Chamberlain College of Nursing

Student Victor Trella 8/04/2016 15

ChamberlainCollege of Nursing

Nursing324 – 325 Care plan Packet

Dateof care: 5/21/16Client Initials: B.D.Sex: FAge: 70Rm# 527

Religion:BaptistAllergies: No known allergiesAdmission date: 5/20/16 Code status: Full

Admittingdiagnosis: Acute pyelonephritis, abdominal pain, acute vomiting,dehydration

SocialHx: Tobacco 5+ cigarettes per day, smoker, no alcohol,marijuana every day, heroin

PMH:Ureteral stent placement 3/10/16

RecentSurgeries: none

ChiefComplaint: Nausea, abdominal pain

NarrativeNote/SBAR:

S:Patient complains of abdominal pain, nausea.

B:Ureteral stent placement, pyelonephritis, patient is 70 years oldnormal aging process

A:70 year old female, BP: 147/79 HR: 80 Resp: 20 O2: 100% pain:6/10 Temp: 100.1 F

R:Treatment, substance abuse counseling

PsychosocialAssessment:

Patientis oriented in time, place and person

Sheis conscious, alert, attentive and responsive

Shespeaks in English. Her speech is orderly, soft and slow. It is easyto follow even though she makes long pauses

Patientis well groomed and her hair is not disheveled (Sandberg, 2012).

Possiblesubstance abuse,

Sheis not married, has an adult son

DIAGNOSTICTESTS

Test

Result

Reason(s) Needed and if abnormal- why?

CXR

n/a

n/a

EKG

n/a

n/a

CT

5/20/16

Urinary Tract Infection

Abdominal Pain LUQ

Others

n/a

n/a

Glucose

5/20/16

101 Normal

To check for possible diabetes

Prescriptions/Orders

Item

Reason (explain specifically why ordered for this patient)

Diet Clear liquid
I/O Intake: 14.96 mL Output: 0 mL Balance: 14.96 mL
VS BP: 147/79 HR: 80 Temp: 100.0 Resp: 20
Activity Normal

Accu-check

101

Foley

n/a

NG tube

n/a

PEG/PEJ tube

n/a

Chest tube

n/a

Trach

n/a

Suctioning

n/a

Drains

n/a

Ostomy

n/a

Dressing change &amp/or wound care

n/a

Treatments

n/a

Special Equipment

n/a

Other

Complete Blood Count w/ Differential, ordered to assess status in regards to anemia and low oxygen levels.

Therapies

Activity/Tx

Reason(s) Needed

Resp.

n/a

n/a

PT

n/a

n/a

OT

n/a

n/a

Speech

n/a

n/a

Other

n/a

n/a

IVACCESS

Type: Peripheral IV

Site: Right hand (20 gauge)

Fluid/rate: N/A

Left forearm discontinued

Reason(s) for IV access: Possible Saline Hydration

70-110 mg/dl

Gluc

K+

Cre

CO2

Result

Normal

Labs only as indicated

Result

Normal

NA

140

Normal

135-145mEq/L

Albumin

3.7

Normal

3.5-5gm/dl

K

4.2

Normal

3.5-5.0mEq/L

Total Protein

n/a

N/a

6.4-8.3 gm/dl

Cl

106

Normal

98-106mEq/L

Hgb

12.5

Normal

12-18m/dl

CO2

24

Normal

23-29 mEq/L

Hct

36.8

Low

37-52m/dl

Calcium

8.2

Low

9-10.5mg/dl

Platelets

190

Normal

150-400 M/mm3

Mag

n/a

N/a

1.3-2.1mEq/L

PT

6.8

Low

11-12.5 sec

Phos

n/a

N/a

PTT

n/a

N/a

30-40 sec

BUN

19

Normal

6-20 mg/dL

D. Bilirubin

n/a

N/a

0.1-0.3 mg/dl

55-70%

Creatinine

1.21

Normal

0.6-1.3 mg/dL

T. Bilirubin

0.3

Normal

0.3-1 mg/dl

WBC

10.6

Normal

4-11 mg/dL

Glucose

n/a

N/a

80-100mg/dl

Lymphocytes

7.6

Low

20-40%

Ca++

Phos

Mg+

Alk. Phos.

