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A 22- year-old woman presents to the ED with complaints of bladder fullness , incomplete bladder...

A 22- year-old woman presents to the ED with complaints of bladder fullness , incomplete bladder emptying , and severe pain in her right flank. She rates the pain a 9 on a 0-10 numeric pain scale. Patient states she has a history of kidney stones . She also states when she is able to void, it burns and has a foul odor . Vital signs: HR 85 , BP 120/80 , RR 16, SPO2 98% on RA, temp 100.9 (oral). Pt takes the following medications : Hydrochlorothiazide (HCTZ ) 25 mg PO daily , Detrol LA 2 mg PO daily Lab results : CBC : WBC 26 Urinalysis : WBC (too many to count), Bacteria (5+, large), Leukoesterase (+) Positive , Protein (-) negative , Ketones (-) negative.
Assessment? Diagnosis? Evaluation ? Implementation ? Planning?

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Expert Solution

Assessment-subjective data includes fever,right flank pain,bladder fullness,incomplete bladder emptying,burning micturation and foul odour in urine.

Objective data-pain score 9,oral temperature 100.9F,elevated wbc in blood(26) and wbc as well as bacteria in urine.

The reason might be kidney stones as it is one of the cause for UTI.

Diagnosis-urinary tract infection.

Planning-withhold hydrochlorothiazide because it is a diuretic ,as patient has delayed bladder emptying it will worst the condition.

Detrol also should withhold as it is used to treat an overactive bladder.As patient has delayed emptying it will also affect patient condition.

Analgesics and antipyretic can be given as adviced by doctor,example paracetamol which has both effects.As pain score is 9 intravenous therapy is better.Asses the pattern of voiding and its frequency.provide comfortable position.Encourage to pass urine.Asses bladder .Administer antibiotics as adviced by doctor.Can arrange for a cystoscopy or ultrasound to identify for any stones.Give more fluids.

Implementation-provide comfortable position.provide privacy.Encourage to pass urine.Administer medications as per order.provide psychological support.Provide cold application to encourage urination.Maintain proper hygiene.

Evaluation-Reduced pain and temperature. Can pass urine without pain.wbc is reduced in urine and blood.

Nightingale answered 3 weeks ago
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