UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

FUNDAMENTAL PATIENT ASSESSMENT TOOL Student: Vanessa Rushing

Assignment Date: 7-21-2016
.
Agency: LRH
 1 PATIENT INFORMATION
Patient Initials: JWL Age: 81 Admission Date: 7-19-2016
Gender: Male Marital Status: Married Primary Medical Diagnosis: UTI, Generalized
Weakness, Pain in Lower Extremities
Primary Language: English
Level of Education: High School Other Medical Diagnoses: (new on this admission)
Occupation (if retired, what from?): Retired Minister No new medical diagnoses on this admission
Number/ages children/siblings: Children (4): Ages-59, 54, 49,46.
Siblings (2): Ages 85, 71(deceased).
Served/Veteran: US Marine Corps Code Status: Full
If yes: Ever deployed?- No
Living Arrangements: Lives at home with wife as main caregiver. Advanced Directives: No
If no, do they want to fill them out? No
Surgery Date: N/A to this admission
Procedure: N/A to this admission
Culture/ Ethnicity /Nationality: American, American Indian
(Cherokee).
Religion: Baptist Type of Insurance: Humana

 1 CHIEF COMPLAINT: “I had extreme pain my lower extremities. They said it was probably because of
this UTI or bladder infection or both. I was feeling really weak as well and I am a strong man for my age so I came in to
see what was going on,”.

 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
The patient is an 81 year old male who was admitted on 7/19/2016 to the ER for a UTI, generalized weakness, and lower
extremity pain. The patient was admitted to the Palliative Care floor to control symptoms of the UTI and manage pain of
the lower extremities. The patient’s history of brain hemorrhages and prostate cancer made him a candidate for the floor.
Patient received a urinalysis which showed some blood in the urine. The patient is now on Levofloxacin to treat the
UTI, Hyoscyamine to treat bladder spasms, and Acetaminophen to treat mild pain.
O-Pain/Weakness started last week
L-Pain-lower extremities, Weakness-whole body
D-Pain-Comes and goes, weakness- constant
C-Pain-sharp and intense
A-Pain-Moving legs, Weakness- Movement
R-Pain Medications
T- Tried heat/ice for pain with no relief
S-Pain- Currently 3/10, Before medications- 8/10

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  2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date Operation or Illness
2001 Removal of cancerous prostate
1995 Brain Hemorrhage (1)
11/2015 Brain Hemorrhage (2)
02/2016 Urinary Tract Clean Out Procedure-Catheter Insertion
Unknown Bilateral cataract surgery
05/2015 Bladder Resection Transurethral
07/02/2016 Bladder Resection Transurethral (2)
Age (in years)

2

Kidney Problems
Environmental

Trouble

Health

Stomach Ulcers
Bleeds Easily

Hypertension
Cause

etc.)
FAMILY
Alcoholism

Glaucoma
Diabetes
Arthritis

Seizures
Anemia

Asthma

of Cancer

Tumor
Problems

Stroke
Allergies

MI, DVT
MEDICAL

Gout
Death

Mental
Heart
HISTORY (if

(angina,
applicable
)
Brain
Father 82
Cancer
Liver
Disease
Mother 67 due to
Alcoholis
m
Brother 85 N/A
Sister 71 COPD
relationship

relationship

relationship

Comments: Include age of onset

Sister: Heavy smoker, substance abuser. Unknown age of onset.

 1 IMMUNIZATION HISTORY
(May state “U” for unknown, except for Tetanus, Flu, and Pna) YES NO
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus (Date) Is within 10 years?
Influenza (flu) (Date) Is within 1 years?
Pneumococcal (pneumonia) (Date) Is within 5 years?
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 Have you had any other vaccines given for international travel or
occupational purposes? Please List
If yes: give date, can state “U” for the patient not knowing date received

 1 ALLERGIES
NAME of
OR ADVERSE Causative Agent
Type of Reaction (describe explicitly)
REACTIONS
Aspirin N/A-Patient could not remember, not in chart
Lipitor Muscle Weakness
NSAIDS N/A-Patient could not remember, not in chart
Medications
Topamax Delirium

N/A
Other (food, tape,
latex, dye, etc.)

