Question

Tur3ig Practicum Week II: Scenario II Name: Ali Al-Ghafri IP. No: 12345 Mr. Ali is 60 years old male, presented to male Outpatient clinic with complains of recurrent urination, urgency, he has history of pain while urination for 3 days, and cloudy urine output which is associated with nausea and vomiting. Blood investigation revealed increased white blood cells WBCS in the urine. Mr. Ali verbalized that he has these complains for first time. V/S were taken and recorded: HR: 98/MIN, 110/50mmhg, Spo2: 94% in room air, RR: 22/min. He is diagnosed as urinary tract infection

1-Formulate 2nursing care plan with one actual nursing diagnosis and one potential nursing diagnosis.

2-Write detailed health education that you will give to Mr. Salim on the discharge

Answer 1

1. ACTUAL NURSING DIAGNOSIS:

ASSESSMENT	DIAGNOSIS	PLANNING	INTERVENTION	EVALUATION
SUBJECTIVE DATA: Patient complains of recurrent urination and urgency. OBJECTIVE DATA: Increased WBC count on blood investigation.	Impaired urinary elimination related to urinary tract infection as manifested by recurrent urination and urgency	Assess for changes in usual voiding pattern(frequency and amount) Encourage high fluid intake(approximately 2-4aliters/day). Instruct the patient about good perineal care and cleansing after each voiding Avoid caffeine, alcohol and use of aspartame. Advise the patient to use cranberry juice/vitamin C Observe for cloudy or bloody urine, foul odor. Promote continued mobility. Cleanse perineal area and keep dry. Monitor BUN, creatinine, and WBC count. Advise the client to complete the dose of antibiotics as ordered by the physician	Patient complains of recurrent urination and urgency Encouraged to take fluid around 2-4 liers/day. Instructed the patient about good perineal care and cleansing after each voiding. Instructed the patient to avoid alcohol and caffeine. Advised the patient to use cranberry juice/ vitamin C Observed cloudy urine promoted continued mobility Monitored increased WBC count. Advised the client to complete the dose of antibiotics as ordered by the physician.	Patient demonstrated and behaviours and tecniques to prevent urinary tract infection.

POTENTIAL NURSING DIAGNOSIS:

ASSESSMENT	DIAGNOSIS	PLANNING	INTERVENTION	EVALUATION
Subjective data: Patient complains of nausea and vomitting Objective data: presence of cloudy urine and increased WBC count.	Risk for fluid volume deficit related to infection as evidence by increased WBC count	Monitor and document vital signs especially BP and Heart rate. Assess skin turgor and oral mucous membranes for signs of dehydration. Maintain intake/ output chart. Assess color and amount of urine. Monitor serum electrolytes and urine osmolality Assess for confusion, agitation, slowed responses Start parentral therapy as per the physician order.	Monitored and documented HR-98/min, BP- 110/50 mm of Hg. Assessed skin turgor and oral mucous membrane for signs of dehydration Maintained intake/output chart Assessed color and amount of urine. Assessed for confusion, agitation and slowed responses	Patient verbalized awareness of causative factors and behaviours essential to correct fluid deficit.

2. HEALTH EDUCATION:

1. Encourage increased fluid intake(approximately 2-4aliters/day).
2. Instruct the patient about good perineal care and cleansing after each voiding
3. Avoid caffeine, alcohol and use of aspartame.
4. Advise the patient to use cranberry juice/vitamin C
5. Promote continued mobility.
6. Cleanse perineal area and keep dry.
7. Advise the client to complete the dose of antibiotics as ordered by the physician
8. Instruct the patient to urinate when the urge occurs.
9. Wipe the perineal region from front to back after bowel movement.
10. Advise patient to report when the signs and symptoms of UTI occurs.

SUMMARY:

ACTUAL NURSING DIAGNOSIS : Impaired urinary elimination related to urinary tract infection as manifested by recurrent urination and urgency

POTENTIAL NURSING DIAGNOSIS: Risk for fluid volume deficit related to infection as evidence by increased WBC count.