Nursing Diagnoses and Care Plan

This assignment provides a comprehensive example of a nursing diagnosis and care plan. It includes a patient's statement about feeling nervous and fearful, potentially indicating anxiety related to health status. A hernia and cancer are also mentioned as potential concerns. The assignment follows Gordon's Functional Health Pattern, with sections on Health Perception & Management, Nutrition/Metabolism, Elimination, Activity/Exercise, Sleep/Rest, Cognitive/Perceptual, Self-Perception/Self-Concept, Role/Relationship, Sexuality/Reproductive, and Coping-Stress Tolerance. It also involves prioritizing problems, making necessary referrals, and formulating collaborative problems.

HA-RLE Worksheet # 23
ASSESSING MALE GENITALIA & RECTUM
Case Study:
Read the following case study. Then work through the steps of analyzing the case study data.
1. First identify abnormal data and strengths in subjective and objective findings;
2. Assemble cue clusters;
3. Draw inferences;
4. Make possible nursing diagnoses;
5. Identify defining characteristics;
6. Confirm or rule out the diagnoses; and
7. Document your conclusions.
Use the table below to collect subjective and objective data provided to guide you. Propose nursing
diagnoses that are specific to the client in the case study. Identify collaborative problems, if any, for this
client. Finally identify data, if any, which point toward a medical problem requiring a referral.
Don Alqoujel is a 32-year-old African American man who arrives at the clinic for an evaluation by
a nurse practitioner. He complains that his right testicle feels heavy or weighted down. He appears very
nervous and explains that he has been experiencing this feeling for about 3 months. He explains that he
came in today because “my wife is very upset about it and pleaded with me to go to a doctor.” When
interviewed, the client reports that he does not have trouble becoming erect, but he states, “I feel like it
takes longer to ejaculate.” He denies past medical problems or a family history of cancer.
He explains that he has not had a genital examination in years- “I really don’t like to go to the
doctor unless I have a problem” He says he has never done, and does not really know how to do, a
testicular self-examination. He tells you that he is afraid he might have cancer.
Your physical examination reveals a normal adult pubic hair patter and no excoriation or
infestation in the pubic hair or at the base of the penis. The penis is circumcised and free or rashes,
lesions, and discoloration. No tenderness or nodules are noted on palpation. The urinary meatus is
located in the mid-glans and no discharge is revealed on palpation. Inspection of the scrotum reveals an
enlarged right scrotum and redness on the scrotal sac, but no lesions. Palpation of the left testicle,
epididymis, and spermatic cord reveal no tenderness, nodules or swelling. Palpation of the right testicle
reveals a 2-cm, nonmobile, nontender nodule on the anterior portion of the testicle. The left epididymis
and spermatic cord are free of tenderness, nodules, and swelling. No red glow is seen on
transillumination of the scrotal contents on either side. No bulges are noted in the inguinal or femoral
canal.
Note: Please secure consent before starting the interview to actual client….
NURSING INTERVIEW GUIDE TO COLLECT SUBJECTIVE DATA
QUESTIONS FINDINGS
Biographical Data
Name (use Code Name or Alyas) D.A.
Address, Phone Number N/A
Date and Place of Birth N/A
Nationality or Ethnicity African american

Marital Status Married
Religious or Spiritual Practices N/A
Primary and Secondary Languages spoken,
written, and read; Birth Language
N/A
Educational Level College graduate
Occupation and Working Status N/A
Who lives with the client? Identify significant
others
Wife
Caregivers and support people for the client wife
Present History (Reasons for Seeking Health Care)
What is your major health care or concern? He complains that his right testicle feels heavy or
weighted down.
Are you comfortable with seeking care from this
organization? Past Experiences good or not?
N/A
Current Symptoms
Pain in penis, scrotum, testes or groin? When interviewed, the client reports that he
does not have trouble becoming erect, but he
states, “I feel like it takes longer to ejaculate.”
Lesions on penis or genital area? N/A
Lumps, swelling or masses in scrotum, genital or
groin area?
Swelling right scrotum
Heaviness or dragging feeling in scrotum? He complains that his right testicle feels heavy or
weighted down.
Difficulty urinating(hesitancy, frequency or
difficulty starting or maintaining a stream)?
N/A
Frequent night time urination? N/A
Changes in color, odor or amount of urine? N/A
Pain or burning when urinating? N/A
Incontinence or dribbling of urine? N/A
Recent changes in sexual activity pattern or
sexual desire?
When interviewed, the client reports that he
does not have trouble becoming erect, but he
states, “I feel like it takes longer to ejaculate.”
Difficulty in attaining or maintaining an erection?
Problems with ejaculation?
When interviewed, the client reports that he
does not have trouble becoming erect, but he
states, “I feel like it takes longer to ejaculate.”
Fertility problems? N/A
Problems with bowels (bowel patter changes,
constipation , diarrhea, bowel control, stool
color, blood or mucus in stool, pain or itching in
rectal area, hemorrhoids)?
N/A
Anal and perianal problems(lumps, ulcers,
lesions, rashes, redness)?
N/A
Past Health History
Previous problems related to your pelvic
area( surgeries, treatments and results)?
N/A
Date of last testicular exam by physician or nurse
practitioner? Results?
He explains that he has not had a genital
examination in years- “I really don’t like to go to