 5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to
diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or
treatment)
A Urinary Tract Infection (UTI) is caused by infecting microorganisms Escherichia coli and Staphylococcus
saprophyticus. The bacterial contamination of the urine occurs by retrograde movement of gram-negative bacilli into the
urethra and bladder and can go further on to the ureter and kidney’s. Clinical manifestations include frequency, urgency,
Dysuria, suprapubic pain, and lower back pain. In more serious infections hematuria, cloudy urine, and flank pain are
Symptoms that a patient can experience. Risk factors for a UTI include urinary tract obstruction, weakened immune
System, kidney stones, diabetes, and urinary tract defects. Diagnoses is done by urine culture of specific microorganisms
With counts of 10,000/ml or more from freshly voided urine. Treatment for a UTI includes being placed on a
Microorganism specific antibiotic. The amount of time that a person can be on this antibiotic differs based on the type of
UTI and how severe the infection is. The most common amount of time is 3-7 days treatment. The prognosis of UTI’s is
Commonly over after treatment with antibiotics but some people are prone to have recurring UTI’s due to age or other
Medical ailments.

 5 MEDICATIONS: [Include both prescription and OTC; hospital , home (reconciliation), routine, and PRN medication (if
given in last 48°). Give trade and generic name.]
Name: Dexamethasone Concentration: 50pg/ml Dosage Amount: 0.5 mg (1 Tab)
Route: Oral Frequency: Daily
Pharmaceutical class: Corticosteriod Home Hospital or Both
Indication: Management of inflammatory and allergic ophthalmic processes.
Adverse/ Side effects: Vision changes, bruising, swelling, headache, dizziness, muscle weakness, bloating, dry skin, acne, sweating, HTN, hypokalemia
Nursing considerations/ Patient Teaching: Do not receive a “live” vaccine, do not take if fungal infection present, do NOT stop taking suddenly

Name: Hydrocortisone topical Concentration: 2.5% Dosage Amount: 1 app

Route: Topical Frequency: PRN, Daily at bedtime

Pharmaceutical class: Glucocorticoid
Home Hospital or Both
Indication: Treat inflammation
Adverse/ Side effects: Thinning of skin, headaches, nausea, trouble sleeping, stretch marks, increased sweating
Nursing considerations/ Patient Teaching: Apply at bedtime, stop using at signs of allergic reaction

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Name: Hyoscyamine Concentration: Dosage Amount: 1 tab, 0.125 mg

Route: oral Frequency: PRN, 4x daily

Pharmaceutical class: Central muscarinic antagonist Home Hospital or Both

Indication: Bladder spasms
Adverse/ Side effects: Tachycardia, blurred vision, anxiety, memory loss, dry mouth, itchiness, hives, swelling
Nursing considerations/ Patient Teaching: Avoid hot temperatures, do not drive or operate machinery, watch for symptoms of mental disturbances

Name: Lisinopril Concentration Dosage Amount: 1 tab, 2.5mg

Route: oral Frequency:Daily

Pharmaceutical class: ACE inhibitor Home Hospital or Both
Indication:Treat HTN
Adverse/ Side effects: Dark urine, sore throat, chills, dizziness, nausea, vomiting, confusion, weakness
Nursing considerations/ Patient Teaching: Stand or sit up slowly to avoid hypotension, do not stop taking this medication without doctors notice

Name: Levofloxacin Concentration: 100mL/hr Dosage Amount: 750 mg

Route: IV, IVPB, Frequency: q24h

Pharmaceutical class: Fluoroquinolone Home Hospital or Both

Indication: Treats infections
Adverse/ Side effects: mild headache, mild nausea, blistering/peeling skin, dark urine, dizziness, diarrhea, loss of appetite
Nursing considerations/ Patient Teaching: Wear sunscreen, medicine may cause tendonitis, do not drive or operate machinery

Name: Acetaminophen Concentration Dosage Amount: 650 mg

Route: oral Frequency: PRN

Pharmaceutical class: Analgesic Home Hospital or Both
Indication: Mild Pain
Adverse/ Side effects: Dark urine, loss of appetite, vomiting of blood, light-headedness, itching, hives, swelling
Nursing considerations/ Patient Teaching: Read labels of OTC to check doses

Name: Docusate Concentration Dosage Amount:100mg

Route: oral Frequency: PRN, bid

Pharmaceutical class: Stool softener Home Hospital or Both
Indication: Constipation
Adverse/ Side effects:Bitter taste, bloating, gas, nausea, vomiting, swelling
Nursing considerations/ Patient Teaching: Discontinue if rectal bleeding occurs

