Scenario: Daniel, a 73 years old, came to the emergency room with a temperature
ID: 238448 • Letter: S
Question
Scenario:
Daniel, a 73 years old, came to the emergency room with a temperature of 100.2 F. He complained of abdominal pain. He rated the pain at 10 on a scale of 1-10. He was admitted and diagnosed with urinary tract infection and urosepsis. Past medical history includes prostate cancer.
Daniel reports incontinence related to having a indwelling foley catheter during chemotherapy for about 3 weeks. It was removed last week. The RN obtained only 30 mL of dark brown urine, with no visible blood noted when the patient was catheterized with an 18 Fr Foley catheter in the emergency room. Daniel reported that he has not been drinking fluids because it hurts when try to go. He reported not unintentional weight loss or gain of 10 pounds or greater. Upon inspection, no visible edema. Upon palpation, no edema noted. A saline lock was placed in the left forearm for antibiotic therapy, it is patent and free of signs of infection.
The nursing process is a valuable tool for RN to use in practice to ensure the best possible care for your patients.
Assess and observe both physiologic and psychological needs of the patient.
Describe the problem and provide supporting data for its identification
Focus on problems that are controllable
Use outcome (NOC) to identify goals that are plausible and measurable
Use scientific principles and rationale to develop alternative courses of actions
Perform safe and effective nursing care
Document the effectiveness of the plan of care for the individual patient based on current problems and abnormal signs and symptoms
Develop nursing diagnoses based on facts and supporting data according to NANDA
Use interventions (NIC) to identify nursing interventions in response related to the nursing diagnoses.
Establish a plan of care outlining appropriate independent, dependent and/or interdependent nursing actions based on assessment data and analysis for goal attainment.
Evaluate extent to which goals had been achieved.
Review, modify, or resolve plan of care.
Underline all the cues and problems in the scenario.
Cluster the relevant data into groups.
Identify and prioritize 3 nursing diagnosis.
What goal or goals do you expect for this patient.
Explanation / Answer
Physiologic and psychological needs of the patient:
1.Impaired urinary elimination
2.Infection
3.Acute pain
4.Hyperthermia
5.Deficient knowledge
NURSING CARE PLAN
Elaborated first 4 major problems of the patient by using NANDA nursing diagnosis and the interventions included for the 5th problem also in the care plans.
ASSESSMENT
DIAGNOSIS
GOAL
INTERVENTION
RATIONALE
IMPLEMENTATION
EVALUATION
Subjective data
Patient says that he is having the complaint of pain while passing urine
Objective data
30 ml of dark brown urine removed by foley’s catheter
Dysfunction in urinary elimination related to frequent urination as evidenced by patient complaints dysuria
Client will achieve normal urinary elimination pattern as evidenced by patient verbalized absence of dysuria
Assess the patients elimination pattern
Palpate the bladder every 4 hours
Encourage increased fluid intake(3-4 litres)
Encourage the client to void every 2-3 hours
Maintain acidic environment of the bladder by the use of agents such as vit-c, Mandelamine
To plan interventions
To determine the presence of urinary retention
To improve renal blood flow
To prevent the accumulation of urine thus eliminating the number of bacteria
To prevent the occurrence of bacterial growth
Having pain while passing urine
Palpated the bladder every 4 hours
Encouraged increased fluid intake.Maintained I/O chart
Encouraged to void every 2-3 hours.Maintained I/O chart
Administered medications as per doctor’s order
Client achieved normal urinary elimination pattern as evidenced by patient verbalized no pain while passing urine.
Care plan 1
Care plan 2
ASSESSMENT
DIAGNOSIS
GOAL
INTERVENTION
RATIONALE
IMPLEMENTATION
EVALUATION
Subjective data
Patient says that he had the indwelling catheter for past 3 weeks during the treatment of chemotherapy
Objective data
Fever 100.2 F
Abdominal pain at 100 on a pain scale of 1-10
Infection related to indwelling catheter as evidenced by fever and abdominal pain
Client will be free of urinary tract infection as evidenced by the absence of fever and pain.
Assess the signs and symptoms of urinary tract infection
Monitor laboratory as indicated like WBC count, urinalysis, urine culture and sensitivity
Encourage increased fluid intake(3-4 litres)
Encourage the client to void every 2-3 hours
Limit the use of indwelling catheters to manage incontinence
Maintain acidic environment of the bladder by the use of agents such as vit-c, Mandelamine
Add antibiotics
To plan interventions
To determine the severity of infection and determine antibiotic most suitable to treat infection
To improve renal blood flow
To prevent the accumulation of urine thus eliminating the number of bacteria
To reduce the occurrence of UTI
To prevent the occurrence of bacterial growth
To eradicate the bacterial growth
Having fever and pain while passing urine
Monitored WBC count, urinalysis, urine culture and sensitivity
Encouraged increased fluid intake.Maintained I/O chart
Encouraged to void every 2-3 hours.Maintained I/O chart
Limited the use of foley’s catheter.
