GROUP

GROUP 11
NURSING CARE PLAN
CASE
CASE SCENARIO
CASE SCENARIO
SCENARIO

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.
D
R C CONNECTING THE
DOTS
Increase heart rate, decrease
or absent urine output,
weakness, anxiety, paleness,
cold, rapid breathing,
REASON confusion and
unconsciousness.
This is may due to either
loss of salt and water or
a decreased in blood
DEFINITION volume. It may be
confused with
Hypovolemia also known dehydration
as volume depletion is a
state of decreased in
intravascular volume..
D
R C CONNECTING THE
DOTS
Discomfort, Sweating,
thirst, nausea, stomach
pain, diarrhea, vomiting,
REASON headache, muscle
weakness, lethargy, dry
Gastroenteritis is an
inflammation of the lining of the
mouth and lips.
intestines caused by a virus,
DEFINITION bacteria, or parasites. Viral
Gastro, infectious diarrhea, traveler's gastroenteritis is the second most
diarrhea, stomach bug, “stomach flu”, common illness in the U.S. The
in medical terms, it all boils down to cause is often a norovirus
one thing - gastroenteritis - which infection. It spreads through
literally means an inflammation (itis) contaminated food or water or by
of your stomach (gastro) and contact with an infected person.
intestines (entero) that typically makes
its presence known in the form of
vomiting and/or diarrhea. This disease
is caused by a virus, bacteria, or
parasites. It spreads through
contaminated food or water or by
contact with an infected person.
D
R C CONNECTING THE
DOTS
Decrease urine output,
abdominal pain, loss of
appetite, shortness of
REASON breath, difficulty of
swallowing, diarrhea
There are many different Fatigue, numbness,
DEFINITION types of amyloidosis. Some bruising.
Amyloidosis is the name for a group of varieties are hereditary.
rare, serious conditions caused by a build- Others are caused by outside
up of an abnormal protein called amyloid factors, such as inflammatory
in organs and tissues throughout the body. diseases or long-term
The build-up of amyloid proteins (deposits) dialysis. Many types affect
can make it difficult for the organs and multiple organs, while others
tissues to work properly. Without treatment, affect only one part of the
this can lead to organ failure. Unlike other
body.
proteins, amyloid does not have a
supportive role in the body. Instead, the
buildup of amyloid protein leads to organ
damage. Amyloidosis commonly affects
organs, including the heart, kidneys, and
liver.
 DEMOGRAPHIC INFO
Name: Steve Rogers Sex: Male
Age: 80 years old

CHIEF
SEVERE COMPLAI
c
PAIN
NT
• Weak
9/10
• vomited four
times
• Abdominal
DOCTORS
pain (9/10)
ORDER • Poor appetite
• Anxious
N/A
FEVER TACHYPNEA MEDICAL
cC
38.2 STEVE c
22 cpm DIAGNOSI
ROGERS S
Gastroenteritis
Amyloidosis
Hypovolemia
ASSESSMENT
TEMP: 38.2 C PR: 80 bpm
BP: 130/80 RR: 22 cpm
mmHg
 ASSESSMENT NURSING BACKGROUND PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS KNOWLEDGE
 After 24 hours of 1.  monitor VS every 1-2 1. helps to evaluate the  After 24 hours of
Subjective: Hyperthermia Infectious agents hours and as needed.  efficacy of treatment and
Mr. Rogers’ related to (Pyrogens) nursing monitors for effective nursing
daughter stated that 2. provide tepid sponge
alterations in intervention, the bath.
complications that may intervention, the
her father was weak, Monocytes patient will: occur as a result of
goal was met:
vomited four times fluid as 3. decreases increased temperature.
and has pain in his evidenced by Pyrogenic  maintain environmental   the patient was
2. increases heat loss by
belly. She also fever, tachypnea cytokines normal body
temperature and
evaporation. It helps able to obtain
remove extra blankets
stated that his and temperature by as warranted. prevent chilling that may
body
appetite is poor and Anterior aggravate and increase
dehydration. 37C. temperature. temperature of
he is very anxious. hypothalamus 4. promote adequate
his pain is a 9 on a intake of fluids, discuss
3.  helps reduce 37.4°C.
 be afebrile its importance.
scale of 1-10. Elevated anterior temperature by   vital signs are
with stable radiation/conduction.
regulatory set point 5. monitor intake and stable to normal
Objectives: vital signs. output every 2-4 hours.
4. to prevent dehydration. range.
Vital signs: Increase heat   was able to have
 will achieve 6. monitor the patient’s
Temp: 38.2C conservation mental status every 2
and maintain a 5. helps to identify fluid a balanced
HR: 80 bpm (vasoconstriction hours.
status changes and
RR: 22 cpm behaviour changes) balanced intake and
7. assess the patient for imbalances, and allows
BP: 140/80 intake and output.
every shift. for prompt treatment.
-lethargic Increase heat output with  the patient is
-vomited three times production adequate 6. because fever can cause negative on
(100 milliliters of (involuntary hydration. anxiousness together lethargic state.
greenish fluid) muscular with pain and loss of
- 150 milliliters of contraction)  patient will appetite.
urine in the urinal report feeling
fever 7. to observe improvement  
less lethargic on the patient’s lethargic
within 24 state.
hours.
 