Name: Nitroglycerin Concentration: 50mcg/mL (IV) Dosage Amount: 0.4 mg (1 tab)

Route: Sublingual Frequency: PRN

Pharmaceutical class: Antianginal Home Hospital or Both
Indication: Treat/prevent chest pain
Adverse/ Side effects:Trouble breathing, increased chest pain, ongoing headache, itching, hives, swelling
Nursing considerations/ Patient Teaching: headaches go away with time, if after 15 minutes angina does not go away go to hospital immediately

Name Concentration Dosage Amount

Route Frequency
Pharmaceutical class Home Hospital or Both
Indication

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Adverse/ Side effects
Nursing considerations/ Patient Teaching

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 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Regular Analysis of home diet (Compare to “My Plate” and
Diet patient follows at home? Regular Consider co-morbidities and cultural considerations):
24 HR average home diet: - According to My Plate the patient consumes too
Breakfast: 2 eggs scrambled, small bowl of grits, 2 slices Much sodium and sugar for his age, height, and weight
bacon, 1 cup of coffee, 2 slices toast with strawberry jelly And not enough fruits or vegetables. His protein intake
Lunch: Glass of sweet tea, sandwich on white bread with Is at a good level but is advised to stay away from
ham, chicken, 1 slice of cheese and mayonnaise. Panera processed or excessively fatty meats. Recommended is 2
Bread at times. cups of fruit a day which can be consumed at breakfast
Or as a snack (instead of ice cream!). Vegetables should be
Dinner: Dr. Pepper (can), steak, vegetables (broccoli or Included with 2.5 cups and should vary. Grains should be
carrots). consumed with 6 ounces and the patient is advised to
consume whole grains more. The patient should also be
Consuming more dairy according to My Plate but since the
patient is experiencing constipation it is not advised to
consume excessive amounts of dairy.
Snacks: M&M’s candies, ice cream Sodium should be limited to 2,300mg a day and sugars
Limited to 50mg a day.
Liquids (include alcohol): Sweet tea, water, Dr. Pepper,
coffee in the morning.

Use this link for the nutritional analysis by comparing the patients
24 HR average home diet to the recommended portions, and use
“My Plate” as a reference.

 1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? Wife

How do you generally cope with stress? or What do you do when you are upset? The patient states “I put it (stress) out of
my head, I pray about it, and I ask the lord to help and guide my way through this tough and stressful time,”.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life). Patient denied
Any recent difficulties like depression, anxiety, feeling overwhelmed. Patient denies any troubles with relationships,
friends, or social life.

+2 DOMESTIC VIOLENCE ASSESSMENT

Consider beginning with: “Unfortunately many, children, as well as adult women and men have been or currently are
unsafe in their relationships in their homes. I am going to ask some questions that help me to make sure that you are
safe.”

Have you ever felt unsafe in a close relationship? No.

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Have you ever been talked down to? __No __. Have you ever been hit punched or slapped?__No__.
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you? __No__.
If yes, have you sought help for this? __No__.

Are you currently in a safe relationship? Yes.

 4 DEVELOPMENTAL CONSIDERATIONS:
Erikson’s stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry vs.
Inferiority Identity vs. Role Confusion/Diffusion Intimacy vs. Isolation Generativity vs. Self absorption/Stagnation Ego Integrity vs. Despair
Check one box and give the textbook definition (with citation and reference) of both parts of Erickson’s developmental stage
for your
patient’s age group: According to Treas (2014) “The task of this stage is the acceptance of one’s life, worth, and eventual death. Ego
integrity reflects a satisfaction with life and an understanding of one’s place in the life cycle. A sense of loss, discomfort with life and
aging, and a fear of death are seen in despair,”. (pg. 164).

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
My patient is currently in the final stage called Ego Integrity Versus Despair. In this stage of life a person who is above
the age of 65 is battling whether they lived their life fully and are now accepting of death or are becoming more
Unsettled with the idea of dying and feel a sense of loss or that there life is unfulfilled. My patient leaned more towards
the ego integrity side of his stage. My patient was joyful, talkative, and very in love all while sitting in his hospital
bed day after day. My patient was not scared of death, in fact it was welcomed as a new adventure. My patient joked
about his age and seemed accepting of the fact that he was getting older.
Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life:
The impact that my patient’s hospitalization/condition had on my patient’s stage of life made it easier to accept the aging
Process and all that comes along with it. My patient was able to understand that death is a part of life.

