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 &/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 |
<0.03 ng/mL |
MHC |
26 |
Low |
27-31 pg |
||||
INR BNP |
N/a |
N/a |
<100 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 |
<200 mg/dl |
D-Dimer |
N/a |
N/a |
<250-600 ng/mL |
||||
HDL LDL |
N/a |
N/a |
>45 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 |
<2 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
List other disciplines involved in the Patient’s Care:
Nurse, Attending Physician, PrimaryCare Physician, Urologist, Substance Abuse Counselor
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.
Describe and discuss patient teaching:
Patient teaching about smokingcessation. Patient teaching about the benefits of substance abusecounseling. Patient teaching about diet, exercise, general wellbeing.
List what you taught or reinforced to the patient/family. Name of pamphlet or handout used (if applicable)
Education about the benefitsof smoking cessation.
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 & 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