100

N/a

3-120 units/l

Monocytes

6.9

Normal

2-8%

9-10.5mg/dl

1.3-2.1mEq/L

3-4.5mg/dl

ALT

AST

25

37

Normal

Normal

4-36 units/L

0-35 units/dl

Eosinophils

0.3

Low

1-4%

5-10M/mm3

150-400 M/mm3

HCT

Amylase

N/a

N/a

60-120 units/dl

Basophils

0.9

Normal

0.5-1%

M 42-52%

F 37-47%

Lipase

N/a

N/a

0-160 units/L

MCV

86.8

Normal

80-95 m3

PT

PTT

CPK

N/a

N/a

30-170 units/L

MCHC

33.9

Normal

32-36 gm/dl

11-12.5 sec.

30-40 sec.

Troponin

N/a

N/a

&lt0.03 ng/mL

MHC

26

Low

27-31 pg

INR

BNP

N/a

N/a

&lt100 pg/mL

MPV

8.9

Normal

7.4-10.4 fL

1.0-2.0

LDH

N/a

N/a

100-190 units/L

Sed. Rate

N/a

N/a

15 mm/hr

Cholesterol

N/a

N/a

&lt200 mg/dl

D-Dimer

N/a

N/a

&lt250-600 ng/mL

HDL

LDL

N/a

N/a

&gt45 mg/dl

60-180 mg/dl

Bleeding Time

N/a

N/a

1-9 minutes

Triglycerides

N/a

N/a

35-160 mg/dl

Digoxin level

N/a

N/a

15-25 ng/mL

Abnormal Labs: Please document abnormal labs here. Add morelines if needed.

Test/Finding

Result

Reason out of Norm

5/20/16

Ca

8.2 Low

Eating disorder or nutritional deficiency, kidney disease

5/20/16

Hct

36.8 Low

Nutritional problems (low iron, B 12, folate and malnutrition)

5/20/16

PT

6.8 Low

Possible Bleeding disorder

5/20/16

Lymphocytes

7.6 Low

Acute infection (viral, bacterial), Smoking, Hyposplenism, Acute stress response

5/20/16

Monocytes

6.9 Low

Chronic inflammatory conditions

5/20/16

Esnophils

0.3 High

Alcohol intoxication, Overproduction of certain steroids in the body (such as cortisol)

Pathophysiology Treatments

Antibiotic therapy is essential in the treatment of acute pyelonephritis and prevents progression of the infection. Urine culture and sensitivity testing should always be performed, and empirical therapy should be tailored to the infecting uropathogen.[ CITATION Lag14 l 2057 ]

Patients presenting with complicated pyelonephritis should be managed as inpatients and treated empirically with broad-spectrum parenteral antibiotics.[ CITATION San12 l 2057 ]

Acute pyelonephritis results from bacterial invasion of the renal parenchyma. Bacteria usually reach the kidney by ascending from the lower urinary tract. Bacteria may also reach the kidney via the bloodstream. [ CITATION Sch16 l 2057 ]

Medical Diagnosis

Acute Pyelonephritis

Risk Factors

Female anatomy. Women have a greater risk of kidney infection than do men. A woman`s urethra is much shorter than a man`s, so bacteria have less distance to travel from outside the body to the bladder. The proximity of the urethra to the vagina and anus also creates more opportunities for bacteria to enter the bladder. [ CITATION Fox14 l 2057 ]

Obstruction in the urinary tract. Anything that slows the flow of urine or reduces your ability to completely empty your bladder when urinating, such as a kidney stone, structural abnormalities in your urinary system or, in men, an enlarged prostate gland, can increase your risk of kidney infection.[ CITATION Fox14 l 2057 ]

Weakened immune system. Medical conditions that impair your immune system, such as diabetes and HIV, increase your risk of kidney infection. Certain medications, such as drugs taken to prevent rejection of transplanted organs, have a similar effect.[ CITATION Fox14 l 2057 ]

Damage to nerves around the bladder. Nerve or spinal cord damage may block the sensations of a bladder infection so that you`re unaware when it`s advancing to a kidney infection.[ CITATION Fox14 l 2057 ]

Nursingdiagnosis

Acute pain related to infection of the kidneys as evidenced by abdominal pain.[ CITATION Fox14 l 2057 ]

Impaired urinary elimination related to kidney infection as evidenced by decreased urine output.