+3 CULTURAL ASSESSMENT:
“What do you think is the cause of your illness?”- The patient states “I think the cause is because of the internal problems
with my bladder and muscles. I have no more strength anymore. I used to be a fairly strong man but those brain
hemorrhages really got me,”.

What does your illness mean to you? The patient states “It means that I am dependent on other people, I can’t do what I
want to do, and I can’t go home,”.

+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Consider beginning with: “I am asking about your sexual history in order to obtain information that will screen for
possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.
All of these questions are confidential and protected in your medical record”

Have you ever been sexually active? __Yes__.

Do you prefer women, men or both genders? __Women__.
Are you aware of ever having a sexually transmitted infection? __No__.
Have you or a partner ever had an abnormal pap smear? __No__.
Have you or your partner received the Gardasil (HPV) vaccination? __No__.

Are you currently sexually active? __No__. If yes, are you in a monogamous relationship? __N/A__. When sexually
active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended pregnancy?
__N/A__.

How long have you been with your current partner? __61 Years__
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Have any medical or surgical conditions changed your ability to have sexual activity? ___Yes__.
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No.

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±1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life? The patient states “my religion is supremely important in my life,”.

Do your religious beliefs influence your current condition? Patient denies that religious beliefs influence current condition.

+3 SMOKING, CHEMICAL USE, OCCUPATIONAL/ENVIRONMENTAL EXPOSURES:

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No
How much?(specify daily amount) For how many years? X years
If so, what? N/A
N/A N/A
(age thru )

If applicable, when did the

Pack Years: N/A
patient quit? N/A

Does anyone in the patient’s household smoke tobacco? If Has the patient ever tried to quit? N/A
so, what, and how much? No If yes, what did they use to try to quit? N/A

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? N/A How much? N/A For how many years? N/A
Volume: (age thru )
Frequency:
If applicable, when did the patient quit?
N/A

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No
If so, what? N/A
How much? N/A For how many years? N/A
(age thru )

Is the patient currently using these drugs? If not, when did he/she quit?
Yes No N/A

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks. No

5. For Veterans: Have you had any kind of service related exposure? No.

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 10 REVIEW OF SYSTEMS NARRATIVE

General Constitution (OLDCART anything checked above)

How do you view your overall health? Patient states “It has been better I’ll admit but I just want to get better fast,”.

Integumentary: No changes in appearance of skin, no problems with nails, no dandruff, no psoriasis, no

hives or rashes, no skin infections, uses sunscreen whenever in the sun for long periods of time SPF 50.
HEENT:. Difficulty seeing in the dark, cataracts were removed, no difficulty hearing, no ear infections, no
sinus pain or infections, no nose bleeds, no post-nasal drip, no oral infections, no dental problems, brushes
teeth 2x a day, sees dentist 2x a year, has vision screenings annually.
Pulmonary: No difficulty breathing, small productive cough, no asthma, no bronchitis, no emphysema, no
pneumonia, no TB, no environmental allergies.
Cardiovascular: Patient is hypertensive, patient has hyperlipidemia, patient has chest pain/angina-O-
Patient does not remember, L-Chest, D-Intermittent, C-Intense, A-Too much walking or movement, R-
Nitro, lying down, resting, T-Nitroglycerin, resting, S-8/10. No history of MI, no CAD, no CHF, no
murmurs, no thrombus, no rheumatic fever, no myocarditis, no arrhythmias, last EKG screening-2015.
GI: Patient does have indigestion at times, Last colonoscopy was in Fall 2015.
GU: Patient does have nocturia, dysuria, hematuria, polyuria, and a bladder infection. All of these- O-1 week
ago, L-Bladder/GU system, D-Constant, C-burning, A-Associated with the UTI, R-catheter helps with pressure
and polyuria, T-antibiotics, S-4/10
Women/Men Only: Patient has had prostate removed due to cancer.
Musculoskeletal: Patient has weakness/pain (oldcart in HPI), past fracture in arm.

