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story of Present Problem:

Jean Kelly is an 82-year-old woman who has been feeling more fatigued the last three days and has had a fever the last twenty-four hours. She reports a painful, burning sensation when she urinates as well as frequency of urination the last week. Her daughter became concerned and brought her to the emergency department (ED) when she did not know what day it was. She is mentally alert with no history of confusion. While taking her bath today, she was weak and unable to get out of the tub and used her personal life alert button to call for medical assistance.

The nurse collects the following data:

T: 101.8 F/38.8 C (oral)
P: 110 (regular)
R: 24 (regular)
BP: 102/50
O2 sat: 98% room air

 

Pain Scale:

Provoking/Palliative: Nothing/Nothing
Quality: Ache
Region/Radiation: Right flank
Severity: 5/10
Timing: Continuous

 

The nurse recognizes the need to validate his/her concern of fluid volume deficit and performs a set of orthostatic VS and obtains the following:

Position: HR: BP:
Supine 110 102/50
Standing 132 92/42

 

Current Assessment:  
GENERAL APPEARANCE: Resting comfortably, appears in no acute distress
RESP: Breath sounds clear with equal aeration bilaterally, nonlabored respiratory effort
CARDIAC: Pink, warm and dry, no edema, heart sounds regular-S1S2, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks
NEURO: Alert and oriented x2-is not consistently oriented to date and place, c/o dizziness when she sits up
GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants
GU: Dysuria and frequency of urination persists, right flank tenderness to gentle palpation
SKIN: Skin integrity intact, lips dry, oral mucosa tacky dry

Once relevant clinical data is recognized, now the nurse needs to do something. The following four questions close out this brief clinical reasoning journal.  Answer the 4 questions then respond to 2 classmates discussion post.

What is the primary problem that your patient is most likely presenting?
What nursing priority(ies) will guide your plan of care? List at least 3 nursing priorities.
What nursing diagnosis will guide your plan of care? List at least 3 nursing diagnosis.
What interventions will you initiate for each nursing diagnosis? List at least 5 interventions for each nursing diagnosis.
What medications do you anticipate administering? 
What educational/discharge PRIORITIES will be needed to develop a teaching plan for this patient and/or family?

 

SCIENCE
HEALTH SCIENCE
NURSING
NURSING 112

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