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Careplansample.pdf
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DO NOT COPY, OR TAKE THE INFORMATION AS YOUR OWN FROM THIS CARE PLAN. THIS IS SOLELY FOR EXAMPLE PURPOSES.
Student Name: PROPERTY OF RESURRECTION UNIV Week: 3 Dates of Care: March 11, 2018
Patient Demographics, Health History and Admission History
Patient
TM
Sex M
Age
79
Room
2131
Admitting Date
2/5/2018
Admitting Chief Complaint: Guillain Barre Syndrome/AIDP s/p IVIG (1/31 – 2/4); Paraplegia
Attending Physician/Treatment Team: Eric Brehm, MD James Daniel, RN Melissa Perez, CNA
Consultants seen during this hospitalization: Neurology (Steven B. Nussbaum, MD); Cardiac (Kim Ki, MD); GU/Renal (John Michael Li, MD); Dermatology (Cosette Burian, MD); Psychiatry (Richard Clarey, MD)
Present Diagnosis: Exacerbation of chronic demyelinating polyneuropathy; Paraplegia; Dementia with behavior disturbance
ER Management: CBC &ESR, screening for viral markers, toxic metal, serum CPK level, thyroid profile
Allergies: Shellfish
Code Status: DNR Isolation Status: None
Admission Height: 6’0”
Admission Weight: 172lb
Arm Band Status: Fall
Communication needs: Pt presents easily agitated with impaired concentration r/t dementia, causing barriers to effective communication. Nursing interventions include: Learn patient needs and pay attention to nonverbal cues; Manage irritability by promoting self-soothing techniques and de-escalating as needed
Past Medical History: Acute GI bleeding (Hx of tx with proton pump inhibitors); BPH (Hx of tx with alpha-blockers); GERD (Hx of tx with proton pump inhibitors, antacid); HTN (Hx of tx with ACE inhibitor, diuretic); A-Fib (Hx of tx with Xarelto and Metoprolol); Urinary retention (Hx of tx with I&O catheter); AKI (s/p IVF on 2/3); Dementia with possible acute worsening (Hx of tx with donepezil)
Significant events during this hospitalization: Refusing food and increased agitation—consult with psychiatry ordered for evaluation and medication recommendation. Night Delirium, treated with PO Trazadone 50 mg scheduled and additional 25 mg Q6 hours PRN. New areas of blanching erythema on feet—orthotics to readjust shoes.
Tests, treatments and interventions impacting clinical day’s care:
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Continue to encourage timed voids, can use condom catheter during therapies if interrupting therapy. Intermittent catheterization as needed. Started on Flomax 0.4 mg QHS (2/19). Continue to monitor and encourage PO intake. Apply barrier ointment to L buttock DTI (present at admission). Utilize foam for protection on multiple abrasions to bilateral knees and elbows (present at admission). Apply Medihoney and foam daily to R foot ulcer (prior cellulitis). Monitor electrolytes and replete as needed. Maintain scheduled physical therapy to improve strength, cognition, and balance.
Advance Directives/Ethical considerations: DNR. Despite acute worsening of dementia symptoms, Pt remains decisional at this time.
Health Assessments
Vital Signs: (2 sets per day)
Time 8:00AM
T 97.9 Oral
P 82 Radial
R 18 Observed
B/P 113/70 Automatic
Pulse Ox 97% Right Index
Pain Score 2 Subjective
Time 12:00PM
T 97.3 Oral
P 79 Radial
R 18 Observed
B/P 125/72 Automatic
Pulse Ox 98% Right Index
Pain Score 1 Subjective
Pain Assessments and Interventions: Patient seen and assessed for pain. Pt was asked if he currently was experiencing any pain or discomfort. Pt confirmed that he had very mild pain. Pt asked to rate pain on a scale from 1-10, with 1 being the least and 10 being the most. Pt reports a pain rating of 2. Pt states that his pain is located at posterior neck and bilateral elbows and upper arms. Pt noted to appear without grimaces or other nonverbal cues of pain or distress. Interventions: Acetaminophen 650 mg 2-tab(s) Q4hr PRN for pain, may pre-medicate for treatment. Comfort measures maintained, Pt propped on pillows, and items that could pose hazard potential removed from Pt’s vicinity. Maintain physical therapy schedule and encourage Pt to participate.
