Nursing Nursing Process Paper

Client Profile

The patient is a white 80year old whose religion is unknown and was admitted on February 2, 2022, for a UTI infection. Care for the patient began on the day of admission. He is a father of three and a grandfather of five, living with his spouse. The social-economic status of the patient is low to middle class had a career as a factory worker. The patient had a full code status of Contrast Dye allergy. The history records reflected an altered mental state, and dementia and frustration were noted, hypertension, Gastroesophageal Reflux Disease (GERD), and Stage 4 chronic kidney disease. Blindness in the left eye was detected, but no challenges were observed with hearing. The patient denies any pain, can move with minimal assistance, has a good appetite, and shows the adjustment to aging since his hobby is spending time with his grandchildren.

The patients respiratory rate was regular, with 96% and 97% oxygen levels in the morning and afternoon. The patient expressed challenges with urination. The skin integrity was normal for his age. However, the patient needs assistance with a bed bath and oral care. The patient has no sexual observations noted but complained of penile discharge. Psychologically, the patient received no support from the family but interacted well with the hospital staff. The lab results showed RBC clotting with a result of 3.45 while the normal range is 4.35 to 5.65 and a stroke risk since the result for autoimmune was 1.8 while the normal range is 14-17.5 and monocyte levels were 10.8 while the normal range is 80-100,000. Mean Corpuscular Volume (MCV), Mean Corpuscular Hemoglobin (MCH), and Mean Platelet Volume (MPV) results reflected a normal condition.

Diagnosis

Urinary Tract Infection (UTI) is categorized into either complicated or uncomplicated and typically affects healthy people and people who do not have neurological or structural tract abnormalities. The infections are differentiated into lower or upper UTIs. UTI affects approximately 150 million people worldwide. The serious sequelae are recurrence of pyelonephritis with sepsis, pre-term birth complications, frequent antimicrobial use, and renal damage while still young. Prior infections, sexual activity, obesity, genetics, and genetic susceptibility are significant causes of the high incidence of TI cases (Kaufman et al., 2019). Complicated UTIs are associated with risk factors that compromise the urinary tract or the host defense, including urinary retention, urinary obstructions, renal failure, pregnancy, renal transplantation, and foreign bodies in the urinary tract, such as indwelling catheters.

The presence of indwelling catheters causes infections referred to as Catheter-Associated UTIs (CAUTIS), which are associated with high rates of mortality and morbidity. These are secondary bloodstream infections. Prolonged catheterization in old age, diabetes, and being female are risk factors for the development of CAUTIS (Pujades-Rodriguez et al., 2019). UTIs are caused by Gram-negative and Gram-positive bacteria and fungi, yeast. The most common cause for complicated and uncomplicated UTIs is the uropathogenic Escherichia coli(UPEC). There is a prevalence of saprophyticus,Enterococcus faecalis, Klebsiella pneumonia,Staphylococcus, group BStreptococcus(GBS),and Proteus mirabilis for uncomplicated UTI infections, Staphylococcus aureus, Pseudomonas aeruginosa,andCandidaspp. Complicated UTIs are caused by the prevalence of causative agents such as Candidaspp.,S. aureus, K. pneumonia, P. aeruginosa P mirabilis,Enterococcusspp.,and GBS (Murgia et al., 2018). Further, complicated UTIs are associated with urinary tract abnormalities, exposure to antibiotics, and indwelling catheters.

Patients who are asymptomatically suffering from UTIs are administered antibiotics that can result in long-term alteration of the normal micro biodata of the gastrointestinal tract with the development of microorganisms that are resistant to drugs (Chu & Lowder, 2018). The presence of areas that are not affected by changes in the micro biodata increases the risk of colonization with the drug-resistant microorganisms. Pathogens in the urinary tract colonize and adapt to the environment of the bladder, persist and disseminate in the urinary tract, and evade immune system surveillance.

Adherence to the pathogens is a core event at the initial stages of UTI pathogenesis. Typically, the infection begins with the infection of the periureteral by an uropathogen originating from the gut or other areas of contamination, such as a failing kidney, and then colonizing the urethra. Eventually, the infection migrates to the bladder. Multiple bacterial adhesins recognize the bladder epithelium and begin colonization (Gharbi et al., 2019). Since UPEC survives by invading the bladder epithelium, they produce proteases and toxins that synthesize siderophores to obtain iron. the colonization of the bladders epithelium, the pathogens subsequently advance into the kidneys, where they colonize the renal epithelium producing tissue-damaging toxins.

