NURSING CARE PLAN PSYCHIATRIC

Client Initials: MP

Culture/Ethnicity: Hispanic

Support system: one son, married and live with his own family

Unit: Room/Bed:

Religion: Catholic

Age: 72 Sex: female

Language: Spanish

Weight:190 lbs Height: 5’04 BMI: 32.6

Marital status: widow

Current medical diagnosis

Occupation: Retired

Siblings: None

I-Uncomplicated UTI acute Cystitis

Health insurance: N/A

Name of significant other/primary caregiver

II- Diabetes Mellitus Type II

Current work status:N/A

None

III- Obesity

Highest grade completed: High School

Genogram: Use back of page

IV- HTN

Diagnostic procedures: CBC w/ Diff, EKG, A1C, Basic Metabolic Panel, urinalysis.

Surgical procedures: N/A

Urinary tract infections (UTIs) are common in females, accounting for over 6 million patient visits to physicians per year in the United States. Cystitis (bladder infection) represents the majority of these infections. Cystitis is caused by germs, most often bacteria, being E coli the most representative counting for more than 90 % of cases. The microorganism the urethra and then the bladder causing localized mucosal swelling and irritation. The infection commonly develops in the bladder but it can also spread to the upper urinary tract.

Women tend to get infections more often than men. This happens because their urethra is shorter and closer to the anus. Women are more likely to get an infection after sexual intercourse or when using a diaphragm for birth control. Menopause also increases the risk for a urinary tract infection.

DEVELOPMENTAL STAGE/THEORIST

Vital signs: Temp: 98.7, HR 88 bpm RR19 bpm B/P: 140/90, SpO2%:96 __________________________________

____________________________________

Allergies/Side effects: NKA

Denied any allergy of medicaments. _________________________________

Diet with rationale ____________________________________

Low Sodium: 2g Na, 16g protein, 1800Kcal. As nutritional management of his HTN, and DM

Protein-caloric intake has to be adjusted to compensate metabolic needs, and promote healthy weight ___________________________________

____________________________________

Activity/ walk 15 minutes 3 times a week

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Limitations/prosthetic devices

_None________________________

Theorist: Erikson” Maturity Ego- Integrity versus despair”

If a person looking back on his or her life can believe that it has been meaningful and relatively successful, then a sense of integrity develops.

If all that is seen is wasted opportunities and meaninglessness, then the person will be disgusted. Despair will follow disgust if the person feels it is too late to change.

Despair can be seen in his occasional lack of interest and commitment in his health.

BRIEF HEALTH HISTORY

72 years old Hispanic female patient with a chief complain of increased frequency since three days ago. Came into our facility complaining of dysuria, burning urination and hypogastric discomfort. Patient states she have to use the restroom many times at night. The nurse recorded BP 140/90 on admission. The patient states she have been taking her meds regularly and that her BP had improved since last visit which was 190/110

Surgery Hx: N/A.

Home meds: Metformin 500 mg twice a day

Lisinopril 10 mg twice a day

Hydrochlorothiazide 25 mg daily

ASA 81 mg QD.

Ordered Ciprofloxacin 250 mg twice a day / 3 days

PERTINENT LABORATORY DATA Lab Test #1

_______________________

CBC w/ Differential

_______________________

Results:

Hemoglobin: 12.5 g/dl (normal)

Hematocrit: 36.8% (normal)

MCV: 90 (Normal)

Platelets 350 000 ( normal)

Laukocytes:15x10(9)/L (elevated)

Neutrophils: 9.0 x 10(9)/L( abnormal)

_______________________

.Leukocytes and neutrophils are above normal levels in relation with patient urinary tract infection

PERTINENT LABORATORY DATA Lab Test #2

______________________

Basic Metabolic/ Hb-A1C

______________________

Results:

Hb-A1C 7 (adequate)

Glucose: 218198 mg/dl ↑

 BUN: 21 mg/dl (slightly ↑)

Creatinine: 1.2 mg/dl

K: 3.2 mmol / Lt(normal)

Na: 137 mmol /Lt(normal)

_______________________

Value of Hb-A1C in 7 is considered acceptable for a patient with DM

Glucose level is slightly high due to base disease (DM type II).

BUN and Creatinine are high and borderline impossible relation with chronic renal damage of Type II DM.

PERTINENT LABORATORY DATA Lab Test #3

______________________

EKG _______________________

Results:

Normal rhythm.  