Respiratory Assessment and Intervention: Patient seen and assessed for respiratory impairment. Pt denies SOB. Pt noted to be breathing with equal bilateral chest expansion and unlabored. Respirations observed to be within normal range. During auscultation no adventitious sounds heard. Will continue to monitor signs of distress. No supplemental oxygen needed at this time.
Neurosensory Assessments and Interventions: Patient seen and assessed for neurosensory impairment. Pt denies any complaints at this time. Cranial nerves noted to be without impairment/dysfunction; assessed during 5-minute assessment at bedside. Patient presents with neurogenic bladder r/t paraplegia. Pt has impaired mobility which is precipitating skin breakdown; Pt presents with stage 2 pressure ulcer at sacral area, it’s shallow and has visible loss of dermis, and it measures (L) 2cm x (W) 3cm; Pt also presents with stage 1 wound on right heel, with non-blanchable redness. Pt also has hx of dementia w/ possible acute worsening. Will intervene with intermittent catheter when bladder scan reveals 250 mL of retained urine. Will change dressings on
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wounds and document change in size; will also encourage Pt to be shift weight more—especially while in wheel chair. Will consult with psych. Side rails raised, bed alarm on, comfort measures maintained.
Cardiovascular Assessments and Interventions: Patient seen and assessed for cardiovascular impairment/dysfunction. Pt denies any SOB, LH, or pain. Pt presents with active dysrhythmia, noted as A-Fib during auscultation; Pt has hx of chronic A- Fib. Heart rate at 82 bpm, +2. BP WNL. Of note, despite current A-Fib, Pt presents with normal heart sounds—S1 and S2 auscultated at apex. Will continue to monitor Pt’s vitals. Will administer scheduled rivaroxaban (Xarelto) 20mg daily, and monitor effects. Chest x-ray performed prior to admission, unremarkable.
Musculoskeletal Assessments and Interventions: Patient seen and assessed for musculoskeletal impairment/dysfunction. Pt denies any discomfort currently, however did remind this writer of slight pain felt at posterior neck and bilateral upper arms. Pt presents with (L) knee contusion, paraplegia, and edema to peripheral LE. Pt cannot ambulate, remains in bed with bed alarm on, wearing edema boots on both feet d/t peripheral swelling r/t immobility. Pt requires minimal assistance to rollover in bed, and maximum assistance to transfer—requires mechanical lift to get out of bed and transferred to and from wheelchair. No weakness noted on upper extremities, though Pt appears dysphoric and lethargic when not demanding and irritable. Pt is on fall risk precaution. Bed is kept at lowest position with rails up. Knee x-ray was negative. Comfort measures maintained.
Renal Assessments and Interventions: Patient seen and assessed for renal impairment/dysfunction. Pt denies any discomfort currently; denies urgency to urinate or pain r/t to urinary retention. No distention noted. Pt has PMH of AKI. Previous urine noted to be amber color and cloudy. Hematuria noted in UA. Slightly elevated BUN. Creatinine and Chloride levels unremarkable. Pt fluid intake from previous day noted to be 3 L, and most recent output from +7 hours ago noted as 300 ml; Pt 50/50 incontinence status, with prn straight catheter, Q 8hrs. Bladder scanner revealed 250 mL of retained urine. Intermittent catheter initiated. Pt encouraged to intake 2-4 L of fluids during this shift to help maintain renal function. Comfort measures maintained.
Skin and Integument Assessments and Interventions: Patient seen and assessed for integumentary impairment. Pt does not verbalize any complaints at this time. Pt presents with a stage 2 pressure ulcer at sacral area, it is shallow with visible loss of dermis, and measures 2 cm in length and 3 cm in width. Pt also presents with stage 1 wound on his right heel with noted redness (non-blanchable). Pt has severely impaired skin integrity 2/2 immobility, and a L buttock DTI present at admission. Pt also has cellulitis on R foot and multiple abrasions to bilateral knees and elbows, present at admission. DTI being treated with barrier ointment, applied daily. Cellulitis on R foot being treated with Medihoney and foam daily, appears to be improving. Bilateral abrasions being treated with foam for protection. Pressure ulcers monitored daily and dressed, and pictures taken to document progress. Orthotics consult to adjust shoes re erythema on feet. Care instructions include to protect skin from maceration and “moisture associated dermatitis” with a moisture barrier or
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protective film.
