The nursing process: framework and clinical application

Nursing 201 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 patient’s 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 B Streptococcus (GBS), and Proteus mirabilis for uncomplicated UTI infections, Staphylococcus aureus, Pseudomonas aeruginosa, and Candida spp. Complicated UTIs are caused by the prevalence of causative agents such as Candida spp., S. aureus, K. pneumonia, P. aeruginosa P mirabilis, Enterococcus spp., 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 bladder’s 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, and Enterococcus spp, 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 host’s 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, Proteus spp., and Haemophilus spp., 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 patient’s 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 patient’s 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 patient’s 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 out; a small amount of bleed noted. Capillary refill 1-2 sec. no edema was noted; sleep; comfortable environment; even RR noted; a positive range of motion was observed and sensitivity of lower and upper extremities. No sputum or cough, nausea, or vomiting was noted. The left had blindness; adequate hearing was not noted. The patient was able to make simple direction turns and position himself. Denies weakness but admits the need for minimal assistance ambulating; soft abdomen; assisted with bed bath and oral care. Zero support was noted from the family but interacts well with the hospital staff; maintained fluid & electrolyte balance; patient denies discomfort but requires x1 assistance; turning every 2 hours. Bed low, locked position; side rails up x3. No sexual observations were noted (See Appendix A).

The eighth stage of Erik Erickson’s development of man, integrity versus despair, is applicable since the patient is 80 years old (Gilleard, 2020). The core concern in this stage is whether the individual has led a satisfactory life. Therefore, the contrast is that one might be egotistical and deny aging. Despair and wisdom are the foundational determinants if the patient has psychological conflict. Since this stage begins at 65 years and the patient is 80 years old, he is presented with core life changes that reflect life. The core virtue is wisdom, where individuals are accepted, have a feeling of wholeness, lack regret, and are at peace (Gilleard, 2020). The patient is forced to face their ideals of morality. The patient desired to work with the military and ended up as a factory worker; however, the perception of the wholeness of life is not limited to his career; rather, he enjoys playing with his grandchildren. The denial of loss of hearing and withdrawal of the foley display a sense of bitterness. The interventions to this challenge will involve educating the patient on why keeping the catheter in place is important.

Nursing Diagnoses Prioritized

Urinary retention is related to the interruption of the lateral spinal tract. The interruption of the lateral spinal tract is evidenced by residual urine, dribbling of urine, and small voiding. Complect UTI is evidenced by 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. UTI infection is related to a possible foley catheter being pulled out. The increase in the blood pressure results from antihypertensives being effective but was necessitated by the decline of the renal absorption rates.

Caring Interventions

The caring interventions will perform sterile or clean intermittent catheterization as a short-term goal to offer the patient relief. After determining the treatment plan, the immediate goal is to help the patient consistently urinate by discharge. If the amount of discharge is above 300mL, a urine culture will be sent to the laboratory to determine if the patient should begin antimicrobial therapy (Kaufman et al., 2019). The onset of the care plan should be characterized by the concern for the well-being of the patient in the short-term and the long term. The development of a rapport should be considered for the patient’s contribution and the nurse showing respect and compassion towards the patient. The cause of the infection is suspected to be the withdrawn foley, although the history of chronic disease is a predetermining factor UTI infection. To work towards optimal health, developing a good rapport with the patient is critical to ensure effective communication in treatment, especially after the patient’s catheterization, to ensure they understand its importance ((Pujades-Rodriguez et al., 2019). Good rapport is founded on showing compassion towards the patient, making the nurse more observant of the care environment, and applying their critical thinking skills to determine strategies towards realizing optimal care.

Therefore, the initial stages of interaction with the patients should be carried out diligently through keen listening to incorporate information gathered into the nursing process. For example, he would like assistance to integrate assisted dining and bathing into the nursing process.

Medications

As prescribed in Appendix B, the recommended mediation contains all the medication prescribed, dose, side effects, actions, and interactions.

Diagnostic Test Results and Lab Information

Appendix C discusses lab results and the diagnostic concerning UTIs.

Diet and Nutrition

The patient was on a cardiac diet on admission, and due to discomfort, assistance with feeding was necessitated. Upon admission, he weighed 119 pounds, had no dentures, and had a good appetite was noted. However, the patient’s mouth was pink but not moist, no vomiting or nausea was noticed. All feeding activities involved the patient’s assistance with feeding, which he tolerated well. The management of the challenges associated with creating a common goal makes it possible for the corporation to address these difficulties. All the consumption was 100% liquid. Besides the limitation with feeding himself, he consumed 25%-50% of breakfast and 50% -70% of lunch.

Physical and Psychosocial Response to Treatment

The patient expressed discomfort by the withdrawal of the foley catheter. The patient was in denial of their limited hearing ability that was not observable, and any discomfort or pain. While there were no verbal or signs of pain, the patient was limited in motion, even though he could make minor adjustments; after every two hours, minimal assistance would be required. The patient expressed he enjoys his grandchildren. Even though the patient desired to have served in the military, he worked in the factory but did not resent him. He was cooperative with the hospital staff and remained calm. However, confusion had been noticed, dementia, and denies weakness. His religion is unknown, and he does not display religious behavior.