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.

Answer the following questions.

Question 1

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.

Question 2

·         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.

Answer 1

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 5^th 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)