Gastrointestinal Assessment and Intervention: Patient seen and assessed for GI impairment. Pt denies any current complaints. Pt is 50/50 bowel incontinent. Pt is on a regular diet, thin with calorie count. Pt PMH of acute GI bleeding and GERD. Pt HGB at 10.0 (low), may indicate GI bleeding. Pt will use adult diapers, staff will continue to monitor for bowel movements. Pt will be administered docusate-senna Q12pm, to help with bowel movements.
Endocrine Assessment and Intervention: Patient seen and assessed for endocrine impairment/dysfunction. Pt denies any current complaints. Pt glucose noted to be within normal range at 96 mg/dL. BUN at 24 mg/dL. And creatinine at 0.88 mg/dL. NO report of DM, thyroid gland dysfunction, or other endocrine system disorders noted in chart.
Reproductive Assessment and Intervention: Patient seen and assessed for reproductive dysfunction. Pt denies any current complaints. Pt has PMH, treated in the past with alpha- blockers. No current reproductive system disorder noted in Pt’s chart. Will continue to monitor and maintain comfort measures.
Vascular Access Assessment and intervention: Pt is nonverbal and unable to respond to questions related to vascular access assessment. Pt has 20 gauge peripheral IV located in right hand. Dressing dry and intact, skin surrounding appears to be impaired, with tears and excessive dryness noted. No signs of infection or infiltration at site.
Safety Assessment and Intervention: ID band in place—Pt on Fall precaution. Bed is in lowest position, with rails up. Pt does not ambulate, and requires maximum assistance for transfers to and from bed; Pt requires minimal assistance to roll over in bed. Pt monitored and comfort/safety measures maintained.
Post-operative/Post-procedural Assessment and Intervention:
N/A
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Psychosocial Assessment and Interventions: Pt is AOx4, presents easily agitated and with an irritable mood and congruent affect, however, is easily redirectable. Pt is a widowed Caucasian male, 79, with 2 children (son Ted and daughter Alyse) and an extended family—which makes up his social support system. Pt is a former proprietor of several bars in the Chicagoland area, and currently has his nephew and son overseeing the family business. Pt resides at the Brookdale assisted living facility
Cultural/Spiritual Assessment and Interventions: Per Pt chart, religion noted as “non/no religion.” Pt is complete DNR. Admitted to spinal injury unit at Shirley Ryan Ability Lab (former RIC Chicago). Pt at times is irritable and angry, however has been noted to be more cooperative in afternoon and has presented at times with a bright affect and euthymic mood.
Growth & Development Assessment and intervention: Regarding Pt’s growth and development, and based on his current condition and presentation—notably as angry/hostile and with a low threshold for frustration, we can say that employing Erikson’s model of development he is at the ninth stage of development, in which “introspection is replaced by the attention demanded to one's loss of capacities and disintegration” (W. W. Norton, 1998, pp. 112-113).
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Pertinent Diagnostic Data Diagnostic Data Results Normal Lab Values Significance within your patient
WBC 6.0 4.0-11.0 Within normal range
RBC 3.83 4.34-5.60 Below normal range, may indicate active bleeding.
HGB 10.9 13.0-17.0 Below normal range, may indicate GI bleeding.
HCT 33.7% 38.6-49.2 Below normal range, may indicate active ulcer or other bleeding issue.
Platelets 199 150-450 Within normal range
PT 16.4 10.1-13.1 sec Above normal range, indicates that blood is taking too long to form a clot.
INR 1.5 0.9-1.1 Above normal range, indicating that the blood is clotting slower.
PTT 48 25-36 sec Above normal range, may indicate bleeding problem.
Cholesterol
Glucose 93 70-99 Within normal range
BUN 20.8 6.0-20.0 Slightly elevated, could indicate renal dysfunction.
Creatinine 3.95 0.7-1.3 Above normal range, may indicate impaired kidney function or kidney disease.
Sodium 148 133-144 Slightly elevated, hypernatremia, could indicate dehydration or loss of body fluids.
Potassium 3.9 3.5-5.1 Within normal range
Chloride 116 98-107 Elevated levels, could indicate dehydration or kidney disease.
Calcium 9.0 8.6-10.3 Within normal range
T Protein 6.4 6.4-8.9 Within normal range
Albumin 2.2 3.5-5.7 Below normal range, may indicate inflammation or malnutrition.