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Immunologic: Patient does not have a fever, no HIV/AIDS, no lupus, no rheumatoid arthritis, no sarcoidosis, no
tumor, no life threatening allergic reactions, no enlarged lymph nodes.
Patient does experience chills and night sweats. O-1 week ago, L-Whole body, D- Comes and goes, C-shaky, A-Associated with UTI,
R-Antibiotics, T- Antibiotics, S-5/10.
Hematologic/Oncologic: Patient did have prostate cancer, prostate has since been removed in 2001. Patient does
not bleed or bruise easily, no anemia, and patients’ blood type is O+.
Metabolic/Endocrine: No Diabetes, no hypo/hyperthyroidism, no intolerance to heat/cold, no osteoporosis
Central Nervous System: Patient has experienced 2 brain hemorrhages. The first in 1995, the second in 2015. No
migraines, seizures, ticks or tremors, no encephalitis, meningitis,
Mental Illness: No depression, no schizophrenia, no anxiety, no bipolar disorder.
Childhood Diseases: Patient did have measles and mumps- age unknown. Patient did not have polio, scarlet
fever, or chicken pox.

Is there any problem that is not mentioned that your patient sought medical attention for with anyone? No.

Any other questions or comments that your patient would like you to know? No.

±10 PHYSICAL EXAMINATION:

General survey: The patient is an 81 year old male who is alert and oriented x3. The patient is in no sign of distress or
discomfort and is in a cheerful and talkative mood.
Height: 173 cm Weight: 85.9 kg BMI:28 Pain (include rating and location) 3/10-Lower extremities Pulse: 85 Blood
Pressure (include location)136/73 mmHg, Left upper arm Temperature (route taken)98.6, oral
Respirations 17 SpO2 98% Room Air or O2: Room Air
Overall Appearance: Clean, maintains eye contact, no obvious handicaps, hair combed, dressed appropriately.
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Overall Behavior: Awake, calm, relaxed, interacts well with others, cooperative, judgement intact.
Speech: Clear, crisp diction.
Mood and Affect: Pleasant, cooperative, cheerful, talkative.
Integumentary: Skin is warm, dry and intact. No rashes, lesions, or deformities present. Capillary refill <3 seconds and
skin turgor is elastic. Hair is evenly distributed, smooth, normal coloring, and clean.
IV Access 20 Gauge in Right Hand. Inserted on 7-19-2016. No redness, edema, or discharge on IV site. Fluids infusing –
Normal Saline at 100mL/hour.
HEENT: Facial features are symmetric, no palpable lymph nodes, PEERLA intact, peripheral vision intact, EOM intact
through 6 cardinal fields of gaze, sclera is white and conjunctiva is clear with no discharge, ears are symmetric with no
lesions or abnormal discharge, nose is without lesions or discharge, mouth and tongue are pink and moist, lips are smooth
and intact, no clicking of TMJ
Pulmonary/Thorax: Lungs sounds heard, clear and equal bilaterally. Respirations are regular, unlabored, and no use of
accessory muscles. Chest expansion is symmetric. Slight cough present with sputum production. Sputum is thin and pale
yellow.
Cardiovascular: Heart sounds heard, no extra sounds heard. S1, S2 are audible and regular. No lifts, thrills or heaves
present. No murmurs, clicks, or adventitious sounds heard. Rate and Rhythm are normal and clear. Pulses are bilaterally
equal 2+ in radial and pedal pulses. Edema is not present anywhere. Extremities were warm with capillary refill < 3
seconds.
GI: Bowel sounds heard and active x 4 quadrants; no bruits auscultated. Abdomen is non-tender to palpation and patient
denies pain. Last bowel movement was 07/21/16 being semi-formed and light brown and normal for the patient.
GU: Urine output is cloudy and light yellow with some blood intermittently. Foley catheter inserted on 07-22-2016.
Genitalia is clean, moist, and without discharge or odors.
Musculoskeletal: Full ROM intact in all extremities without crepitus. Strength equal bilaterally in hands and feet rated 5.
Sensation is intact.
Neurological: Patient is alert and oriented x3 to person, place, and time. Sensation intact to touch, pain, and vibration. CN
2-12 grossly intact. Patient too weak to stand from UTI.

±10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as
abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):
Pertinent includes labs that are checked when on certain medications, monitored for the disease process, need
prior to and after surgery, and pertinent to hospitalization. Do not forget to include diagnostic tests, such as
Ultrasounds, X-rays, CT, MRI, HIDA, etc. If a lab or test is not in the chart (such as one that is done preop) then
include why you expect it to be done and what results you expect to see.

