion

about feelings.

6. Expresses feelings reduces

anxiety.

7. This promotes an atmosphere

of caring and permits

explanation or correction of

misperceptions.

8. Client may need to be where

he is at a point in time after the

diagnosis or treatment regimen

Short Term:

After 3 hours of nursing

interventions, the client

appeared relaxed and

aware of feelings.

Specifically, the client:

Verbalized

awareness of

feeling of anxiety.

Appeared at ease

and more

relaxed.

Reported

reduction of

anxiety.

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NURSING CARE PLAN 1

ASSESSMENT NURSING DIAGNOSIS CLIENT GOAL OUTCOME

CRITERIA

` NURSING INTERVENTIONS RATIONALE ACTUAL EVALUATION

SUBJECTIVE CUES

“Makulbaan man ko sa akong umaabot na operasyon ma’am oi. Hadlok ko ba unsa pa kahay mahitabo nako.” as verbalized by the patient. OBJECTIVE CUES:  Restlessness  Poor eye contact  Hand tremors and facial tension noted  Increased in perspiration  Cold hands and fingers observed

 Vital Signs:

o T = 36.5 C o PR= 80 bpm o RR = 20 cpm o BP = 110/80 mmHg

o SPO2= 98%

Moderate Anxiety related to upcoming Transurethral Resection of the Prostate (TURP) Secondary to Prostate Adenocarcinoma SCIENTIFIC BASIS: If the tumor has caused a blockage around the prostate area, the only treatment for this situation is an invasive surgery and it is totally normal to feel anxious before surgery. Even if operations can restore your health or even save lives, most people feel uncomfortable about “going under the knife” because it can be hard not to worry about the operation and remember important things that are told about the operation, such as the advice about how to prepare for it or about recovering afterwards. REFERENCE: Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2017). Nurse's Pocket Guide. Philadelphia: F.A. DAVIS COMPANY.] Short Term: After 3 hours of nursing interventions, the client will be able to appear relaxed and aware of feelings. Specifically, the client will be able to:  Verbalize awareness of feeling of anxiety.  Appear at ease and more relaxed.  Report reduction of anxiety. Independent:

Monitored vital signs.
Established a therapeutic relationship and remained aware of own feelings.
Informed client and SO of the nurse’s intraoperative advocate role.
Allowed patient to talk about anxious feelings and examine anxiety, provoking situations if they are identifiable.
Acknowledged normalcy of fear.
Encouraged the client to acknowledge and express feelings.
Provided an active-listen attitude during conversation of feelings.
Accepted the client as is.
1. To identify physical responses associated with both medical and emotional conditions.
2. To avoid transmission of anxiety.
3. May minimize urinary retention and overdistention of the bladder.
4. Talking about anxiety, producing situations, and anxious feeling can help the patient perceive the situation realistically and recognize factors leading to the anxious feeling.
5. Opens door for discussion about feelings.
6. Expresses feelings reduces anxiety.
7. This promotes an atmosphere of caring and permits explanation or correction of misperceptions.
8. Client may need to be where he is at a point in time after the diagnosis or treatment regimen Short Term: After 3 hours of nursing interventions, the client appeared relaxed and aware of feelings. Specifically, the client:  Verbalized awareness of feeling of anxiety.  Appeared at ease and more relaxed.  Reported reduction of anxiety.

Discussed or demonstrated routine procedures and processes that may frighten or concern client, such as lights, IVs, Blood Pressure (BP) cuff, electrodes, etc.
Encouraged relaxation and distraction techniques such as music of patient’s choosing.
Provided health teaching and accurate information about the importance of every treatment regimen on the current condition in a simple, direct, and honest terms.
Allowed client to use anxiety for coping with situation, if helpful.
Assisted in developing a new anxiety reducing skills.
Assisted in developing awareness of negative thoughts and substituting a positive thought.
Prevented unnecessary body exposure during transfer. of condition.
Can provide reassurance that client safety precautions are constantly ongoing, alleviate client’s anxiety, as well as provide information or formulating intraoperative care.
Music is a simple, inexpensive, esthetically pleasing means of alleviating anxiety.
To help client understand and identify what is reality.
Moderate anxiety heightens awareness and permits the client to focus on dealing with situation.
Discovering new coping method provides the patient with a variety of ways to manage anxiety.
To eliminate negative self-talk.
Preserves client’s modesty, reduces fear of loss of dignity and inability to exercise control and reinforces privacy.

Nursing Care Plan for Prostate Adenocarcinoma: A Case Study, Assignments of Earth science

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Partial preview of the text

Download Nursing Care Plan for Prostate Adenocarcinoma: A Case Study and more Assignments Earth science in PDF only on Docsity!

NURSING CARE PLAN 1

ASSESSMENT NURSING DIAGNOSIS CLIENT GOAL OUTCOME

CRITERIA

` NURSING INTERVENTIONS RATIONALE ACTUAL EVALUATION

SUBJECTIVE CUES

 Vital Signs:

o SPO2= 98%

NURSING CARE PLAN 2

ASSESSMENT NURSING DIAGNOSIS CLIENT GOAL OUTCOME ` NURSING INTERVENTIONS RATIONALE ACTUAL EVALUATION

good hand washing and

proper perineal care.

8. Emphasized the

importance of keeping the

area clean and dry.

9. Encourage to void every

2-3 hours.

Dependent:

1. Obtained specimen for

antibody-coated bacteria.

Collaborative:

1. Referred to urinary

continence specialist as

indicated.

2. Referred and prepared

patient for surgery.

3. Follow-up ultrasound

results and referred to

physician.

perineal care reduce skin

irritation and risk of

ascending infection.

8. To reduce the risk of

infection and skin

breakdown.

9. To facilitate flushing of

bacteria from the bladder

and avoid urine

accumulation.

1. To help diagnose bacterial

infection of the kidney or

prostate.

1. Collaboration with

specialists is helpful for

developing individual plan

of care to meet patient’s

specific needs using the

latest techniques,

continence products.

2. Surgical removal of

obstruction may be

necessary

3. Provides visual evidence

of proper alignment to

determine the level of

activity and need for

changes in or additional

therapy.