SGOT
SGPT
Alk Phos 176 40-129 Above normal range, indicative of hepatic dysfunction.
Magnesium 1.9 1.6-2.6 Within normal range
Amylase
Lipase
eGFR
CK
CK-MB
Troponin I
Myoglobin
LDI
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Diagnostic Data Results Normal Lab Values Significance within your patient
Urinalysis
Color Amber Yellow-Straw May indicate disease.
Character Cloudy Clear May indicate excess protein or crystalline substances.
Spec. Grav. 1.022 1.001-1.035 Within normal range
pH 5.5 5.0-8.0 Within normal range
Protein Negative Negative Within normal range
Glucose Negative Negative Within normal range
Blood Small Negative May indicate kidney dysfunction
Nitrites Negative Negative Within normal range
RBC 0-3 0-3/hpf Within normal range
WBC 51-100 0-5/hpf May indicate kidney dysfunction
Urine Culture n/a n/a n/a
Current Plan of Care: Manage symptoms, monitor for distress, monitor wounds, complete rehabilitation regiment, including PT/OT/RT, and stabilize mood. Discharge back to ALF. Code status: DNR per patient and son—confirmed on admission. Follow up appointments and aftercare: John Michael Li, MD—2-4 weeks after rehab; Eric Brehm, MD—within 7-days of discharge.
Discharge Plan: Patient to be discharged back to assisted living facility, The Brookdale, with follow-up aftercare appointments with PCP, neurology, and PT.
Teaching Needs: Educate patient and family members about need to improve mobility and independence, medications, and ongoing therapy and importance of adherence to treatment s/p discharge. Educate about available counseling services, home care, outpatient rehabilitation, and necessary medical equipment.
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Pathophysiological Discussion
Pt is a 79-year-old Caucasian male, AOx4, admitted to the spinal cord injury unit d/t symptoms
of Guillain Barre Syndrome (AIDP) s/p immunoglobulin intravenous therapy from 1/31 – 2/4;
recurrence of neurogenic bowel r/t paraplegia, resulting in urinary retention requiring
intermittent catheterization. Pt diagnosed with Guillain Barre Syndrome after spinal cord surgery
following a compression fracture at the T7 and T11 level of his spinal cord. Pt’s compression
fracture was precipitated by progression of osteoporosis, diagnosed 5 years earlier. Pt lives at a
skilled nursing facility and has good social support. Pt presented to ED at NWM on 1/29 c/o
weakness and tingling at upper peripheral extremities, and dysphagia. Pt was admitted to general
medical floor and started on IVIG therapy. Intravenous immunoglobulin is used to treat
autoimmune syndromes by introducing antibodies into the patient’s veins from an external
plasma source, typically from donated blood (VanMeter & Hubert, 2014). Guillain Barre
Syndrome is an autoimmune disorder in which the spleen produces antibodies that attack the host
nerve cells, this can be precipitated by the flu, surgery, or other infections—it is not very
common, and occurs in approximately 40 out of 1-million people.
The Pt’s neurologic dysfunction resulting from his spinal cord injury has caused him to
experience bladder malfunction. The Pt has experienced a complete spinal cord lesion, the type
of injury that results in significant loss of function: “total loss of sensation and voluntary muscle
control below the lesion” (Hinkle & Cheever, 2014, p. 2010). The patient has experienced a few
episodes of urinary retention since his hospitalization, and it is likely that his loss of sensation
has added to the challenges already faced by the lack of reflex activity of his bladder, as Hinkle
& Cheever (2014) point out, “because the patient has no sensation of bladder distention,
overstretching of the bladder and detrusor muscle may occur, delaying the return of bladder
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function” (p. 2017). And because of this, the patient has standing orders for intermittent
catheterization to avoid over-distention of the bladder.
Another complication that has arisen as a result of Pt’s immobility d/t paraplegia is skin
impairment and breakdown. Pt had reportedly been struggling with pressure ulcers prior to
hospitalization but has experienced worsening skin breakdown since being hospitalized in late
January. The pressure ulcer is a common co-occurring condition with impaired mobility, i.e.
paraplegia, and has been known to delay rehabilitation in 20% to 30% of patients (VanMeter &
Hubert, 2014). Impaired sensation prevents the Pt from recognizing the physical cues that an
ulcer is forming, and this keeps the Pt from reflexively shifting his position to avoid the pain and
preventing further skin breakdown. It is therefore a high priority to have the Pt repositioned at
least every 2 hours—especially while hospitalized. This repositioning helps to prevent ulcers and
can help prevent thrombosis as well. As VanMeter & Hubert (2014) explain, “turning not only
assists in the prevention of pressure ulcers but also prevents pooling of blood and edema in the
dependent areas” (p. 324). Pt utilizes Ted hose to prevent DVT in his lower extremities and has
a daily regiment of physical therapy during hospitalization. Pt is encouraged by staff to be as
mobile as possible, and to be as independent as he can.
