Case:

A male patient, age 35 years old was hospitalized to the hospital with the complaints of
severe abdominal pain. He says the symptom appeared yesterday after he done his 15-km
marathon training. He says that his pain steadily increased, he is nauseated, his urine is dark
and smoky colors.

Instruction:
Please read down the book about assessment chapter nursing care for urinary system

Answer the following:

A. Clinical reasoning:
1. What are the possible cause of his symptoms (pain, nausea and dark urine)
2. What would your priority assessment for this patient?
3. What questions would you as to him?
4. What should be included in the physical assessment? What would you be looking
for?
5. What diagnostic studies might be ordered for him?

Answers
1. Heart diseases like hepatitis, sirosis.
2. Assessment for the severe abdominal pain.
3. Ask him about his past health history, and activity before he doing his 15 km
marathon training.
4. Should be included in the physical assessment is vital sign, score of ROM,
inspection the abdomen, auscultation the sound of the bowel, palpation the
patient’s abdomen.
5. Nephrotic Syndrome

B. Focused Assessment:
Write down the finding of focused assessments:
Subjective:
1. Severe abdominal pain
2. Nausea
3. The pain increased steadily.

Objective
Diagnostic :
1. The color of urin is dark and smoky colors.
2. Patient look gloomy because of the pain.

Physical Assessment
 Inspection
1. Skin see the scars and dilation of the vein.
2. Umbilicus is there any inflammation or hernia.
 3. Countour of abdomen symmetry or not.

 Palpate
1. Pressure the abdomen is there any feel pain or not.
2. Feel the mass in the lower abdomen.

 Percuss
1. Measure the content of the gas distribution in abdomen and identified is it mass or
liquid.

 Auscultate
1. Listen the sound bowel, klik for the normal sound and thundering with frequency 5-
34/ minutes.

C. Write down two nursing diagnosis and provide the rationale why you develop the
diagnosis:
1. Impaired urinary elimination related to urinary tract infection.

Rationale : Identifies characteristics of bladder function.

2. Activity intolerance related to immobility.

Rationale : Because of the fatigue.

D. Identify the 3 priority of nursing intervention for each diagnosis:

1. Observe for cloudy or bloody urine, foul odor. Dipstick urine as indicated.
2. Gradually progress patient activity with the following :
1. ROM exercise
2. Deep-breathing exercise
3. Sitting up in a chair.
Reference:

Herdman, T. H & Kamitsuru, S. (Eds). (2014). NANDA International Nursing Diagnoses:

Definition & Classification, 2015-2017. Oxford: Wiley Blackwell.