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CASE SCENARIO – Number 1:
Gary Taylor is an 87-year-old male diagnosed with bladder cancer and admitted to hospital for an elective transurethral resection of bladder tumour surgery. Prior to his surgery, Mr Taylor was independent and mobile, walking with the assistance of a walking stick due to arthritis of his left hip.
After surgery Mr Taylor was transferred to the surgical-oncology ward. His vital signs on admission to the ward were:
Respiratory Rate (RR) O2 Saturation
Heart Rate (HR) Blood Pressure (BP) ACVPU
Temperature
14 bpm
99% on room air 70 bpm
133/74 mmHg Alert
37.0 C
He had a three-way catheter and continuous saline bladder irrigation in situ. Mr Taylor was eating and drinking, speaking in whole sentences and aware of his location and current circumstances.
On day four a trial without a three-way catheter (TWOC) was performed. Mr Taylor developed urinary retention (225 mLs of residual urine – showed in the ultrasonographic assessment). Mr . T aylor experienced dysuria. It was decided to insert a Foley catheter to help him pass urine and 245 mLs of haematuria was drained.
The following day, Mr Taylor developed confusion. He did not recognise he was in a hospital, tried to pull out the catheter and leave the ward to go and see his wife.
His vital signs on day five were:
Respiratory Rate (RR) O2 Saturation
Heart Rate (HR) Blood Pressure (BP) ACVPU
Temperature
20 bpm
98% on room air 80 bpm
118/74 mmHg Confused
37.7C
Past medical history included hypertension for which he is prescribed ramipril, and arthritis of the left hip for which he takes paracetamol as required. Diagnosed with bladder cancer after he attended the GP two weeks ago complaining of haematuria.
Mr Taylor lives with his daughter and her family after his wife died one year ago.
Medication: Ramipril 2.5 mg OD; Paracetamol 1000 mg (PRN).
Levett Jones’ Clinical Reasoning Cycle
Step 3 – Process the above information and use the information to: (A-E Assessment (showing normal and compare and why, NEWS Score and why
Step 4 – Identify problems/issues
Step 5 – Establish goals and a treatment plan

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