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Nursing Diagnoses List the nursing diagnoses for this patient. Use NANDA format (diagnosis, related to, as evidenced by) and place the diagnoses in their priority order. Briefly discuss the rationale for this priority order.
Priority Nursing Diagnosis Related to As Evidence By Rationale
1 Impaired skin integrity Immobility As evidence by pressure ulcer of sacral region, stage 2
Immobility leads to pressure, shear, and friction (Gulanick & Myers, 2017).
2 Impaired Urinary Elimination
Neurogenic bladder; disruption in bladder innervation
Bladder distension; incontinence/overflow, retention
Pt observed to have mildly distended bladder; Pt 50/50 incontinence status, with prn straight catheter orders Q 8hrs if unable to void. As Glulanic & Myers (2017) mention, “Perception of bladder fullness, bladder distention above symphysis pubis implies urinary retention” (p. 205)
3 Impaired physical mobility
Compression fracture at T7 and T11 level of spinal cord
Paralysis of lower extremities
Pt’s limitations will be assessed continuously, with goal of improving mobility, preventing pressure sores, and providing education and encouraging treatment plan compliance—esp. PT
4 Constipation Gastrointestinal atony
Bowel incontinence and difficulty passing stools.
Pt’s constipation will necessitate intervention by administration of stool softeners and increase of fiber in diet.
5 Chronic pain Prolonged immobility and exacerbation of behavioral disturbances
Subjective complaints of pain, and agitated presentation
Encourage Pt to report pain. Utilizing cognitive behavioral therapy— reframing Pt’s dysfunctional beliefs— may help alleviate psychic injury
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Medication Dose, Route &
Frequency
Classification Purpose /
Mechanism of
Action
Significant Side
Effects / Adverse
Reactions
Nursing Implications
(Flomax) tamsulosin
0.4 mg, PO, HS Peripherally acting
antiadrenergics
Decreases
contractions in
smooth muscle of the
prostatic capsule by
preferentially
binding to alpha1-
adrenergic receptors.
Therapeutic Effects:
Decreased symptoms
of prostatic
hyperplasia (urinary
urgency, hesitancy,
nocturia).
CNS: dizziness,
headaches. EENT:
rhinitis. CV:
orthostatic
hypotension. GU:
priapism,
retrograde/diminished
ejaculation.
Assess Pt for urinary
hesitancy, feeling of
incomplete bladder
emptying, interruption
of urinary stream,
impairment of size
and force of urinary
stream, terminal
urinary dribbling,
straining to start flow,
dysuria, urgency.
Atorvastatin
10 mg, PO, QD Therapeutic: lipid-
lowering agents
Pharmacologic:
HMG-CoA reductase
inhibitors
Pregnancy Category
X
Inhibits 3-hydroxy-3-
methylglutaryl-
coenzyme A (HMG-
CoA) reductase, an
enzyme
which is responsible
for catalyzing an
early step in the
synthesis of
cholesterol.
Therapeutic
Effects: Lowering of
total and LDL
cholesterol and
triglycerides
CNS: amnesia,
confusion, dizziness,
headache, insomnia,
memory loss. EENT:
rhinitis. Resp:
bronchitis. CV: chest
pain, peripheral
edema. GI: abdominal
cramps, constipation,
diarrhea, flatus,
heartburn. Endo:
hyperglycemia. GU:
erectile dysfunction
Evaluate serum
cholesterol and
triglyceride levels
before initiating, after
2– 4 wk of therapy,
and periodically
thereafter.
If symptoms of
serious liver injury,
hyperbilirubinemia, or
jaundice occurs
discontinue
atorvastatin and do
not restart
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Thiamine
100 mg, PO, QD Therapeutic: vitamins
Pharmacologic: water
soluble vitamins
Pregnancy Category
A
Required for
carbohydrate
metabolism.
