Urosepsis Care Plan

Step 1 Assessment

• dark yellow, odorous urine
• pale dry skin
• poor skin turgor
• dry mucous membranes
• refusing liquids
• minimal appetite
• 140/98, hr=106
• weight 102-usually 115
• thin extremities
• minimal right leg movement
• unequal palmar grips-right weaker
• red 2 cm spot on right elbow
• oriented x2
• occasionally confused and disoriented in the past few months
• incontinent of bowel and urine in the past few weeks
• confined to bed

Step #2 Determination of the Patient's Problem(s)/Nursing Diagnosis

• Deficient fluid volume r/t loss of fluid AEB dark yellow, odorous urine, pale dry skin, poor skin turgor and dry mucous membranes
• Imbalanced nutrition: less than body requirements r/t inability to ingest food AEB weight of 102, thin extremities, minimal appetite (whatever that is, you need to be more specific about this)
• Total incontinence r/t dementia AEB unaware of incontinence of bowel and bladder
• Impaired physical mobility r/t ??? (need a cause here, probably her dementia) AEB minimal right leg movement, confinement to bed and unequal hand grips
• Impaired skin integrity r/t pressure and incontinence AEB stage ii ulcer on sacrum that is 2cm in diameter 1cm in depth and tender to touch and 2 cm red spot on the right elbow
• Acute confusion r/t ??? (probably dementia) AEB disorientation to ??? and confusion to ??? over the past few months

Step #3 Planning (write measurable goals/outcomes and nursing interventions)

Remember that your goals are a reflection and anticipation of what will happen when your nursing interventions are performed. So, think about what nursing interventions you will be doing when putting your goals together. Your nursing interventions target each of the AEB items of your diagnostic statements. Just as a doctor treats signs and symptoms of a disease, we also treat the symptoms of a nursing problem.

Nutritional imbalance of less than the body requires related to the refusal of fluids and minimal appetite as reported by the daughter, manifested by dark orderous urine, dry skin, and poor skin turgor.

• This is not an official Nanda diagnosis the way you have written it. i know what you mean, however.
• This diagnosis has to do with intake of nutrients insufficient to meet metabolic needs (page 74, Nanda international nursing diagnoses: definitions and classifications 2009-2011). dark ordorous urine, dry skin and poor skin turgor do not have anything to do with the intake of nutrients and are inappropriate symptoms to pair with this diagnosis.
• You also need to be more specific about a minimal appetite. we are scientific. report a percentage of what she is eating.

Management of ineffective family care related to the care of skin integrity manifested by stage II pressure ulcer called a blister by caretaker daughter

• I have no idea what this diagnosis is. It is not Nanda.
• The related factor has nothing to do with the management of care.
• The symptoms also have nothing to do with the management of care.