Complicated UTI infection begins when bacteria attach to a urinary catheter, a bladder stone, or a kidney stone or are held in the urinary tract due to physical obstruction. Pathogens, such as P. aeruginosa, P. mirabilis,andEnterococcusspp, cause complicated UTIs (Murgia et al., 2018). These uropathogens create a biofilm responsible for the persistence of the colonization. Such pathogens initiate the infection using pili to mediate adhesion to the hosts environmental surfaces (Chu & Lowder, 2018). They facilitate the invasion of the host tissue and promote the interbacterial interaction that creates the biofilm. Gram-negative bacteria, like E. coli, Proteusspp.,andHaemophilusspp., have a conserved family of adhesive chaperones that usher pathway pili.

The biofilm is formed after the type 1 pilus adhesin, FimH, binds mannosylated uroplakins actin bacterial and rearrangement and bacterial internalization through mechanisms activation that results in the activation of the RHO-family GTPases. UPEC can subvert host defenses in the host cell and resist antibacterial treatment. The defense system senses the Toll-Like Receptors 4 (TLR4) trigger the production of lipopolysaccharide (LPS) that induces cyclic AMP (cAMP) (Pujades-Rodriguez et al., 2019). This mechanism results in the vascular UPEC through the apical plasma membrane. However, UPEC subverts this defense mechanism by moving into the cytoplasm, where it multiplies, forming intracellular bacteria. These bacteria exist in an Intracellular Bacteria Community (IBC) that establishes a cycle that attacks new host cells.

The patient was experiencing small voiding that limited their ability to discharge urine whenever he had the urge. The urinary tract infections were apparent in the lower and the upper tracts. Structural abnormalities such as infected cysts, renal abscesses, and calculi. Laboratory inspection of a urine sample to determine if complicating factors were associated with the patients structural, metabolic, and functional conditions. Examples of complicating factors include poorly controlled diabetes, chronic obstruction, indwelling urinary catheter, nephrolithiasis, chronic renal insufficiency, immunosuppression, and pregnancy (Gharbi et al., 2019). Since there was no observable sexual activity by the patient, infection resulting from sexual activity was ruled as the source of infection. Being an elderly patient, the complicating factors are deemed a possible cause of the infections. Consequently, the tests on blood cultures were required since the patient was dehydrated and there was suspicion of pyelonephritis presence, and the patient was suspected to be immunocompromised. The patients history of hypertension raised this suspicion, Gastroesophageal Reflux Disease (GERD), and Stage 4 chronic kidney disease.

The patient also displayed signs of being confused and frustrated. Thus, the patients responses cannot be relied on primarily to determine a treatment plan. The lab results showed RBC clotting with a result of 3.45 while the normal range is 4.35 to 5.65 and a stroke risk since the result for autoimmune was 1.8 while the normal range is 14-17.5 and monocyte levels were 10.8 while the normal range is 80-100,000. Mean Corpuscular Volume (MCV), Mean Corpuscular Hemoglobin (MCH), and Mean Platelet Volume (MPV) results reflected a normal condition. The history of the kidney was the source of the infection since it had advanced to the administration of antihypertensives with the increase in blood pressure.

The evaluation of the medical list, due to the absence of urinary output, barely dripping, intermittent catheterization is recommended. This intervention will purpose to reduce the CAUTIs. To prevent the development of CAUTIS, intermittent catheterization is considered the preferred long-term management (Beahm et al., 2017). Since the patient is elderly with contributing factors from their hypertension medical history, this intervention will ensure post residual voids greater than 300 mL. scheduled voiding to prevent bladder overdistention. Evaluation of the medical list, Prazosin, Flomax, Latanoprost, and Heparin are prescribed to lower the blood pressure, relax the bladder, increase visibility in the left eye, and inhibit reactions that result in blood clotting.