ASSESSMENT NURSING BACKGROUND PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS KNOWLEDGE
Subjective: Imbalance AGING After 4 hours of 1. Greet and 1. To determine After 4 hours of
Mr. Rogers’   nursing care, the identify the the clients nursing intervention,
nutrition : less DECREASED TASTE
daughter stated that than body patient will be able clients name. need. the patient takes
BUDS
her father was   to take adequate 2. Demonstrate 2. Monitor and adequate amount of
weak, vomited four requirements amount of calories clients ability to document the calories or nutrients
times and has pain related to loss of LOSS OF APPETITE or nutrients as taste food. vital signs of by the pain scale of 2
in his belly. She appetite due to   evidenced by Pain 3. Cooperate with the client out of 10 and the vital
also stated that his aging. scale 2 out of 10, the family to 3. All factors that signs were normal.
appetite is poor and DECREASED FOOD
absence of serve foods that can affect the  
he is very anxious. INTAKE
  vomiting and are liked by the ingestion and The goal was met.
his pain is a 9 on a
normal rate patient at the digestion of
scale of 1-10.
INTAKE temperature of 36.8 same time highly nutrients.
Objectives: INSUFFIECIENT TO and RR of 16 cpm. rich in nutrients. 4. To facilitate
MEET THE 4. Encourage to buy balanced foods.
Vital signs: METABOLIC NEEDS
Temp: 38.2C medication or 5. To provide
 
