Mr. B has been assigned to your care for the day shift. Mr. B is a 78year old male client in the hospital who is medically discharged. He is waiting for homecare to be initiated.

QUESTION

Instructions:

Read the following case study, choose 2 nursing diagnosis and develop a care plan utilizing the steps of the nursing process. Remember to set 2 realistic goals for the client and develop nursing interventions that could help meet these goals, as well as the rationale for the interventions. You may consider a short-term goal and a long-term goal to work toward. Nursing interventions must be specific, and measurable. Remember to prioritize.

Case study.

Mr. B has been assigned to your care for the day shift. Mr. B is a 78year old male client in the hospital who is medically discharged. He is waiting for homecare to be initiated. He has a below the knee amputation of the Rt. leg and has prostate cancer. As a result of the prostate cancer Mr. B is unable to void on his own and has a Foley catheter. He has been nauseated and vomiting as a result of the chemotherapy that he is receiving. He has been NPO for the past two days and has an IV of R/L infusing at 100 mls/ hr. Mr. B usually is able to perform his own care and is ambulatory with prosthesis, but because of his vomiting and resulting weakness he requires partial assistance with his bath. During his morning bath you notice yellowish drainage around the Foley catheter. No other findings were noted.

By midafternoon the client has been free of vomiting for 6 hours and is beginning to feel hungry. You consult with his Dr. and the doctor orders the IV to be discontinued and to start the client on clear fluids.

Mr. B’s vital signs for 1000 hours are B/P 110/70, Pulse 68, RR-18, and Temp. 37°C, oxygen saturation on room air is 98%.

Mr. B’s vital signs for 1400 hours are B/P 118/74, Pulse 70, RR-18, and Temp. 36.8°C, oxygen saturation on room air is 96%.

The Dr. requested that the client be weighed. You did so and the client’s weight is 70 Kg.

Mr. B’s intake for dinner: 250 mls apple juice, 250 mls 7-up, 500 mls water, 500mls clear soup broth and a bowl of Jell-O.

Nursing Care Plan:

Nursing Diagnosis

Nursing Goal(s)

Nursing Interventions and Rationale

Evaluation

ANSWER

Nursing Care Plan for a Client with Below Knee Amputation and Prostate Cancer: Addressing Skin Integrity and Nutrition

Nursing Diagnosis 1: Impaired Skin Integrity related to the presence of drainage around the Foley catheter.

Nursing Goal 1

The client will exhibit improved skin integrity as evidenced by the absence of drainage and intact skin around the Foley catheter site within two weeks.

Nursing Interventions and Rationale

Assess the Foley catheter insertion site and surrounding skin for signs of infection or irritation at least twice a day. 

Rationale: Regular assessment allows for early identification of any skin breakdown or infection, enabling prompt intervention and prevention of complications (Nagle, 2022).

Clean the Foley catheter insertion site using sterile technique and prescribed solution as per facility policy. 

Rationale: Proper cleaning and maintenance of the insertion site reduce the risk of infection and promote healing.

Ensure adequate hydration by encouraging the client to drink fluids as tolerated. Rationale: Sufficient hydration promotes tissue perfusion and aids in the maintenance of skin integrity.

Educate the client and family on proper catheter care, including the importance of maintaining a clean and dry catheter site, and reporting any changes or concerns promptly. 

Rationale: Client and family education empowers them to actively participate in care, prevent complications, and seek early intervention.

Collaborate with the healthcare team to consider alternative urinary management options, such as intermittent catheterization or condom catheter, if appropriate. 

Rationale: Exploring alternative options may reduce the risk of skin breakdown and promote better quality of life for the client.

Evaluation

After two weeks of implementing the nursing interventions, the client’s Foley catheter site shows no signs of drainage or skin breakdown, indicating improved skin integrity (Willson et al., 2009). The client and family demonstrate understanding of catheter care, and the client’s condition remains stable without any related complications.

Nursing Diagnosis 2: Imbalanced Nutrition: Less Than Body Requirements related to NPO status and vomiting.

Nursing Goal 2

The client will achieve balanced nutrition as evidenced by stable weight, improved appetite, and absence of vomiting within one month.

Nursing Interventions and Rationale

Assess the client’s nutritional status, including weight, dietary preferences, and any dietary restrictions. 

Rationale: A comprehensive assessment helps identify specific nutritional needs and individualize the care plan accordingly.

Collaborate with the dietitian to develop a well-balanced meal plan that meets the client’s nutritional requirements, taking into account any dietary restrictions or preferences.

Rationale: A customized meal plan ensures that the client receives adequate nutrition while considering their individual needs and preferences.

Monitor the client’s weight regularly and document any changes. 

Rationale: Regular weight monitoring helps track the effectiveness of the nutritional interventions and identifies any trends that may require adjustment in the care plan.

Encourage small, frequent meals and snacks that are easy to digest and well-tolerated.

Rationale: Small, frequent meals help prevent overwhelming the digestive system and prevent nausea and vomiting.

Administer antiemetic medications as prescribed by the physician to alleviate nausea and vomiting.

Rationale: Antiemetics can help control symptoms, improve appetite, and enhance the client’s ability to tolerate oral intake.

Provide oral care before and after meals to enhance the client’s sense of taste and prevent oral complications. 

Rationale: Maintaining oral hygiene stimulates the taste buds and improves the client’s desire to eat, ensuring optimal oral health.

Evaluation

After one month of implementing the nursing interventions, the client’s weight remains stable, indicating a balanced nutrition status. The client reports an improved appetite and has not experienced any episodes of vomiting (Bsn, 2023). The client’s energy levels have increased, and they are able to participate in self-care activities more independently. The care team will continue to monitor the client’s nutritional status and adjust interventions as necessary.

References 

Nagle, S. M. (2022, October 19). Wound Assessment. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK482198/ 

Willson, M., Wilde, M. H., Webb, M., Thompson, D. M., Parker, D., Harwood, J., Callan, L., & Gray, M. (2009). Nursing Interventions to Reduce the Risk of Catheter-Associated Urinary Tract Infection. Journal of Wound Ostomy and Continence Nursing, 36(2), 137–154. https://doi.org/10.1097/01.won.0000347655.56851.04 

Bsn, G. W., RN. (2023). Imbalanced Nutrition Nursing Care Plan and Management. Nurseslabs. https://nurseslabs.com/imbalanced-nutrition-less-body-requirements/ 

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