UTI Care Plan - Care Plan PDF

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Actual Patient Initials: ___________, Rm#______ Age: _____ M/F, Allergies: ____________, Date of care: ___________

Primary Dx: Urosepsis Co-morbidities and PMH: Diabetes, congestive heart failure, How do the co-morbidities and PMH impact the primary dx’s: The patient has diabetes mellitus, which might have led to the current diagnosis. For instance, diabetes mellitus impairs circulation (Schmidt, 2019). Impaired circulation prevents the quick transfer of white blood cells to fight infections. This reduced immunity could have contributed to the occurrence of the urinary tract infection. Additionally, the high glucose level often leads to dysuria and increases the risk of UTI (Prajapati, 2019). Therefore, diabetes could have led to UTI in this patient. Finally, incomplete bladder emptying due to diabetes could have led to the current diagnosis. Actual/ Potential Complications: Sepsis can progress and impair blood flow to vital organs that include the heart, brain, and kidneys. Thus, the patient may experience shock. Additionally, blood clots may occur due to the infection circulatory system, thus leading to organ failure. The primary diagnosis, in this case, is the actual complication of diabetes in this patient. Failure to manage this patient can lead to permanent kidney damage. The patient is also prone to recurrent infection if not treated well.

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Patient Initials:___________, Rm#______ Age: _____ M/F, Allergies:____________, Date of care:___________

Priority#1: _____ Fluid balance ___ Priority#2: _____ Elimination ___ Assessment: Risk for deficient fluid volume Assessment: Incomplete voiding Meds: 100Ml lactated ringer’s iv at 30ml per hour. Meds: None Labs: sodium 135 mEq/L, potassium 4.4 mEq/L, Labs: sodium 135 mEq/L, potassium 4.4 mEq/L, Chloride 100 mEq/L, Calcium 9 mg/dL, Phosphorus 3.7 Chloride 100 mEq/L, Calcium 9 mg/dL, Specific mg/dL, BUN 21 mg/dL, Creatinine 1.0mg/dL, Albumin gravity 1.039, WBC 10, RBC 4-6 3.2mg/dL Ordered Medical Treatments: None Ordered Medical Treatments: None NANDA/Nursing Diagnosis: Impaired urinary NANDA/Nursing Diagnosis: Risk for deficient fluid elimination related to sepsis as evidenced by incomplete voiding. volume related to vasodilaton NOC: Increased risk for fluid volume deficit NOC: urinary elimination Expected Outcomes: Expected Outcomes:  Long-term outcome/goal (by discharge)  Long-term outcome/goal (by discharge) The patient will have adequate circulatory volume The patient will have regular urinary voiding after after discharge. six hours.  Short term outcome/goal (by the end of your  Short term outcome/goal (by the end of your shift) shift) The patient will have adequate circulatory volume after The patient will have no complaints about urinary elimination by during discharge. seven hours NIC: Management of urine elimination NIC: Fluid management Interventions (A/D/M/T) with rationales for Levels Interventions (A/D/M/T) with rationales for Levels I, II & LPN: I, II & LPN: 1. Assess for dry mucus membranes after every hour. To 1. Assess the elimination pattern for 12 hours. Elimination pattern helps to determine the basis for determine dehydration. appropriate interventions (Chu, & Lowder, 2018). In 2. Observe peripheral edema after every five hours. this case, the patient has only voided once. Therefore, Edema occurs due to fluid loss from the vascular the interventions should help to determine any compartment (Roumelioti et al., 2018). 3. Monitor blood pressure. Low blood pressure is due to problems after 12hours and initiate measures to promote adequate voiding. deficient volume. 4. Palpate peripheral pulses. Weak pulses are a sign of 2. Palpate the urinary bladder. Patients with infections in the urinary tract are more likely to have urinary deficient fluid volume 5. Give parenteral fluids. To maintain tissue perfusion retention (Chu, & Lowder, 2018). The bladder will have urine in case of retension. and prevent dehydration. 3. Encourage the patient to take fluids. Oral intake is Actual Outcomes: necessary for increasing urinary output. It can assist the 1.No Data patient to achieve normal urinary pattern. 2.No Data 4. Encourage the patient to wipe from front to back. 3.No Data Wiping from front to back can prevent the transfer of 4.No Data infections, which can further impair urinary elimination. 5.No Data 5. Make the bladder’s environment acidic. An acidic Evaluation: No Data environment prevents the occurrence of infections, which can impair urinary elimination. Actual Outcomes: 1.No Data 2.No Data 3.No Data 4.No Data 5.No Data Evaluation: No Data Student Name:

Actual Patient Initials: ___________, Rm#______ Age: _____ M/F, Allergies: ____________, Date of care: ___________

Priority#3: _____ Pain ___ Assessment: Pain Meds: None Labs: Not Applicable Ordered Medical Treatments: None NANDA/Nursing Diagnosis: Pain related to the inflammation of the urethra as evidenced by agitation NOC: Pain reduction Expected Outcomes:  Long-term outcome/goal (by discharge) Patient will have no pain during discharge.  Short term outcome/goal (by the end of your shift) By the end of seven hours, the patient will have no pain NIC: Pain management Interventions (A/D/M/T) with rationales for Levels I, II & LPN: 1. 2. 3. 4. 5. Actual Outcomes: 1. 2. 3. 4. 5. Evaluation: No Data

Priority#4: _____ Mobility ___ Assessment: Unable to walk fast and freely due to pain Meds: None Labs: Not Applicable Ordered Medical Treatments: None NANDA/Nursing Diagnosis: Impaired mobility related to pain as evidenced by the patient’s inability to walk faster NOC: Improved mobility Expected Outcomes:  Long-term outcome/goal (by discharge) By the end of six days, the patient will report improvement in sleeping pattern.  Short term outcome/goal (by the end of your shift) Patient will feel rested after 12 hours. NIC: Ensure sleeping Interventions (A/D/M/T) with rationales for Levels I, II & LPN: 1. 2. 3 4 5 Actual Outcomes: 1. 2. 3. 4. 5. Evaluation: No Data

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Patient Initials:___________, Rm#______ Age: _____ M/F, Allergies:____________, Date of care:___________

Priority#5: _____ Neurosensory ___ Assessment: History of diabetes Meds: Glyburide Labs: sodium 135 mEq/L, potassium 4.4 mEq/L Ordered Medical Treatments: None NANDA/Nursing Diagnosis: Risk for poor sensation in the feet related to diabetes mellitus NOC: Adequate sensation Expected Outcomes:  Long-term outcome/goal (by discharge) The patient will be free from poor sensation in the feet after six days  Short term outcome/goal (by the end of your shift)  The patient will be free from poor sensation in the feet after five hours. NIC: Diabetes management Interventions (A/D/M/T) with rationales for Levels I, II & LPN: 1. 2. 3. 4. 5. Actual Outcomes: 1. 2. 3. 4. 5. Evaluation: No Data

Priority#6: _____ Wellness ___ Assessment: Ready for discharge Meds: None Labs: Not aplicable Ordered Medical Treatments: None NANDA/Nursing Diagnosis: Readiness for enhanced coping related to the patient’s ability to cope with therapies as evidenced by the need for discharge and social support from the neighbour NOC: Increase in knowledge on urosepsis and UTI Expected Outcomes:  Long-term outcome/goal (by discharge) The patient will verbalize causes of urosepsis and readiness to comply with medications by the end of seven days.  Short term outcome/goal (by the end of your shift) The patient will narrate the ability to care for himself after being taught. NIC: Patient education Interventions (A/D/M/T) with rationales for Levels I, II & LPN: 1. 2. 3. 4. 5. Actual Outcomes: 1. 2. 3. 4. 5. Evaluation: No Data

Student Name:

Actual Patient Initials: ___________, Rm#______ Age: _____ M/F, Allergies: ____________, Date of care: ___________