PERTINENT LABORATORY DATA Lab Test #4

_______________________

Urinalysis _____________________

Results:

Appearance: dark, yellow. Specific gravity: 1.001 - 1.035 pH: 4.6 - 8.0 Protein: negative Glucose: 1+ Ketones: negative Bilirubin: negative Occult blood: negative WBC esterase: Positive Nitrite: Positive Casts: none Bacteria: few Yeast: none

Urine Culture

Positive for E coli

_______________________

Urinalysis results are compelling with an urinary tract infection

MEDICATION NAME

TRADE/GENERIC

DOSE ORDER

TIMES ADMINISTER

ROUTE

RATIONALE

RANGE

NURSING IMPLICATIONS

Metformin/Glucophage

Lisinopril

Hydrochlorothiazide mg daily

ASA

Ciprofloxacin

500 mg

 10 mg

25 mg

 81 mg

250 mg

Twice a day.

 Twice a day

Daily.

 Daily

Q 12 hour/3 days

PO

PO

PO

PO

PO

Decrease blood glucose levels.

 Decrease BP

Renal failure prevention

Diuretic decrease BP

Antiplatelet aggregation

Antibiotic

Max dose 2500 mg day

40 mg a day

50 mg a day

 4g a day

Monitor for gastrointestinal side effects / Hypoglycemia

Monitor for side effects (common dry cough)

Monitor for signs and symptoms of hyperkalemia advise ingestion of K rich foods

Monitor for sign of gastrointestinal upset

Monitor for bleeding

Monitor for gastrointestinal upset

NURSING DIAGNOSES

DESCRIBE RATIONALE FOR PRIORITY ORDER

I- Impaired urinary elimination patterns related to lower urinary tract bacterial infection as best evidence by positive urine culture

.

II- Risk of fall related to an increase of the number of voiding during nights

III- Deficient of knowledge related to frequent UTI infections a best evidence by frequent clinic visit presenting symptoms of the disease

The priority order was chosen based on Maslow’s of needs.

Needs are ranked on an ascending scale according to how essential they are.

On the base of this pyramid are the physiological needs.

ASSESSMENT DATA

SUBJECTIVE/

OBJECTIVE

NURSING DIAGNOSIS

PLAN

OUTCOME CRITERIA (CLIENT CENTERED)

INTERVENTIONS

(NURSE CENTERED)

RATIONALE FOR INTERVENTIONS

EVALUATION

Patient reports of frequency, urgency, dysuria, and nocturia

Discomfort at palpation of hypogastric region

Impaired urinary elimination patterns related to lower urinary tract infection (UTI) as best evidence by frequency and dysuria

The client will return to her normal urination patterns within 1 week of treatment.

Explain the importance of compliance with treatment for full length of time medication is prescribed

Explain the importance of increase drink plenty of fluids

Explain importance of follow a voiding pattern

Infection subsided with treatment. UTI will not recur because of inadequate treatment.

Drinking plenty of fluid will increase the urinary elimination and elimination of germs

Voiding holding increases the risk of UTI

Patient remains free of symptoms after finishing treatment

ASSESSMENT DATA

SUBJECTIVE/

OBJECTIVE

NURSING DIAGNOSIS

PLAN

OUTCOME CRITERIA (CLIENT CENTERED)

INTERVENTIONS

(NURSE CENTERED)

RATIONALE FOR INTERVENTIONS

EVALUATION

Subjective:

Increase of voiding pattern during night

Knowledge of illness and its treatment

Risk of fall related to an increase of the number of voiding during nights

Deficient of knowledge related to frequent UTI infections a best evidence by frequent clinic visit presenting symptoms of the disease

The client will safely void during night without falls

The client will be able to have 6–8 hours of uninterrupted sleep within 2 days.

The client will decrease the number of voiding during nights

Client will demonstrate understanding of treatment regimen

The client will learn to identify signs and symptoms of UTI and will notify to the Nurse

Explain the client to keep a light on during night to avoid falling

Explain to client the need to void before bedtime.

Explain the client to reduce caffeine intake

Explain common causes of UTIs.

Explain the complete course of each medication as ordered.

Teach the client how to perform adequate genital hygiene

Keeping a light on avoid stepping into objects increasing risk of falls

Voiding before bedtime avoids vesical stimulation and voiding for over distension

Caffeine acts as stimulant of CNS increasing alertness

Knowledge of causes of disease help in preventing future episodes.

Completing treatment decrease the risk of reinfection and resistance to antibiotics

Adequate genital hygiene prevents urinary tract infection by contamination with rectal or vaginal flora

Client remains free of fall episodes

Client has returned to normal sleep patterns

Presence of sterile urine and absence of symptoms.