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N256 Mini Care Plan

Nursing
Diagnoses
(NANDA)

Expected
(complete before assessment)

Found
(complete after assessment)

1. Infection
2. Impaired elimination
3. Fatigue

1. WBC 11.2, urine-yellow, clear, odorless, afebrile,


vital signs w/in normal range, patient stated that he
has no pain upon urinating or increase frequency
2. Impaired elimination secondary to an enlarged
prostate, urinary retention
3. Patient presented to the ER w/weakness & lethargy,
altered mental status
Urine- yellow, clear, odorless, 60 ml of urine collected,
creatinine 1.5, WBC 11.2
Skin- no open wounds or tear, iv site CDI, slightly
reddened coccyx

Focus of physical
assessment

Signs and symptoms of infection, urinary


assessment, skin integrity

Need more
information
from
patient/family/
doctor about:

Diagnostic Findings
UA/dipstick
Blood cultures
Family/lifestyle dynamic- wife & children
Spiritual findings

No diagnostics/cultures were performed


Lives at home with wife; no children

1. Patient will state signs & symptoms of


infection & early signs of infection
2. Patient will have controlled blood sugar
3. Patient will not fall during out of bed
activities and with PT

1. Patient verbalized signs/symptoms of infection after


patient teaching
2. Blood sugar was not controlled and required insulin
before meals
3. Patient did not fall or complain of dizziness. Bed
alarm implemented, call light w/in reach

1. Assessment of CMP, hx of illness & co-existing


medical problems/psycho-social
2. Focused assessment on urinary function
3. Educate signs & symptoms of infection
4. Educate signs & symptoms of hypo &
hyperglycemia
5. Administer po & iv meds
6. Educate on fall prevention strategies

1. K+ 3.1-3.5, hgb 12.0, cl 107, other medical


problems-diabetes type 2, hypertension,
hyperlipidemia, parkinsonism; patient presents no
signs of psych-social concerns
2. Patient stated having problems with starting
stream, & emptying bladder
3. Patient verbalized signs & symptoms of infection
4. Patient verbalized signs & symptoms of hypohyperglycemia
5. Patient received his medication on time
6. Patient stated fall precautions; use of assistive
support, & orthostatic hypotension
1. patient verbalized his medication &
rationale. Aspirin- mild discomfort,
cefepime- abx treatment for mild infection,
finasteride- bph; insulin Lispro (Humalog)diabetes; Linsopril- hypertension;
Pravastatin- cholesterol; Simethicone- gas;
Sinemet- parkinsonism; Tamsulosin- urinary
retention; prn meds- for mild pain &
constipation
2. Patient stated signs & symptoms of
infection- pain upon urinating, increase
frequency, cloudy with odor urine, malaise,
fever
3. Generalized malaise & changes from
baseline
4. Patient understands he is at risk for re-

Top three
priorities (goals)
for patient care

Nursing
Interventions

Teaching
needed/provided

1.
2.
3.
4.

medication compliance/diet regimen


signs & symptoms of infection
early signs & symptoms of infection
education on way to prevent current
urinary tract infection

Discharge
planning

Patient should be discharged to a nursing care


facility with 24 hour care

current illness due to his co-existing medical


problems- BPH & inadequate fluid intake
Patient lives at home with wife and caregiver

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