Nursing Process

The nursing process approach considers the evidence from laboratory results and the ideal understanding of health by the patient. The nursing process will aim to help the patient urinate by keeping a schedule, voiding the bladder by himself, and subsequent patient dismissal (Ignatavicius et al., 2021). Following the five stages of the nursing process requires assessment, diagnosis, planning, implementation, and evaluation towards accomplishing the nursing responsibilities accordingly (Pinkerton et al., 2020). This process is predicated on providing scientific evidence and sharing information on the possible interventions with the patient and their family to establish an optimal care framework.

The patient was oriented person and place at x3, calm and cooperative, Pulse rate of 80, rate of respiration of 18; responsive through speech; Temperature of 36.6 degrees; SpO2 of 96%, blood pressure of 121/59. He denies a history of smoking with bilateral breath sounds; the oral mucous membranes are pink and moist. Foley Cath snatched out by patient; incontinence; zero BM; auscultated bowel sound x4 quadrant; Failed indwelling foley catheter 2/6/22, normal skin turgor for age; foley pulled...…( ) white patches ( )

Dentures( ) Edentulous ( ) Difficulty Swallowing ( )

Nausea or Vomiting ___None Noted_____

Therapeutic Diet: ____Cardiac Diet________

Appetite: Good ( x) Poor ( ) NPO ( )

Percentage of Food eaten; breakfast _25%-50%__ Lunch _50%-70%__

Related labs: ____________________________

REGULATION (NEUROLOGICAL)

Ex.: Reports of weakness, seizures, residual effects

Of CVA, etc.

Denies weakness; Dementia/confusion noted.

Temperature Morning 36.6__ Lunch 36.5

Blood glucose

Morning ___110___ Lunch __117___

(x ) Alert ( ) Cooperative ( )Lethargic ( ) Withdrawn

( ) Agitated ( ) Unable to assess mental status

( ) Unresponsive __________________________

Speech: ( x) Clear ( ) Aphasic ( ) Dysphasia ( ) Slurred ( )

Orientation: Person (x ) Place (x ) Time ( )

Disoriented: Person ( ) Place ( ) Time ( ) Reoriented (x )

Other ___________________________________________

Related Labs____Glucose________________

STIMULATION

Ex.: Vision, hearing

Stated L eye blindness; denies any problems with hearing

Pupils: Equal (x) Round (x ) Reactive light R ( ) L ( ) Accommodation R ( ) L ( )

Drainage: ___None Noted____

Glasses/Contact Lenses ___N/A______

Artificial eye ______N/A___________

Visual inspection of the ear

Hearing ______Adequate Not Noted_____

Drainage ____N/A_________

Subjective

Objective

COMFORT (PAIN)

Ex.: Report of pain, quality, location, duration, etc.

Denies any pain or discomfort

Facial grimacing, guarding of the affected area, etc.

Pain Scale (0 1) ___0___

If pain radiates: Location ___None Noted___

Nonverbal signs and symptoms of pain:

Simple direction patient able to turn and position self.

Interventions: Assist x1; Turned every 2 hours.

ACTIVITY/REST

The patient states, I can help.

ROM Active in all extremities (X ) Weak hand grip R ( ) L ( )

Upper extremity weakness/immobility R ( ) L ( )

Lower extremity weakness/Immobility R ( ) L ( )

Paralysis-Location _________________________________

Ambulates with (x ) assistance ( ) without assistance

Cane ( ) Walker ( ) Crutches ( ) W/C ( )

Prosthesis __N/A____ADLs_________________

Needs Assistance: Minimum (x ) Moderate ( ) Maximum ( )

Total Bedrest (x ) Up in Chair ( )

Fall Score ____

Labs: ____________________________________

ELIMINATION

Ex.: Bowel habits, voiding pattern, hemorrhoids.

Denies constipation; Last BM 2/5/2022; Failed indwelling foley catheter 2/6/22; foley pulled out; Small amount of bleed noted.

