Kingdom of Saudi Arabia

King Saud Bin Abdul-Aziz University for Health Sciences

College of Nursing

Nursing Care Plan

Student name Lama abdulaziz alshehri

ID 391220621
Section C
Submitted on 8-4-2021

Spring 2021
Subjective data : Mr.omar is 50 year old . Male from saudi
arabia . He is married . Known case of colon cancer stage. Came
to ER complaining of abdominal pain , headache , dizziness,
burning sensation . The patient has a history of diabetes and
hypertension. Has no surgical history . He doesn't have any
allergies to food or medication. The patient on morphine to
control the pain

Objective data : The patient’s GCS 15/15, he is oriented. .

The vital signs as follows: Bp 163/82 mmHg , p: 93 . HR:
97, RR:20, Temp36.7, spO2 97%. His weight is 92.6 kg
and his height is 178 cm. The BMI is 29.2 kg/m², which
consider overweight . Patient with rounded head and short
hair. Patient’s eyes are brown colored and symmetric and
his pupils are equal in size, shape and react equally to the
light. Sclera is white and conjunctiva is pink . The patient
nose is symmetric, no signs of discharges. The patient
has no inflammation in the mouth. Lips are moist. The
patient has normal lungs and breaths sounds. The patient
has abdominal pain with 3/10 pain scale. The patient’s
skin color is pale, skin condition is dry and warm
temperature. The patient has no signs of edema , he has
normal capillary refill within less than 3 seconds. The
patient has balances gait. He has normal spinal curvature.

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Nursing Goal Nursing Rational Evaluation
diagnosis intervention

Impaired achieve Encourage increased To help omprove achieve normal

Urinary normal fluid intake (3-4 liters renal blood flow urinary
Elimination urinary a day if tolerated). elimination
related to elimination pattern, as
urgency pattern, as Encourage the client evidenced by
evidenced by to void every 2-3 To prevent the
evidenced absence sign of
Dysuria hours. accumulation of
by absence urinary
urine
sign of disorders
Palpate the client’s
urinary bladder every 4 (urgency,
disorders hours. oliguria,
To determine the
(urgency, dysuria).
presence of urine
oliguria, retention
dysuria).

Deficient verbalizes Explain to the client Frequent verbalizes

Knowledge knowledge about UTI risk recurrences of knowledge of
related to of causes factors, prevention, UTI may causes and
Unfamiliarity and and treatment. indicate that treatment of
with nature and treatment of the client has UTI, controls risk
treatment of Encouraged the
UTI, controls no factors, and
client to finish all
UTI evidenced risk factors, understanding completes
prescribed
by Lack of and of the disease medical
antibiotics, even if
questions. completes symptoms resolve. and its treatment of
medical management UTI.
treatment of Hygienic
UTI. measures In the first few
days of antibiotic
(showering
therapy, urinary
rather than symptoms of
bathe in a tub.) burning,
frequency, and
urgency usually
resolve. However,
Not finishing the
antibiotic on the
prescribed time
will make the

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 bacteria grow and
multiply again.

Bacteria in the
bath water may
enter the
urethra.
.

Anxiety related Appear Encourage patient to Provides Appear relaxed

to relaxed and share thoughts and opportunity to and report
hospitalization report feelings. examine anxiety is
evidenced by anxiety is realistic fears reduced to a
Feelings of reduced to a Promote calm, manageable
and
helplessness quiet
manageable misconceptions level.
level. environment. about
diagnosis.
Encourage and Facilitates rest,
foster patient conserves
interaction with energy, and
support systems may enhance
coping abilities.

Reduces feelings of
isolation
Risk for ineffective facilitate Set a working An ongoing facilitate
coping related to coping and relationship with relationship coping and
long term disease
increases the patient establishes increases
self- through trust, reduces self-esteem.
esteem. continuity of the feeling of
care. isolation, and
may facilitate
supportive of coping.
coping
behaviors; give A supportive
patient time to presence
relax. creates a
supportive
Point out signs environment to
of positive enhance
progress or coping.
change.
Patients who

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 are coping
ineffectively
may not be
able to assess
their progress
toward
effective
coping.

Change in bowel Return of Regular Movement and Return of normal

habits related to normal bowel exercise bowel function
colon cancer function exercises
evidenced by
stimulate
constipation Increase fiber intake peristalsis and
aid in bowel
Stay hydrated movement.

Insoluble type
of fiber
promotes the
movement of
material
through the
digestive
system and
increases stool
bulk, l
stimulates
peristalsis and
expulsion of
stool from the
bowel

risk for ineffective Knowledge and Tell the patient Patients who Knowledge and
management of acceptance of about the understand the acceptance of the
the therapeutic the prescribed
advantages of effectiveness
prescribed
related to therapeutic therapeutic
regimen adhering to the of the regimen
depression
prescribed suggested
regimen treatment to
reduce risk or
Allow patient’s to promote
participation in health are
planning the more likely to
treatment engage in it

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 program.
Patients who
Develop a participate in
system for the their care have
patient to a greater
observe his or chance of
her own obtaining a
progress. positive result.

Self-monitoring
is a key
component of
a successful
change in
behavior
Risk for muscle Patient take Don't use senna Senna Patient take
weakness related measures to for more than two is POSSIBLY measures to
to senna side prevent muscle
weeks UNSAFE when
prevent muscle
affect weakness and weakness and
recognize signs taken by mouth recognize signs of
of muscle long-term muscle weakness
weakness

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 ‫التعليم ‪ :‬تناول االطعمه الغنيه باإللياف كالفول والعدس والحمص التي تساعد على‬
‫حركه االمعاء مما تؤدي الى تخفيف االمساك‬
‫مارس التمارين الرياضيه البسيطه التي تساعد على عالج االمساك‬
‫التزم بأخذ ادويتك في الوقت المناسب بالجرعه المناسبه‬
‫اخبر الممرض او الطبيب في حال ظهور اي اعراض‬
‫حافظ على معايير السالمه‬
‫طيب تقدر تعيد لي التعليمات الي قلتها لك ؟‬

‫‪Reference‬‬

‫‪Carpenito-Moyet, L., & Carpenito-Moyet, L. (1997). Instructor's guide to‬‬

‫‪accompany Nursing diagnosis (14th ed.). Philadelphia, Pa.: Lippincott.‬‬

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