Therapeutic Effects:
Replacement in
deficiency
states.
CNS: restlessness,
weakness. EENT:
tightness of the throat.
Resp: pulmonary
edema, respiratory
distress. CV:
hypotension,
vasodilation, vascular
collapse. GI: GI
bleeding, nausea.
Derm: cyanosis,
pruritus, sweating,
tingling, urticaria,
warmth.
Assess for anorexia,
GI distress,
irritability,
palpitations,
tachycardia, edema,
paresthesia, muscle
weakness and pain,
depression, memory
loss, confusion,
psychosis, visual
disturbances, elevated
serum
pyruvic acid levels.
Lidocaine topical
(Lidoderm 5%
topical film)
1 patch(es), TD, QD,
PRN
Therapeutic:
anesthetics
(topical/local)
Pregnancy Category
B
Produces local
anesthesia by
inhibiting transport of
ions across neuronal
membranes, thereby
preventing initiation
and conduction of
normal nerve
impulses.
Local: stinging,
burning, contact
dermatitis, erythema
Assess degree of
numbness of affected
part. Dealing with
transdermal you
should monitor for
pain intensity in
affected area
periodically during
therapy.
Trazodone
50 mg, PO, HS Therapeutic:
antidepressants
Pregnancy Category
C
Alters the effects of
serotonin in the CNS.
Therapeutic Effects:
Antidepressant
action,
which may develop
only over several
weeks.
CNS: SI, confusion,
hallucinations. EENT:
blurred vision,
tinnitus. CV:
hypotension,
arrhythmias, chest
pain, hypertension.
GI: dry mouth,
constipation, diarrhea,
nausea, vomiting.
Monitor BP and HR
before beginning.
Assess for ED, sexual
dysfunction. Assess
for serotonin
syndrome—especially
of on an SSRI. Assess
for depression, assess
mental status. Assess
for pain. Assess for
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Derm: rash. GU:
hematuria, erectile
dysfunction, priapism,
urinary frequency.
SI, especially early on
in therapy, and
especially with
children and
adolescents.
Bisacodyl
10 mg, 1 supp, PR,
HS
Therapeutic: laxatives
Pharmacologic:
stimulant laxatives
Pregnancy Category
C
Stimulates peristalsis.
Alters fluid and
electrolyte transport,
producing fluid
accumulation
in the colon.
Therapeutic Effects:
Evacuation of the
colon.
GI: abdominal cramps,
nausea, diarrhea,
rectal burning. MS:
muscle weakness
(with chronic use).
Assess for
hypokalemia with
chronic use. Assess
for abdominal
distension. Assess for
color, consistency,
and amount of stool
produced.
(Seroquel) quetiapine
25 mg, PO, HS Therapeutic:
antipsychotics, mood
stabilizers
Pregnancy Category
C
Acts by serving as an
antagonist of
dopamine and
serotonin. Also
antagonizes
histamine H1
receptors and alpha1-
adrenergic receptors.
Therapeutic Effects:
Decreased
manifestations of
psychoses,
depression, or acute
mania.
CNS: seizures,
dizziness, cognitive
impairment, EPS,
sedation, tardive
dyskinesia,
neuroleptic malignant
syndrome. EENT: ear
pain, rhinitis,
pharyngitis. Resp:
cough, dyspnea. CV:
increased BP in
children, palpitations,
peripheral edema. GI:
pancreatitis, anorexia,
constipation, dry
mouth, dyspepsia.
Derm: sweating.
Endo: weight gain,
Monitor mental status.
Assess for SI. Assess
weight throughout
therapy. Monitor for
EPS. Monitor for
tardive dyskinesia.
Assess for rash.
Monitor for
development of
neuroleptic malignant
syndrome (fever,
respiratory distress,
tachycardia, seizures,
diaphoresis,
hypertension or
hypotension, pallor,
tiredness). Advice Pt
to change positions
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hyperglycemia,
hyperlipidemia.
slowly so as to
minimize orthostatic
hypotension. Advice
Pt to avoid extremes
in temperature; this
drug impairs body
temperature
regulation.
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Nursing Management and Intervention Nursing Diagnosis: Impaired Urinary Elimination related to disruption in bladder innervation, as evidence by bladder distension; incontinence/overflow, retention
Assessment or data collection relative to the nursing diagnosis
Patient Outcome (objective, expected or desired outcomes, or
evaluation parameters)
Interventions/
Implementations
Evaluation
Subjective: Patient reports that he has not voided in +7 hours. States, “nothing has come out, and I’ve been drinking a lot of ice water.” Patient denies any discomfort or pain presently.