Impaired comfort related to inflammation as evidenced by client complaining about discomfort.[ CITATION Fox14 l 2057 ]

System

Finding

System

Finding

Cardiovascular

BP

147/79

GI

Abdominal Contour/Firmness

Symmetric, soft/tender

Pulses (Bilaterally when applicable)

Equal bilaterally

Bowel Sounds X 4 Quadrants

Present

Rhythm

Regular

Last BM

5/20/16 Morning

Apical Rate

80

Bowel Program

N/a

Radial

2+ normal

Dentition

Good

Capillary Refill

&lt2 seconds

Urinary

Amount

Heart Sounds S1, S2,S3,S4, Rub

No abnormal sounds

Continent or

Incontinent

Continent

Murmur

N/a

Bladder Program

N/a

Respiratory

Rate

20

Skin

Integrity

Good

Rhythm

Normal Sinus Rhythm

Hydration/Turgor

Good

Effort

Unlabored, quiet

Lesions/Scars/Wounds (Location and Descriptions)

None

Pulse Oximetry

91% room air

Edema (Location/Amount)

N/a

Breath Sounds

Clear

M/S

Mobility/Strength

Fair

LUL

Clear

Assistive Devices

N/a

LLL

Clear

Immobilization Devices (Traction/Cast/Fixators)

N/a

RUL

Clear

Neurologic

Temperature

100.1 F

RML

Clear

LOC

Alert Oriented x4

RLL

Clear

Speech

Good

Cough

Nonproductive

Vision

PERRLA Yes

Secretions/Sputum Amount/Appearance

N/a

Hearing

Good

Mucous Membrane Color

Pink

Sleep Pattern

Normal

O2 administration

N/a

GCS

15

PAIN

Location

Duration

Cause/Description

Pain Scale

Control Method/Management

Effectiveness of Relief

Pain Assessed

N/a

N/a

0/10

N/a

N/a

*Can finish this bottom part ofpage during Clinical

  1. List other disciplines involved in the Patient’s Care:

Nurse, Attending Physician, PrimaryCare Physician, Urologist, Substance Abuse Counselor

  1. Describe any need for assistance after discharge:

Patient has been advised to followup with primary care physician. Appointment has been made.

Referral for substance abusecounseling has been given to patient.

  1. Describe and discuss patient teaching:

Patient teaching about smokingcessation. Patient teaching about the benefits of substance abusecounseling. Patient teaching about diet, exercise, general wellbeing.

  1. List what you taught or reinforced to the patient/family. Name of pamphlet or handout used (if applicable)

Education about the benefitsof smoking cessation.

  1. Name one of the resources that you looked up (can be a policy or procedure, research article, etc.)

Micromedexwas used to research pharmaceuticals. Mayo clinic was used to obtaininformation about the admitting diagnosis.

Medicationpage

Medication:

Trade and Generic names

Pharmacotherapeutic Classification

&amp Drug Action

Normal Dosage Range

Amt. Dr. ordered

Route and Time

Why is Patient receiving medication?

Life threatening and most common reactions to monitor/observe

Nursing responsibilities

Levaquin

Levoflaxacin

Antibiotic/Anti-infective Agent

HIGH:

750 mg every 24 hrs for 5 days

LOW:

250 mg every 24 hrs for 10 dayd

750 mg

1050 mL

100 mL/hr

IV

924 H-int

Kidney Infection

Serious: Aortic aneurysm, Cardiac arrest, Prolonged QT interval, Torsades de pointes, Ventricular tachycardia, Erythema multiforme, Stevens-Johnson syndrome, Hypoglycemia, Aplastic anemia, Pancytopenia, Thrombocytopenic purpura, Hepatitis, Liver failure, Anaphylactoid reaction, Hypersensitivity reaction, Myasthenia gravis, Exacerbation, Rupture of tendon, Tendinitis, Peripheral neuropathy, Seizure, Retinal detachment, Acute renal failure