HR: 80 bpm multivitamins nutritional
RR: 22 cpm IMBALANCE that prescribed by support.
BP: 140/80 NUTRITION LESS the physician.
-lethargic THAN BODY
-vomited three REQUIREMENT
times (100  
milliliters of
greenish fluid)
- 150 milliliters of
urine in the urinal
ASSESSMENT NURSING BACKGROUND PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS KNOWLEDGE
Subjective: Risk for increase output After 12 hours 1. monitor and 1. to monitor any After 12 hours of
Mr. Rogers’ deficient fluid of nursing document vital unwanted changes nursing intervention,
daughter stated that volume related Decrease in total intervention, signs. on the patient’s the goal was met by:
her father was body water the patient will: 2. assess the color and status.  the patient
weak, vomited four to vomiting as amount of urine. 2. decrease in urine having an equal
times and has pain evidence by Reductions in both  have an 3.  note presence of volume and amount of input
in his belly. She patient the intracellular and equal nausea, vomiting concentrated urine, and output of
also stated that his vomiting three extracellular fluid amount of and fever. as evidenced by a fluid.
appetite is poor and times 100 mL volumes input and 4. Note physical signs darker urine color,  Stable vital signs
he is very anxious. of greenish output of of dehydration. denotes fluid  the patient is able
his pain is a 9 on a Intravascular volume fluid. 5. Encourage to deficit. to excrete clear
fluid and 150
scale of 1-10. depletion  Will have a increase fluid intake 3. these factors are liquids without
milliliters of stable vital providing appealing associated with vomiting.
Objectives: urine in the Weakness, decreased signs liquids. fluid loss.  the patient is
Vital signs: urinal urine output,  be able to 6. Ensure accurate 4. Predictors of fluid negative on
Temp: 38.2C increase temperature excrete intake and output balance that should vomiting.
HR: 80 bpm clear monitoring. be in client’s usual
RR: 22 cpm Fluid volume deficit liquids 7. administer range in a healthy
BP: 140/80 without antiemetic state.
vomiting. medications as 5. For hydration.
-lethargic   achieve ordered. 6. Accurate records
-vomited three absence of are critical in
times (100 vomiting. assessing the
milliliters of patient’s fluid.
greenish fluid)   7.  these drugs will
- 150 milliliters of reduce vomiting
urine in the urinal and the risk for
fluid volume
deficit.
 ASSESSMENT NURSING BACKGROUND PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS KNOWLEDGE
Subjective: Abdominal pain After 6-8hrs of nursing 1. obtain vital signs. 1. vital signs are  After 6-8 hours of
Acute usually affected
Mr. Rogers’ occurs when intervention the patient nursing interventions, the
Abdominal will be able to:
2. Encourage quiet, when pain is goal is met by:
daughter stated that Pain related mechanical or restful atmosphere. present.
her father was weak, chemical stimuli  
vomited four times to infection trigger the pain
 report pain is 3.  use non- 2. To conserve energy.  the patient
as relieved/controlled, pharmacological verbalized relief
and has pain in his receptors in the with the pain scale pain relief 3. works by increasing
belly. She also evidenced by abdomen. Stretch is of 3/10 from 9/10. methods the release of
from pain and rated
stated that his weakness, the primary (relaxation endorphins, it as 3/10 from 9/10.
appetite is poor and mechanical stimulus. exercises, boosting the  
vomiting and  verbalize
he is very anxious. Other mechanical understanding of breathing therapeutic effects  the patient is able to
pain. exercises, music of pain relief understand and
his pain is a 9 on a stimuli, such as condition.
therapy) medications.
scale of 1-10. expansion, relief the condition.
 Verbalize and display
contraction, 4. assess reports 4. change in pain
methods that provide of abdominal characteristics may  the patient is able to
Objectives: compression, pulling,
relief. cramping or pain, indicate developing demonstrate
Vital signs: and twisting of the
noting location, complications. relaxation , skills and
Temp: 38.2C viscera, also induce   duration, intensity diversional activities.
HR: 80 bpm pain. (0-10scale). 5. Patients may
RR: 22 cpm pain in the abdomen Report changes experience an
BP: 140/80 can also be caused by in pain exaggeration in pain
characteristic. or a decreased
an infection of the
ability to tolerate
-lethargic stomach and bowel 5. Get rid of painful stimuli if
-vomited three times (gastroenteritis). It additional environmental,
(100 milliliters of may also be caused by stressors or intrapersonal, or
greenish fluid) a pulled muscle in the sources of intrapsychic factors
- 150 milliliters of abdomen or by an discomfort are further stressing
urine in the urinal injury. whenever possible. them
 ASSESSMENT NURSING BACKGROUND PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS KNOWLEDGE
Subjective: anxiety related to Stress response After 2-4 hrs of nursing 1. Help patient 1. Obtaining insight After 2-4 hrs of nursing
Mr. Rogers’ daughter activated intervention the patient determine allows the patient intervention the goal was
stated that her father
changes/threats of will: precipitants of to reevaluate the met by:
was weak, vomited four health status as Release of anxiety that may threat or identify
times and has pain in evidenced by Identify and verbalized indicate new ways to deal The patient identified and
his belly. She also
corticotropin
anxiety precipitants, interventions. with it. verbalized anxiety
stated that his appetite fever, tachypnea releasing factor
conflicts, and threats. 2. Allow patient to talk 2. Talking about precipitants, conflicts,
is poor and he is very and abdominal (CRF) about anxious anxiety-producing and threats.
anxious. his pain is a 9 demonstrates improve feelings and examine situations and
on a scale of 1-10. pain. Release of concentration and anxiety-provoking anxious feeling the patient was able to
corticotropin accuracy of thoughts.. situations if they are can help the demonstrate improved
Objectives:
identifiable. patient perceive concentration and
Vital signs:
Temp: 38.2C Release of stress 3. Teach the patient and the situation accuracy of thoughts.
HR: 80 bpm hormones from the family about the realistically and
RR: 22 cpm adrenal cortex health problems, recognize factors
BP: 140/80 therapeutic leading to the
-lethargic Negative feedback to interventions, anxious feelings.
-vomited three times prevention of 3. The patient and
the hypothalamus
(100 milliliters of complications, and the family needs
greenish fluid) adaptation in to understand
- 150 milliliters of urine Hypothalamus lifestyle that are what to expect
in the urinal connects with required. from the disease
reticular formation or problem to
allow them to
understand better
the rationale for
needed therapeutic
interventions.
THANK YOU!