Objective: Pt observed to have mildly
distended bladder; Pt fluid intake from
previous day noted to be 3 L, and most
recent output from +7 hours ago noted
as 300 ml; Pt 50/50 incontinence
status, with prn straight catheter
orders Q 8hrs if unable to void.
Pt has hx of bladder and bowel
incontinence r/t neurogenic
dysfunction.
• Pt will achieve urinary
voiding within next hour,
with < 50 mL PVR identified
by bladder scan.
• Pt will verbalize
understanding of condition
during this shift.
• Pt will intake 2-4 L of fluids
during this shift to help
maintain renal function.
• Encourage Pt to void by
providing assistance and
support, monitoring for distress,
and educating Pt on potential
for catheterization.
• Educate Pt on current condition,
re bladder retention, and have
Pt verbalize understanding of
signs and symptoms of urinary
incontinence.
• Provide Pt with plenty of fluids,
including water and clear fluids,
to meet daily intake
requirements—except during
fluid restriction if initiation of
intermittent catheterization is
needed.
• Pt was unable to void
during the shift—goal not
achieved. And because of
the bladder scan (Pt had
250 mL PVR in his
bladder), intermittent
catheterization started.
• Pt verbalized
understanding his
condition, accurately
identifying signs/sxs of
retention and bladder
distention. Goal achieved.
• Pt complied with fluid
intake recommendation,
and by the end of the shift
he had taken in the
recommended volume. As
such, goal was achieved.
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Nursing Diagnosis: Impaired skin integrity related to immobility as evidence by pressure ulcer of sacral region, stage 2
Assessment or data collection relative to the nursing diagnosis
Patient Outcome (objective, expected or desired outcomes, or
evaluation parameters)
Interventions/
Implementations
Evaluation
Subjective: Patient reports that he was not aware that sacral ulcer was getting worse, he states “I had no idea, I can’t feel a thing,” consequently Pt had not been shifting his weight. Objective: Pt presents with a stage 2 pressure ulcer at sacral area, it is shallow with visible loss of dermis, and measures 2 cm in length and 3 cm in width. Pt also presents with abrasions to bilateral knees and elbows, and with stage 1 wound on his right heel with noted redness (non-blanchable). Pt is paraplegic r/t compression factor. Current hospitalization r/t further neurogenic dysfunction d/t Guillain Bare Syndrome s/p spinal surgery.
• Pt will achieve not
experiencing any more skin
breakdown during this shift.
• Pt’s wounds will be dressed
appropriately and kept clean
to prevent any infection
during this shift.
• Pt, while in wheelchair, will
practice shifting positions
every 20 minutes.
• Instructed Pt on how to use his
arms to lift his upper body and
trunk off the surface of the chair
intermittently.
• Educate Pt on how to identify
stage 1 pressure ulcers, as well
as other signs of skin
breakdown, and encourage Pt to
communicate concerns to staff
immediately.
• Provide Pt with appropriate
dressing, especially at
susceptible areas of bony
prominence, and provide Pt
with prophylactic use of
pressure relieving devices.
• Pt observed during shift
utilizing appropriate
mechanics for lifting body
and trunk off the surface
of wheel chair, achieving
goal of practicing shifting
positions.
• Pt was able to verbalize
understanding of how to
identify the early onset of
a stage 1 pressure ulcer,
and further skin
impairment was
prevented during the
shift.
• Pt’s wounds were kept
clean, skin intact, and
infections prevented
during this shift.
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References
VanMeter, K.C. & Hubert, R.J. (2014). Gould’s Pathophysiology for the Health Professions (pp. 324-333). Philadelphia, PA: Saunders; 5th
edition (January 1, 2014)
Hinkle, J.L. & Cheever, K.H. (2010). Brunner and Suddarth's Textbook of Medical-Surgical (pp. 2010, 2017). Philadelphia, PA: Lippincott
Williams & Wilkins; 13th edition (November 26, 2013)
Gulanick, M. & Myers, J.L. (2011). Nursing Care Plans. Diagnoses, Interventions, & Outcomes. New York, NY: Elsevier; 9th edition
(January 10, 2017)