Priority#7: _____ Skin tissue integrity ___ Assessment: Risk for shock Meds: Ringer’s lactate Labs: Not applicable Ordered Medical Treatments: None NANDA/Nursing Diagnosis: Risk for shock related to inadequate blood flow NOC: Improved skin integrity Expected Outcomes:  Long-term outcome/goal (by discharge) The patient will have adequate perfusion after six days.  Short term outcome/goal (by the end of your shift) The patient will have adequate perfusion after seven hours NIC: Prevention of shock Interventions (A/D/M/T) with rationales for Levels I, II & LPN: 1. 2. 3. 4. 5. Actual Outcomes: 1. 2. 3. 4. 5. Evaluation: No Data

Priority#8: _____ Nutrition ___ Assessment: reduced urine output Meds: None Labs: Cholesterol 225mg/dL, Ordered Medical Treatments: None NANDA/Nursing Diagnosis: Poor oral intake related to a lack of appetite as evidenced by reduced urine output NOC: Improved oral intake Expected Outcomes:  Long-term outcome/goal (by discharge) The patient will be consuming a healthy diet after six days.  Short term outcome/goal (by the end of your shift) The patient will be consuming a healthy diet after six hours. NIC: Fluid therapy Interventions (A/D/M/T) with rationales for Levels I, II & LPN: 1. 2. 3. 4. 5. Actual Outcomes: 1. 2. 3. 4. 5. Evaluation: No Data

Student Name:

Patient Initials:___________, Rm#______ Age: _____ M/F, Allergies:____________, Date of care:___________

Priority#10: _____ self expression ___ Priority#9: _____ Oxygenation ___ Assessment: Readiness for enhances self expression Assessment: Risk for impaired gas exchange Meds: None Meds: None Labs: Not applicable Labs: Hemoglobin 11.3 g/dL Ordered Medical Treatments: None Ordered Medical Treatments: None NANDA/Nursing Diagnosis: Readiness for enhances NANDA/Nursing Diagnosis: Risk for impaired gas self expression due to compliance with treatments exchange related to inadequate oxygenation NOC: Adequate self-care NOC: Adequate oxygenation Expected Outcomes: Expected Outcomes:  Long-term outcome/goal (by discharge)  Long-term outcome/goal (by discharge) The patient will manage herself at home after Patient will have no dyspnea or cyanosis after seven discharge. days.  Short term outcome/goal (by the end of your  Short term outcome/goal (by the end of your shift) shift) The patient will narrate the ability to care for Patient will have no dyspnea or cyanosis after seven herself after five hours. hours. NIC: Self-care encouragement NIC: Monitor oxygenation Interventions (A/D/M/T) with rationales for Levels Interventions (A/D/M/T) with rationales for Levels I, II & LPN: I, II & LPN: 1. 1. 2. 2. 3. 3. 4. 4. 5. 5. Actual Outcomes: Actual Outcomes: 1. 1. 2. 2. 3. 3. 4. 4. 5. 5. Evaluation: No Data Evaluation: No Data

Student Name:

Actual Patient Initials: ___________, Rm#______ Age: _____ M/F, Allergies: ____________, Date of care: ___________

References Chu, C. M., & Lowder, J. L. (2018). Diagnosis and treatment of urinary tract infections across age groups. American Journal of Obstetrics and Gynecology, 219(1), 40-51. https://doi.org/10.1016/j.ajog.2017.12.231 Prajapati, A. K. (2019). Urinary tract infection in diabetics. Microbiology of Urinary Tract Infections Microbial Agents and Predisposing Factors. doi:10.5772/intechopen.79575 Roumelioti, M.-E., Glew, R. H., Khitan, Z. J., Rondon-Berrios, H., Argyropoulos, C. P., Malhotra, D., … Tzamaloukas, A. H. (2018). Fluid balance concepts in medicine: Principles and practice. World Journal of Nephrology, 7(1), 1–28. doi:10.5527/wjn.v7.i1.1 Schmidt, A. M. (2019). Diabetes mellitus and cardiovascular disease: Emerging therapeutic approaches. Arteriosclerosis, Thrombosis, and Vascular biology, 39(4), 558-568. https://doi.org/10.1161/ATVBAHA.119.310961

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