Common: Diarrhea, Nausea, Dizziness, Headache, Insomnia

Monitor for fever, CBC, symptomatic improvement

Zosyn

Piperacillin Sodium/Tazobactam Sodium

Antibiotic/Anti-infective Agent

Initial bolus of 2 g/0.25 g infused over 30 minutes, then 12 g/1.5 g over 24 hours or prolonged intermittent infusion (3.375 g over 4 hours every 8 hours

3.375 gm

12.5 mL/hr

IV Piggy back

98 H-int

Kidney Infection

Serious: Acute generalized exanthematous pustulosis, Erythema multiforme, Stevens-Johnson syndrome, Toxic epidermal necrolysis, Clostridium difficile diarrhea, Agranulocytosis, Leukopenia, Neutropenia, Pancytopenia, Thrombocytopenia, Anaphylaxis, Drug hypersensitivity syndrome, Hypersensitivity reaction, Seizure

Common: Pruritus, Rash, Constipation, Diarrhea, Nausea, Oral candidiasis, Vomiting,

Headache, Insomnia, Fever

Monitor CBC, including differential, body temperature, improvement in the signs and symptoms of infection is indicative of efficacy, electrolytes, periodically during therapy in patients with low potassium reserves, receiving chemotherapy or diuretics

Sodium Chloride w/ KCL

Antiasthma/ Dermatological Agent

The dose should be guided by serum sodium levels, clinical condition, patient age and weight

0.9%

20 meq/L

1,000 mL

IV

PRN

Keep patient hydrated, balance potassium levels

May cause serious electrolyte imbalance resulting in fluid or solute overload, hypokalemia and acidosis, or hypernatremia. Fluid or solute overload dilutes serum electrolyte concentrations and may cause congestive heart failure

Monitor hydration and electrolytes

Methadone

Methadone Hydrochloride

Analgesic/CNS Agent

HIGH:

30mg

LOW:

20 mg

79 mg

Oral, daily

NOW

Maintenance therapy

Serious: Decreased vascular flow, left ventricle, Prolonged QT interval, Torsades de pointes, Hypoglycemia, Respiratory acidosis, Respiratory arrest, Respiratory depression, Drug dependence

Common: Hypotension, Diaphoresis, Constipation, Nausea, Vomiting, Asthenia, Dizziness, Lightheadedness, Sedated

Note decrease in the frequency, duration, and severity of pain or relief of signs and symptoms associated with narcotic addiction is indicative of therapeutic efficacy. Periodically reassess pain control and need to continue therapy

#1 Nursing Diagnosis

R/T AEB

Patient’s Goals (label them short term or long term)

Short term-must be measurable for the duration of clinical

Long-term- measurable after clinical)

Nursing Actions

(Interventions in order of priority)

Rationale for Actions

Evaluation of Interventions

Patient/significant/family educational needs

Acute pain

R/T: infection of the kidneys

AEB: abdominal pain

Short-term goal:

The client will experience a satisfactory relief measure as evidenced by improvement in mood and coping by end of shift.

Long-term goal:

The client will experience a satisfactory relief measure as evidenced by return to normal daily activities within 2 weeks (Sandberg, 2012).

Assess the intensity, location, and factors that aggravate or relieve pain.

Encourage drinking plenty of 2-3 liters if no contraindications

Monitor urine output to changes in color, odor and voiding patterns, input and output every 8 hours and monitor the results of urinalysis repeated.

Record the location, the length of the intensity scale (1-10) spread pain.

Give analgesics according to the treatment program.

Assist or encourage the use of focused relaxation breathing.

Give perineal care.

Pain is a sign of possible infection.

To promote urination

To identify indications of progress or deviations from expected results.

To help evaluate the place of obstruction and cause pain.

Analgesics block the path of pain.

Helps redirect the attention and for muscle relaxation.

To prevent contamination of the urethra.

