Case study the nursing process

[roncyn]

On evening shifts, you as an RN was asked by an RPN to assess an older patient who is unwell. He is an 87 years old man with history of diabetes, renal failure, chronic UTI, hypertension and CAD. RPN reports that the patient has c/o abdominal pain, is not eating or drinking well and appears more confused and more lethargic.

Assessments - what assessments would you complete and why ?

Nursing Diagnosis:

You conclude that the patient may have urinary retention. How is this written as a nursing diagnosis?

Planning :

What are your next steps, in terms of planning for management of the patients condition?

Implementation:

What nursing measures will you implement ? and Why?

Evaluation:

What will you evaluate and then what will you document?

[EDNURSE20, BSN]

Warning! You will be slammed on here for asking other to do your homework. No one is going to do it for you. If you want any sort of discussion, give us your answers first.

[meanmaryjean, DNP, RN]

Congratulations on your copy-and-paste skills. You forgot the part where you start the discussion by telling us what you have come.up with thus far.

We are willing to help. But we are not willing to do the work for you and have you fraudulently submit it as your own. Does your instructor know you are doing this?

[traumaRUs, MSN, APRN]

Moved to nursing student assistance forum

[roncyn]

thanks for the advice and suggestions ...i did not mean anything here ..just wanted a discussion...thanks anyways

[roncyn]

here are my answers:

Assessment : i will do abdominal assessment, assess for bowel sounds for possible constipation and assess the bladder for possible urinary retention. Check vitals if stable or not. Why, because resident has history of diabetes, renal failure and chronic UTI.

Nursing Diagnosis: urinary retention and incontinence

Dx will be urinary retention secondary to renal failure and chronic UTI

Planning: monitor for urine output and also monitor for bowel movement

Implementation: if there is a bladder scan available, use bladder scan to see, measure and confirm the urinary retention, and or if decreased urine output or no voiding at all, call doctor ask for an order of in and out catheter or maybe indwelling catheter.

Why - to confirm the nursing diagnosis of urinary retention and to provide relief to resident from the retention and from abdominal pain.

Evaluation:

Resident was evaluated for having urinary retention, so documentation will be about the abdominal assessment, bowel sounds, bladder condition , pain assessment, calling doctor for orders, if in and out was done then document and document how much urine output was drained and how did the resident tolerated procedure, how resident was feeling after the the catheterization and if the pain has been relieved and overall effect of the nursing measures done.

To all who have seen this post of mine, I did not mean anything here, I just dont want to create a bad impression and thank you for your comments and advices. I was just hoping for a good discussion, a support from a colleague, support from co nurses.

If i was wrong i do apologize now and in advance. Please if you have opinions and advices for this case study, I am very much open to it, I maybe wrong with my assessments so I am fine with some constructive criticism, this is just a healthy and friendly discussion.

Thank you.

[Triddin]

Here are my thoughts reading your answers:

Assessment: think more specifically what a uti looks like. What does their urine look like? What about a pain scale for their pain. I'd also do a neuro because a change in LOC doesn't necessarily mean UTI. I'm. It sure where the constipation comes from. What vital signs are you looking for. I would do vital signs independently if th patient history. I don't think your correlation is strong there. How exactly are you going to assess for retention? What does that look like. How about voiding history

Diagnosis- does chronic renal failure cause retention? (Also I think something more than just retention is going on but I would need more data to confirm)

Planning: again, why bowel movements? Also assess for worsening pain, changes in loc

Evaluation- assessment of urine itself. Sample required? What if pain and change of loc doesn't change after the i$o

[Wuzzie]

To all who have seen this post of mine, I did not mean anything here, I just dont want to create a bad impression and thank you for your comments and advices. I was just hoping for a good discussion, a support from a colleague, support from co nurses.

If i was wrong i do apologize now and in advance. Please if you have opinions and advices for this case study, I am very much open to it, I maybe wrong with my assessments so I am fine with some constructive criticism, this is just a healthy and friendly discussion.

Thank you.

No need to beat yourself up. We always like to help our student members. We just ask that they first show us their work. This aids us in understanding how best to assist as well as limiting the chance that we end up doing their homework for them which in the end is no help at all.

[nursej22, MSN, RN]

I would actually do a head to toe assessment, especially if I don't him. Abd pain could be anything from constipation to perforation.

[nursinglove30]

OP I think you did pretty good but I wanted to just share a tip since you asked. As a student myself I stay in my lane and use what is taught at school. I am sure real nurses here can better help you with the answers since they have lots of experience. For me when doing care plan, I proceed with Maslows, and ABC's AKA the nursing model. I also mind the medications the patient is on for teaching purposes. I think once you do that, your brain isn't all over the place with guesses. Hope that helps.