the doctor unless I have a problem”
Tested for HIV? Why tested? Results?
Previous anal or rectal trauma or surgery,
congenital deformities?
N/A
History of blood in stool? N/A
History of prostate enlargement, treatment or
surgery on the prostate?
N/A
Pattern of health screenings (occult blood,
prostate-specific antigen, proctosigmoidoscopy,
colonoscopy)?
N/A
Family History
Family history prostate or testicular cancer?
What type? And which family member?
He denies past medical problems or a family
history of cancer.
Lifestyle and Health Practices
Number of sexual partners? 1
Kind of birth control method N/A
Current or past exposure to chemicals or
radiation?
N/A
Usual daily activity? N/A
Heavy lifting? N/A
Genital problems that affect daily activities? Feeling that scrotum is weighing him down
Fertility concerns? Effect on relationship? Wife is very upset about it
Sexual preference? N/A
Concerns related to sex? States that it takes longer to ejaculate
Stress related to sex? N/A
Knowledge of sexually transmitted diseases and
prevention?
N/A
Do you perform testicular self-examination? Date
last performed?
Patient does not know how to perform self
assessment
Use of laxatives, stool softeners, enemas or other
bowel medications?
N/A
Practice anal sex? N/A
Daily water/fluid intake? N/A
Usual diet (high fiber and roughage, saturated fat
content)?
N/a
Usual exercise pattern? N/A
Any effect on daily life from anal, rectal or bowel
problems or from prostate problems?
N/A

PHYSICAL ASSESSMENT GUIDE TO COLLECT OBJECTIVE DATA
Current Symptoms
Gather equipment (glove, stool, gown, penlight) N/A
Explain the procedure to the client N/A
Ask the client to put on gown N/A
Penis
Inspect the base of the penis and pubic hair for
growth, pattern and excoriation, erythema or
infestation( client is standing while you sit)
physical examination reveals a normal adult pubic
hair patter and The penis is circumcised and No
tenderness or nodules are noted on palpation.
The urinary meatus is located in the mid-glans
and no discharge is revealed on palpation.
Inspection of the scrotum reveals an enlarged
right scrotum and redness on the scrotal sac, but
no lesions. Palpation of the left testicle,
epididymis, and spermatic cord reveal no
tenderness, nodules or swelling. Palpation of the
right testicle reveals a 2-cm, nonmobile,
nontender nodule on the anterior portion of the
testicle. The left epididymis and spermatic cord
are free of tenderness, nodules, and swelling. No
red glow is seen on transillumination of the
scrotal contents on either side. No bulges are
noted in the inguinal or femoral canal.
Inspect the skin of the shaft for rashes, lesions or
lumps
no excoriation or infestation in the pubic hair or
at the base of the penis. free of rashes, lesions,
and discoloration.
Palpate the shaft for hardened areas or areas of
tenderness
No tenderness palpated
Inspect the foreskin (if present) for color, location
and integrity
N/A
Inspect the glans for size, shape, lesions or
redness, and location of the urinary meatus on
the glans (if uncircumcised, ask him to retract his
foreskin to allow for observation)
Palpation of the left testicle, epididymis, and
spermatic cord reveal no tenderness, nodules or
swelling. Palpation of the right testicle reveals a
2-cm, nonmobile, nontender nodule on the
anterior portion of the testicle. The left
epididymis and spermatic cord are free of
tenderness, nodules, and swelling. No red glow is
seen on transillumination of the scrotal contents
on either side.
Palpate for urethral discharge by gently
squeezing the glans between the index finger and
the thumb
N/A
Scrotum
Inspect the size, shape and position (penis is held
out of the way)
N/A
Observe for swelling, lumps or bulges Palpation of the right testicle reveals a 2-cm,
nonmobile, nontender nodule on the anterior
portion of the testicle. The left epididymis and
spermatic cord are free of tenderness, nodules,
and swelling.
Inspect the skin for color, integrity and the
presence of lesions or rashes (spread out the
scrotal folds of skin to perform an accurate
inspection. Lift the sac to inspect the posterior
skin)
Reddish right scrotum