Vital signs were taken

Client was able to express discomfort

Client was given medication

Client was instructed on pain avoidance

Client was provided adequate blankets for warmth

Client was instructed on pain avoidance

Client was given medicine to provide pain relief

Client was given teaching on non-pharmacological pain relief methods.

#2 Nursing Diagnosis

R/T AEB

Patient’s Goals (label them short term or long term)

Short term-must be measurable for the duration of clinical

Long-term- measurable after clinical

Nursing Actions

(Interventions in order of priority)

Rationale for Actions

Evaluation of Interventions

Educational needs

Impaired urinary elimination

R/T: kidney infection

AEB: Decreased urine output

Short-term goal:

The client will be able to identify the cause of impaired urinary elimination by end of shift.

Long-term goal:

The client will be continent within a week.

Monitor input and output characteristics of the urine.

Determine the patient’s voiding patterns, encourage increased fluid intake.

Review full bladder complaints.

Observations in changes of mental status, behavior or level of consciousness.

Reposition the patient every two hours.

Monitor laboratory tests on electrolytes, and creatinine.

Provides information about renal function and presence of complications.

Increased hydration will help flush out bacteria.

Urinary retention may occur causing tissue distention.

Accumulation of residual uremic and electrolyte imbalance can be toxic to the central nervous system.

Repositioning prevents static urine.

Maintain information regarding urinary function.

Determine if normal eliminations are being interrupted or changed.

Urination patterns were assessed.

Fluid intake was increased.

The abdomen and bladder were assessed.

Client was monitored regularly for changes in level of consciousness, and behavior.

Ability to ambulate was assessed and monitored

Laboratory tests were performed and evaluated.

Client was educated about how urinary function can be affected by infection.

Client was educated about how fluid intake can improve kidney infection.

Client was educated about how ambulation and repositioning can prevent further or increased infection.

#3 Nursing Diagnosis

R/T

Patient’s Goals (label them short term or long term)

Short term-must be measurable for the duration of clinical

Long-term- measurable after clinical

Nursing Actions

(Interventions in order of priority)

Rationale for Actions

Evaluation of Interventions

Educational Needs

Impaired comfort

R/T: inflammation of the kidneys

AEB:

Short-term goal:

The client will describe symptoms of impaired comfort by end of shift.

Acknowledge the client’s discomfort

Listen attentively to the client’s discussion of discomfort

Convey that you are assessing the discomfort to better understand the client’s needs

Acknowledgement of a client’s discomfort may provide psychological relief.

Listening to the client describe their discomfort can help to direct treatment.

Client’s discomfort was acknowledged.

Client was able to express, and explain their discomfort.

Client understood that their discomfort was being evaluated.

Client was educated about how non-pharmacological methods might be helpful to discomfort.

AEB: client complaining about discomfort

Long-term goal:

The client will report acceptable control of symptoms as evidenced by measures to improve comfort within 2 weeks.

Provide distraction techniques such as music, television, or massage.

Give analgesics according to the treatment program.

Promote non-pharmacologic methods to control discomfort.

Analgesics provide relief from pain, and provide comfort.

Client was provided with analgesics to control discomfort.

References

B, F. (2014). urinary tract infections syndromes: occurrence, recurrence, risk factors, and disease burden. infectious diseases of north america, 1-13.

Lagace-wiens p, W. A. (2014). ceftazidime-avibactam: an evidence based review of its pharmacological and potential use in treatment of gram negative bacteria infections. core evidence, 9, 13.

Sandberg T, S. G. (2012). Ciprofloxacin for 7 days vesus 14 days in women with acute pyelonephrits: a randomised open-label and double blind, placebo controlled, non-inferiority trial. the lancet, 484- 490.

Schneeberger C, H. F. (2016). febrile urinary tract infections: pyelonephritis and urosepsis. current opinion in infectious diseases, 80-85.

Wagenlehner F, S. J. (2016). Ceftazidine-avibactam vesus doripenem for the treatment of complicated urinary tract infections, including acute pyelonephritis. clinical infectious diseases, 378.

V 1.6 Edit date 10_2010_6_2012