NURSING CARE PLAN PSYCHIATRIC
SCHOOLOF NURSING:
CLINICAL WORKSHEET: NURSING PROCESS CARE PLAN
STUDENT NAME :
DATE:
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Client Initials: |
Culture/Ethnicity: |
Support system: |
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Unit: Room/Bed: |
Religion: |
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Age: Sex: female |
Language: |
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Weight: Height: BMI: |
Marital status: |
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Current medical diagnosis |
Occupation: |
Siblings: |
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Health insurance: |
Name of significant other/primary caregiver |
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Current work status: |
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Highest grade completed: |
Genogram: |
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Diagnostic procedures: |
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Surgical procedures: |
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DEVELOPMENTAL STAGE/THEORIST |
Vital signs: Allergies/Side effects: | |
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BRIEF HEALTH HISTORY |
PERTINENT LABORATORY DATA Lab Test #
1
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Results:
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PERTINENT LABORATORY DATA Lab Test #2
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Results:
PERTINENT LABORATORY DATA Lab Test #3
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Results:
PERTINENT LABORATORY DATA Lab Test #4
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Results:
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MEDICATION NAME TRADE/GENERIC |
DOSE ORDER |
TIMES ADMINISTER |
ROUTE |
RATIONALE |
RANGE |
NURSING IMPLICATIONS |
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NURSING DIAGNOSES |
DESCRIBE RATIONALE FOR PRIORITY ORDER |
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ASSESSMENT DATA SUBJECTIVE/ OBJECTIVE |
NURSING DIAGNOSIS |
PLAN OUTCOME CRITERIA (CLIENT CENTERED) |
INTERVENTIONS (NURSE CENTERED) |
RATIONALE FOR INTERVENTIONS |
EVALUATION |
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SCHOOL
OF NURSING:
CLINICAL WORKSHEET: NURSING PROCESS CARE
PLAN
STUDENT NAME :
DATE: 09/08/20
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5
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Client Initials: MP |
Culture/Ethnicity: Hispanic |
Support system: one son, married and live with his own family |
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Unit: Room/Bed: |
Religion: Catholic |
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Age: 72 Sex: female |
Language: Spanish |
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Weight:190 lbs Height: 5’04 BMI: 32 . 6 |
Marital status: widow |
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Current medical diagnosis |
Occupation: Retired |
Siblings: None |
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I-Uncomplicated UTI acute Cystitis |
Health insurance: N/A |
Name of significant other/primary caregiver |
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II- Diabetes Mellitus Type II |
Current work status:N/A |
None |
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III- Obesity |
Highest grade completed: High School |
Genogram: Use back of page |
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IV- HTN |
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Diagnostic procedures: CBC w/ Diff, EKG, A1C, Basic Metabolic Panel, urinalysis. |
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Surgical procedures: N/A |
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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
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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 ___________________________________
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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/
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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
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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:15×10(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 ______________________ 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.
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PERTINENT LABORATORY DATA Lab Test #3 ______________________ EKG _______________________ Results: Normal rhythm. |
PERTINENT LABORATORY DATA Lab Test #4 _______________________ Urinalysis _____________________ Results: Appearance: dark, yellow. Urine Culture Positive for E coli _______________________ Urinalysis results are compelling with an urinary tract infection |
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MEDICATION NAME TRADE/GENERIC |
DOSE ORDER |
TIMES ADMINISTER |
ROUTE |
RATIONALE |
RANGE |
NURSING IMPLICATIONS |
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Metformin/Glucophage Lisinopril Hydrochlorothiazide mg daily ASA Ciprofloxacin |
500 mg 10 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 |
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NURSING DIAGNOSES |
DESCRIBE RATIONALE FOR PRIORITY ORDER |
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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. |
SAMPLE PLAN OF CARE
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ASSESSMENT DATA SUBJECTIVE/ OBJECTIVE |
NURSING DIAGNOSIS |
PLAN
OUTCOME CRITERIA (CLIENT CENTERED) |
INTERVENTIONS (NURSE CENTERED) |
RATIONALE FOR INTERVENTIONS |
EVALUATION |
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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 |
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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. |
References
Potter & Perry (2013) Fundamentals of nursing.
Jensen (2015) Physical examination and Health Assessment
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