Urine: Continent ( ) Incontinent ( ) Absent ( x)

Urine Color: Straw ( ) Amber ( ) Hematuria ( ) Clear ( x) Cloudy ( ) Foul Odor ( ) Sediment ( )

other __________________________________

Foley (x ) Dialysis ( ) Type __Indwelling foley___

Shunt Assessment: Bruit ( ) Thrill ( )Genitalia: Tendness/Swelling/Discharge _Small amt of blood noted__

Bowel Sounds: Present/Active X 4 Quadrants ( x) Diminished ( ) Abdomen: Soft (x ) Firm ( ) Distended ( ) Tender ( ) Location________________________________

Bowel: Continent ( ) Incontinent (x) diarrhea ( )

Constipation ( )

Description of Stool: __None noted______

Intake __237 mL__ Output __Not noted___

(Indicate period of time) Last BM_2/5/202___

Related labs and tests________________________

SAFETY (includes integumentary)

Risk for falls, breakdown, depression, hearing, vision impairment, ambulatory devices

Assist x1; side rails up x3; Bed low, locked position.

Skin Temperature: Warm (x ) Cool ( ) Dry ( )

Diaphoretic ( )

Skin Turgor: Normal for age ( x) Tenting ( )

SKIN INTEGRITY describe lesions, wounds, pressure areas, or any breakdown _None Noted________

Abnormal Color: Describe, location __None Noted__

Skin Turgor: Normal for age (x ) Tenting ( )

Edema: Pitting ( ) 1+:2 mm ( ) 2+ 4mm ( ) 3+ 6 mm ( ) 4+ 8mm ( ) Location _____________________________

Braden Score____________ Fall Score_________

Related labs and tests______________________

HYGIENE

Ex.: Ex.: Reported inability to perform ADL, etc. Reports of ability to assist with hygiene, etc.

Assisted with bed bath and oral care.

Hygiene Observed: Secretions, odor, skin integrity, general appearance, etc.

Independent ( ) Requires Assistance (x )

Total Care ( )

PSYCHOSOCIAL (EMOTIONAL REACTIONS) (FAMILY PATTERN ALTERATIONS)

Ex.: Describe support system, response to stress, etc.

Zero support was noted from the family.

Observed non-verbal behavior, interactions with significant others, etc.

The patient interacts appropriately with hospital staff.

SEXUAL (SEX)

Ex.: F: Last pap smear, self-breast exam, LMP, description of the menstrual cycle, menopause, etc.

M: Penile discharge, complaints, etc.

Sexual Observations

No sexual observations were noted.

TEACHING/LEARNING patient identifies

The patient voiced no teaching/ learning opportunity.

TEACHING/LEARNING you identify

Maintain fluid & electrolyte balance; Educate patient on how important keeping the Foley catheter in place.

DISCHARGE PLANNING you identify

Patient successful on the foley; urinate on his own.

Appendix B: Medication List

Drug Name

Generic/Trade

Classification

Dose

Route

Time

Indication

(Uses)

Action

Side Effects

Nursing Implications

Heparin 5,000u

Anticoagulant

1mL

SubQ

q 8 hrs

Treat blood vessels, heart, and lung

Inhibits reactions that lead to clotting blood and formation of fibrin clots

Abdominal pain

Monitor tightness of the throat

Latanoprost 0.005%

Prostaglandin

One gtt

Ophthalmic

Once-daily

Treat glaucoma

Increase IOP

Changes in the eye color

Increased pigmentation

Lipitor

HMG-CoA Inhibitor

40mg

PO

QHS

Treat cholesterol

Decrease cholesterol

Joint pain

Monitor chest pain

Singulair

Leukotriene receptor antagonist

10mg

PO

QHS

Prevent asthma attacks

Reduces the risk of asthma flare-ups

HA, cough

Take meds same time each day

Prazosin

Alpha Blocker

2mg

PO

QHS

Treat HTN

Lower BP

HA, N/V

Monitor BP and pulse rate

Seroquel

Atypical antipsychotics

25mg

PO

TID

Restore balance in the brain

Decrease hallucinations

Weight gain, dry mouth

Severe CNS depression

Flomax

Alpha-Blocker

0.8

mg

PO

Every meal

Improve urination

Relaxes muscles in the prostate and bladder

Problems with ejaculation

Get up slowly when rising

Valproic Acid 500mg

Anticonvulsants

10 mL

PO

BID

Mental/ Mood

Treat seizures

Diarrhea, hair loss

Monitor for clotting defects

Cipro

Fluoroquinolones

500 mg

PO

BID

Treat bacterial infections

Inhibits DNA replication

N/V, pale skin

Avoid breastfeeding

Amlodipine

Calcium Channel blocker

2.5

Mg

PO

QD

Treat…