Hello, I am doing hospital clinical and I need to do a care plan on my pt-Pt had medical DX abdominal pain and they did some tests that resulted in UTI. She has Hx of seizures also her Bp was throughout the day so they are monitoring her before discharge. Pt is on UTI medication, Seizure medication, and bolus for BP. At the end of my shift she had a seizure so I don't really know what the out come will be for her :(
Now I have to do a care plan: I am asking for help to develop a nursing diagnosis and other help like long and short term goals...please help. (in the nursing dx must have a problem, etiology and manifestation per the instructor)...please help Nursing Diagnosis of Urinary Tract Infection Essay Example
- Acute Pain related to abdominal discomfort and UTI infection, as evidenced by patient reports of abdominal pain and discomfort.
- Risk for Injury related to seizure activity, as evidenced by patient history of seizures and recent seizure activity.
- Deficient Knowledge related to medication management and discharge instructions, as evidenced by patient questions and confusion about medication regimens and discharge plans
UTI (urinary tract infection): infection of the urinary tract Medicine used antibiotics and penicillin.
1.Acute Pain Short-term goal: The patient will report a pain level of 3 or less on a scale of 0–10 within 30 minutes of medication administration. Interventions: Assess pain level and location every 4 hours and as needed. Administer pain medication as ordered and assess effectiveness. Use distraction techniques (such as music, relaxation, or imagery) to help the patient manage pain. Encourage the patient to change positions frequently to relieve abdominal discomfort. Monitor for adverse effects of pain medication. Long-term goal: Patient will have pain well-managed and be able to perform activities of daily living without significant discomfort. Interventions: Continue to assess and manage pain as described above. Encourage the patient to take medications on a regular schedule to maintain pain control. Provide education on non-pharmacologic pain management techniques (such as heat or cold therapy, massage, or exercise) that the patient can use at home. Collaborate with physical therapy and occupational therapy to develop a plan to gradually increase activity level.
Seizures—uncontrolled electrical activity in the brain
2.risk of injury Short-term goal: The patient will remain free from injury during hospitalization. Interventions: Assess seizure history and activity every 4 hours and as needed. Ensure that the patient's bed is in the lowest position with side rails up. Stay with the patient during seizure activity to prevent falls and injury. Provide a padded tongue depressor or similar object to prevent the patient from biting their tongue during a seizure. Collaborate with the healthcare provider to adjust seizure medication as needed. Long-term goal: Patient will remain free from injury at home. Interventions: Provide education on seizure precautions, including avoiding activities that could be dangerous during a seizure (such as swimming or driving). Encourage the patient to wear a medical alert bracelet to alert others to the seizure disorder. Teach the patient and family members how to recognize signs of seizure activity and what to do if a seizure occurs. Collaborate with the healthcare provider to develop a plan for follow-up care and monitoring.
Deficient Knowledge Short-term goal: The patient will verbalize understanding of medication regimens and discharge instructions. Interventions: Review medication regimen and side effects with the patient and family members. Use teach-back method to assess patient understanding of medication management. Provide written instructions for medication management and discharge instructions. Provide contact information for healthcare provider and encourage patient to call with any questions or concerns. Long-term goal: Patient will be able to manage medications and follow-up care independently. Interventions: Provide ongoing education on medication management and potential side effects. Collaborate with the healthcare provider to simplify medication regimen as appropriate. Encourage the patient to schedule and attend follow-up appointments as scheduled.
The patient has abdominal pain and an UTI, a history of seizures, and fluctuating blood pressure. They are on medications for these conditions, but she had a seizure during the shift. The goal is to prevent future seizures and keep the patient safe. The care plan includes regularly assessing seizure activity, staying with the patient during seizures, providing a padded tongue depressor, and adjusting seizure medication if needed. The long-term goal is for the patient to remain injury-free at home, and the plan includes education on seizure precautions, wearing a medical alert bracelet, and teaching the patient and family how to recognize and manage seizures. The patient needs education on their medication and discharge instructions, and the goal is for them to manage their medications and follow-up care independently. Nursing Diagnosis of Urinary Tract Infection Essay Example