Palpate the scrotal contents (testes and
epididymis) between your thrum and first 2
fingers. Note size, shape, consistency and
presence of tenderness or nodules. Palpate each
spermatic cord and vas deferens. Noting nodules,
swelling or tenderness.
Palpation of the right testicle reveals a 2-cm,
nonmobile, nontender nodule on the anterior
portion of the testicle. The left epididymis and
spermatic cord are free of tenderness, nodules,
and swelling.
Transilluminate the scrotal contents (if a mass or
swelling was noted) look for a red glow.
Right scrotum has a swelling red glow
Inguinal Area
Inspect for inguinal and femoral hernia, watching
for bulges while the client bears down.
N/A
Palpate for inguinal hernia, observing for bulges
or masses. Have the client shift weight to the left
to palpate the right inguinal canal. Place index
finger into the right scrotum and press upward to
the slit-like opening of the external inguinal ring,
ask him to bear down and cough. Repeat for left
side.
N/A
Palpate for femoral hernia on the front of the
thigh in the femoral canal area. Ak him to bear
down or cough while feeling for bulges. Repeat
on the other side.
N/A
Inspect and palpate for scrotal hernia (if a mass
was detected during inspection or palpation of
the scrotum) Ask the client to lie down, and note
whether the bulge disappears. If it remains,
auscultate it for bowel sounds. Then gently
palpate the mass and try to push it up into the
abdomen unless it is too tender.
N/A
Anus and Peri-anal Area
Inspect for lumps, ulcers, lesions, rashes, redness
( note size, shape, location, distribution and
configuration)
N/A
Inspect sacrococcygeal area for swelling, redness,
dimpling or presence of hair in pilonidal area
N/A
Inspect for rectal prolapse with Valsalva
maneuver
N/A
Palpate for anal sphincter tone, tenderness,
nodules or hardness
N/A
Rectum and Prostate
Palpate rectal mucosa for tenderness,
irregularities, nodules and hardness
N/A
Palpate peritoneal cavity for tenderness or
nodules or “rectal shelf”
N/A
Palpate the prostate gland for tenderness, size,
shape, texture or irregularities
N/A
Inspect the feces for blood and perform occult
blood test
N/A
Analysis of data
Formulate nursing diagnoses (wellness, risk,
actual)
Altered sexuality pattern r/t altered body
function as manifested by the statement, “I
feel like it takes longer to ejaculate.”
Anxiety r/t health status as evidenced by the
nervousness and fear of the patient that he
might have cancer
Formulate collaborative problems RC: hernia
RC: cancer
Make necessary referrals Refer to physician for further evaluations

Reference:
Weber, J., Kelley, J. and Sprengel, A. (2014). Lab Manual for Health Assessment in Nursing. 5th Edition.
Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Name of Student Yr & Sec
Clinical Instructor Area
Date of Exposure Hospital
GORDON’S FUNCTIONAL HEALTH PATTERN
Functional Health
Pattern
Cue Cluster Inference Diagnostic
Statement
Priority Rationale
1. Health
Perception &
Management
2. Nutrition /
Metabolism
3. Elimination
Pattern
4. Activity /
Exercise
5. Sleep / Rest

6. Cognitive /
Perceptual
7. Self –
Perception / Self
- Concept
8. Role /
Relationship
9. Sexuality /
Reproductive
10. Coping – Stress
Tolerance
11. Value Belief

PROBLEM IDENTIFICATION
Problem (PES) Date Identified Time Date Resolved
PRIORITIZATION OF PROBLEMS
Nursing Diagnosis Prioritization Rationale

Name of Student Yr & Sec
Clinical Instructor Area

Date of Exposure Hospital
GORDON’S FUNCTIONAL HEALTH PATTERN
Functional Health
Pattern
Cue Cluster Inference Diagnostic
Statement
Priority Rationale
1. Health
Perception
&
Manageme
nt
2. Nutrition /
Metabolism
3. Elimination Pattern
4. Activity / Exercise
5. Sleep / Rest
6. Cognitive / Perceptual

7. Self – Perception /
Self - Concept
8. Role / Relationship
9. Sexuality /
Reproductive
10. Coping – Stress
Tolerance
11. Value Belief
PROBLEM IDENTIFICATION
Problem (PES) Date Identified Time Date Resolved

PRIORITIZATION OF PROBLEMS
Nursing Diagnosis Prioritization Rationale

NURSING CARE PLAN
Name of Patient Rm/Bed No. Age Chief Complaints
Address Admission Date Sex Diagnosis
ASSESSMENT HEALTH
PATTERN
NURSING DIAGNOSIS DESIRED OUTCOME INTERVENTION EVALUATION REMARKS
Subjective Cues: Note: Use P-E-S format
Background Knowledge
Objective Cues

ASSESSMENT HEALTH
PATTERN
NURSING DIAGNOSIS DESIRED OUTCOME INTERVENTION EVALUATION REMARKS

Name of Student Yr & Sec
Clinical Instructor Area
Date of Exposure Hospital
DIAGNOSTIC EXAMINATIONS
Name of Patient Rm/Bed No. Age Chief Complaints
Address Admission Date Sex Diagnosis
Date Ordered Diagnostic
Examination
Normal
Values Result Significance