Lab Dates Trend Analysis

Urinalysis Macroscopic Upon admit, the patient’s The amount of infection
UA Appear: Cloudy (clear) urinalysis and urine fighting cells present in
UA Blood: 2+ (0)
UA pH: 7.5 (5.0-6.0)
All on 07-19-2016 culture test results all the patient’s urine
Microscopic pointed towards an indicates that there is an
UA WBC: Too numerous to infection with high infection present that is
count amounts of WBC’s in the being fought off. The
Urine culture urine and 10,000 CFU’s WBC count was too high
10,000 CFU/mL (Below
10,000)
in the urine. The WBC’s to count furthering the
are attempting to fight off fact that there is an
the infection present in infection in the urinary
the patient’s urinary tract. tract.

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+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet, vitals, activity, scheduled
diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
Diet: Patient is on a regular diet at the hospital and follows a regular diet at home. Patient has no need for special
Restrictions because he does not have dysphagia, diabetes, or severe cardiac problems.
Vitals: Patient has vitals checked every 4 hours which is the standard protocol for this floor on the hospital. The
Patient has vitals checked to watch blood pressure in case it spikes up and to watch heart rate to ensure it does not
Drop too low.
Activity: Patient is on bed rest due to foley catheter insertion and severe muscle weakness. This makes the
Patient a fall risk and too much activity can wear the patient out extremely.
Scheduled Diagnostic Tests: Patient is not scheduled for any diagnostic tests at this time.

 8 NURSING DIAGNOSES (actual and potential - listed in order of priority)

1. Impaired urinary elimination related to Urinary Tract Infection as evidenced by dysuria, frequency, urgency, and
Hematuria.

2.Fatigue related to poor physical condition as evidenced by generalized weakness.

3.Acute confusion related to Urinary Tract Infection as evidenced by fluctuations in cognition.

4. Acute pain related to UTI flank pain as evidenced by patient rates pain as a 6/10.

5. Risk for recurrent UTI’s related to past surgical history as evidenced by severe scar tissue in bladder.

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± 15 CARE PLAN
Nursing Diagnosis: Impaired Urinary Elimination r/t urinary tract infection aeb dysuria, hematuria, frequency, and urgency
Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
The patient will state absence of The nurse will administer the The patient will be receiving the The goal will be evaluated by
Pain, excessive urgency, and blood Antibiotics and pain medications Medications that are relieving the Asking the patient to rate their pain
During urination by the discharge As ordered. Pain and fighting off the infection On a scale of 0-10 and comment
Date. Present. On the urgency and blood in the
Urine.
Patient will demonstrate voiding The nurse will monitor the The nurse will be able to see how
Frequency no more than every Frequency that the patient the patient is progressing in terms The goal will be evaluated by
2 hours by the discharge date. Is voiding. Of voiding frequency and see if Asking the patient if the frequency
Any other interventions need to Of voiding pattern has lowered. If
yes, then the goal was met.
*Patient will recognize the signs The nurse will provide the patient Happen.
and
Symptoms of a UTI and retain With educational resources about
Knowledge of UTI prevention. UTI’s and provide the patient The patient will be able to prevent The patient will demonstrate back
With proper information. Further UTI’s with the knowledge To the nurse the knowledge of
Presented. The signs and symptoms of a UTI
Include a minimum of one And also relay the information of
Long term goal per care plan UTI prevention back to the nurse.
±2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
□SS Consult
□Dietary Consult
□PT/ OT
□Pastoral Care
□Durable Medical Needs
□F/U appointments
□Med Instruction/Prescription
 □ are any of the patient’s medications available at a discount pharmacy? □Yes □ No
□Rehab/ HH

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□Palliative Care

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 References

Huether, Sue E., McCance, Kathyryn L. (2012). Understanding Pathophysiology. St. Louis,

Missouri: Elsevier.

Hayes, Evelyn R., Kee, Joyce LeFever., McCuistion, Linda E. (2015). Pharmacology: A Patient-

Centered Nursing Process Approach. St. Louis, Missouri: Elsevier.

Treas, Leslie S., Wilkinson, Judith M. (2014). Basic Nursing: Concepts, Skills, and Reasoning.

Philadelphia, Pennsylvania: F.A. Davis Company.

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