Care Plan Assignment UTI PDF

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Care Plan Assignment UTI...

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Care Plan Assignment Name:

Date: Assignment: ATI Real Life UTI Clinical Instructor:

This assignment will be graded. Grading points:  Nursing Diagnosis are specific and appropriate to this patient. (MUST BE NANDA APPROVED) Use your Nurse Pocket Guide or the website I have posted on the reference page of this example, or your Med-Surg Book, or other resources to find the appropriate diagnoses-cite references on last page of this assignment) -40  Nursing Diagnoses are prioritized (#1 most important, etc) : 15  Goals are specific and measurable: 10  AEB only with Actual: 5  Three most important nursing interventions (with rationale) for each diagnosis: 30 – Be sure to hit more than just one phase of the nursing process (so all three shouldn’t be assessment interventions) *note this example does not provide rationales, but you should state why you are choosing the interventions you did…this will help with critical thinking) You may want to pop your rationale in a different text color.

Patients Medical Diagnosis: (Choose most significant) Urinary tract infection Hypotension

Current problems: (List any significant problems or concerns) 1. High blood pressure 2. Fever 3. Pain in abdomen 4.

Nursing diagnosis #1 #1: Impaired urinary elimination R/T: Not urinating fully AEB: urinary hesitancy Goal: Patient will achieve normal urinary elimination without his catheter within 36 hours.

Nursing Interventions: #1 1. Assess the patients I&O. Rational: Gives us a basis on how much the patient is urinating and where we would like to get him to and seeing how much is actually staying in and not exiting. 2. Encourage the patient to intake more fluids. Rational: Increasing fluids helps to increase urination and hopefully get more fluid out. 3. Palpate the bladder every 4 hours. Rational: Looking for urinary retiention of the bladder.

Nursing diagnosis #2 #2: Infection R/T: Urinary tract infection AEB: Low blood pressure and fever Goal: Patient will be free from urinary tract infection and fever by discharge. ____________________________________________________________________________ __

Nursing Interventions:#2 1. Have the patient take his antibiotics to completion even if things get better. Rational: Not finishing the medications could lead to reinfection. 2. Monitor s/s of UTI such as pain and fever. Rational: We want to keep these under control to help our patient become free from infection and not let it further progress. 3. Have the patient increase intake of fluids if allowed. Rational: Drinking more fluids helps our patient to urinate more and can flush out more bacteria.

Nursing diagnosis #3 #3: Acute pain R/T: Infection of the bladder and retention. AEB: Patient stated he had stabbing pain from abdomen to back. Goal: Patient stated he was at a 9 out of 10. The goal is to have the patients pain around a 3 or 4 with in 12hours of medications. ____________________________________________________________________________ __

Nursing Interventions: #3 1. Assess the patients pain every 4 hours. Rational: Assessing the patients pain every 4 hours will let us know if the patients pain is getting better or worse and will help us decide if any extra interventions are needed. 2. Administer pain medication. Rational: The patients pain is at a 9 so he needs medication to bring the pain down to help him fight his infection. 3. Use alternative pain techniques. Rational: Using alternative pain techniques such as relaxation and a heating pain can help complement pain medications and my help ease the patient.

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