Administered medications as per doctor’s order
Added antibiotic as per doctor’s order
Client is free from infection as evidenced by the absence of fever and pain
Care plan 3
ASSESSMENT
DIAGNOSIS
GOAL
INTERVENTION
RATIONALE
IMPLEMENTATION
EVALUATION
Subjective data
Patient says that he is having the complaint of pain while passing urine
Objective data
Restricted fluid intake. only 30 ml of dark brown urine removed by foley’s catheter and abdominal pain at 100 on a pain scale of 1-10
Acute pain related to inflammation and infection of the urethra and bladder as evidenced by pain
abdominal pain at 100 on a pain scale of 1-10
Client will report satisfactory pain control at a level less than 3-4 on a scale of 1-10
Assess the patient’s description of pain such as quality,nature and severity of pain
Encourage increased fluid intake(3-4 litres)
Encourage the client to void every 2-3 hours
Encourage the use of sitzbath
Instruct to avoid coffee, tea, alcohol and soda
Apply a heating pad to the suprapubic area or lower back
Encourage the use of analgesics(e.g., acetaminophen) or antispasmodics (e.g., phenazopyridine)as per doctor’s advice
To plan interventions
To improve renal blood flow helps in flushing the bacteria
To prevent the accumulation of urine thus eliminating the number of bacteria as well as pain
To reduce perineal pain and promote muscle relaxation
These food can cause irritation to the urinary system
To alleviate pain
To relieve pain, bladder irritability and spasm
Having pain while passing urine
Encouraged increased fluid intake.Maintained I/O chart
Encouraged to void every 2-3 hours.Maintained I/O chart
Encouraged the use of sitzbath
Instructed to avoid coffee, tea, alcohol and soda
Administered medications as per doctor’s order
Client achieved normal urinary elimination pattern as evidenced by patient verbalized no pain while passing urine.
Care plan 4
ASSESSMENT
DIAGNOSIS
GOAL
INTERVENTION
RATIONALE
IMPLEMENTATION
EVALUATION
Subjective data
Patient says that he is having fever
Objective data
Body temperature is 100.2 F
Hyperthermia related to inflammation as evidence by body temperature is 100.2 F
Client will maintain core temperature within normal range (97-99 F)
Assess the signs of increased body temperature like sweating, shivering etc.,
Monitor vital signs especially temperature as imdicated
Encourage increased fluid intake(3-4 litres)
Provide tepid sponge bath
Encourage the use of hypothermia blanket and wrap extremities with bath towels
Maintain bed rest
Administer antipyretic drugs (e.g., acetaminophen) as per doctor’s advice
To plan interventions
To determine appropriate interventions
To prevent dehydration
To reduce fever
To reduce shivering
To reduce metabolic demand and oxygen consumption
To reduce body temperature
Having pain while passing urine
Monitored temperature
Encouraged increased fluid intake.Maintained I/O chart
Provided tepid sponge bath
Provided hypothermia blanket
Encouraged for bed rest
Administered antipyretic drugs (e.g., acetaminophen) as per doctor’s advice
Client maintained core temperature within normal range (97-99 F)
ASSESSMENT
DIAGNOSIS
GOAL
INTERVENTION
RATIONALE
IMPLEMENTATION
EVALUATION
Subjective data
Patient says that he is having the complaint of pain while passing urine
Objective data
30 ml of dark brown urine removed by foley’s catheter
Dysfunction in urinary elimination related to frequent urination as evidenced by patient complaints dysuria
Client will achieve normal urinary elimination pattern as evidenced by patient verbalized absence of dysuria
Assess the patients elimination pattern
Palpate the bladder every 4 hours
Encourage increased fluid intake(3-4 litres)
Encourage the client to void every 2-3 hours
Maintain acidic environment of the bladder by the use of agents such as vit-c, Mandelamine
To plan interventions
To determine the presence of urinary retention
To improve renal blood flow
To prevent the accumulation of urine thus eliminating the number of bacteria
To prevent the occurrence of bacterial growth
Having pain while passing urine
Palpated the bladder every 4 hours
Encouraged increased fluid intake.Maintained I/O chart
Encouraged to void every 2-3 hours.Maintained I/O chart
Administered medications as per doctor’s order
Client achieved normal urinary elimination pattern as evidenced by patient verbalized no pain while passing urine.
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