NUR 513 Rotation

Weekly Care Plan

Name: Vanessa Sanchez

Date of Clinical: June 9, 2015

Pt. initials: C.G.

Age: 18
DOB: 3-15-97
Gender: F
Wt: 60 kg
Ht: 165 cm
BMI: 22 (Healthy) BP Range: 90/70-110/80
Allergies: None
Admit date: 06-08-15
Surgery date: N/A Unit: Labor and Delivery Room: 35
Diagnosis/Diagnoses:
Pyelonephritis
Pathophysiology for medical dx:
Pyelonephritis is an acute or chronic inflammation of the renal pelvis often related to ascending
infection and
obstructive uropathies and may cause abscess formation and scarring with an alteration in renal
function.
This condition may be a cause of pregnancy due to the dilation and relaxation of ureter with
hydroureter
and hydronephrosis; partly caused by obstruction from enlarged uterus and partly from ureteral
relaxation
caused by higher progesterone levels. This condition puts the fetus at risk because the mother
may develop a
fever from the infection, and her blood pressure will decrease, leading to decreased perfusion to the
placenta. In
addition, this condition may lead to pre-term labor, as the infection causes spasms of the ureters,
which can lead to uterine contractions and induce labor. Pre-term labor can lead to serious
conditions,
including low birth weight, breathing difficulties, underdeveloped organs, vision problems, learning
disabilities, and behavioral problems.

Rationale for treatments (Resp Tx, Neuro check 2hr, CXR, MRI, feeding tubes):
Blood cultures were done to find cause of infection.
FFN results were negative, indicating the mother is not likely to go into labor, and steroids are not
necessary to give to the baby.

History of present illness:

UTI treated in January 2015

Past medical history:

OB: G1 P 0 Ab 0 L0
1

GYN: Menarche Cycle 4-5 days; No history of infertility

Surgical: None
Social/family history:
No significant family medical history. Patients supportive, caring, and protective husband was at
bedside.

Change of Shift / Report Notes:

18 y/o female patient G1P0 admitted 06/08/15 with chief complaint of contractions, body aches, back
pain, and fever. Assessment showed a high temperature (99.0 F), high pulse (103), and low blood
pressure (90/70). Labs indicate low Hgb, Hct, and Rbc, in addition to a high WBC, suggesting an
infection. Blood cultures were taken and indicated E. Coli was present. She is taking iron due to low
RBCs, Tylenol for management of pain, and Rocephin (antibiotic) for infection of kidneys
(pyelonephritis). Baby is in stable state with a reassuring assessment of EFM . Fetal Fibronectin
Testing (FFN) was negative. Patient is on a regular diet.

VS
Temp
Pulse
Resp

0800
37.6
C oral
103
22

BP
SaO2
Pain

90/70
L arm
98
8/10

1200
37.3 C
oral
98
19
110/8
0L
arm
100
3/10

Assessment:
General: Affect and facial expression appropriate to situation.
Skin: Mostly warm and dry.
Back: CVA tender x3
HEENT/Neuro: Oriented x4. Grips, flexion, extension strong bilaterally.
Respiratory: Bilateral clear lung sounds; free of fluid
GI: Abdomen soft with no distension at baseline. Normo-active bowel
sounds.
GU: Cloudy urine, with output greater than 30 mL/hr.

M/S: Full ROM on upper extremities and lower extremities.

Pulses: Pulse Rate 103 bpm. Radial 3+, dorsalis pedis 2+. No JVD or bruit.
Activity Level: Patient is able to walk to the bathroom on her own and perform ADLs.

Nursing Diagnosis #1:

Acute pain r/t acute inflammation of renal
tissues.

Nursing Diagnosis #2:

Impaired urinary elimination related to kidney
infection.

Goal
Patient will verbalize relief or control of pain
after 8 hours of nursing interventions.

Goal
Patient will verbalize relief or dysuria after 8
hours of nursing interventions.

Interventions

Interventions

1. Assess the condition of pain experienced by

the client.
Medication
Dosage/
Method Why is the patient on
2. Teach
relaxation techniques.

Frequency
of reducethe
medication
3. Administer ordered analgesics to
pain.

Admin.
325 mg TID
PO
Treatment of iron-
deficiency anemia

Iron

Measure and record the voiding of urine

each time.
Side effects
Nursing2-3
responsibilities
Advise
to urinate every
hours
Palpation of the bladder every 4 hours
CV: hypotension
Encourage
increased

Assess
fluid nutritional
intake
GI: nausea,

status and dietary

diarrhea,
epigastric pain

anemia and need for

patient teaching.

Perform
laboratory tests;
electrolytes,
constipation,
history to determine
dark stools,
possible cause of
BUN,
creatinine.

Assess bowel function

for constipation or
diarrhea.

Notify health care

professional and use
appropriate nursing
measures should thes

30 mL BID

PO

Prenatal
multivitamins are
used to provide the
additional vitamins
needed during
pregnancy.
Minerals may also
be contained in
prenatal
multivitamins.

GI: constipation,
diarrhea, loss of
appetite

Assess patient for

abdominal distention,
presence of bowel
sounds, and usual
patterns of bowel
function

1000mg

PO

Treatment of
urinary/gynecologi
c infection

GI: diarrhea,
nausea,
vomiting,

Assess for infection

(vital signs;
appearance of wound,
sputum, urine, and
stool; WBC) at
beginning of and
throughout therapy.

Before initiating
therapy, obtain a
history to determine
previous use of and
reactions to penicillins
or cephalosporins.

Persons with a
negative history of
penicillin sensitivity
may still have an
allergic response.

Assess overall health

status and alcohol
usage before
administering
acetaminophen.

Patients whoare
malnourished or
chronically abuse
alcoholare at higher
risk of developing
hepatotoxicitywith
chronic use of usual
doses of this drug.

Pre-Natal
Vitamin

ceftriaxone
(Rocephin)

daily

Derm: Rashes

Acetaminophen
(Tylenol)

1000 mg
q6h PRN

PO

Management of
mild to moderate
pain

GI: Nausea,
vomiting,
abdominal pain
GU: Renal Failure
HEMA:
Leukopenia,
neutropenia,
hemolytic
anemia,
thrombocytopeni
a, pancytopenia
INTEG: Rash,
urticarial
TOXICITY:
Cyanosis,
anemia

PLANOFCARE
PATIENTSINITIALS:C.G.
AGE/SEX:18/F

DATE: 060915
STUDENTNAME:VanessaSanchez
PATTERN
MANIFESTATION

Subjective:
Ihavehadpainful
urinationforthe
past3daysas,
verbalizedbythe
patient.
Objective:
Guardingbehavior
Facialgrimace
Irritable
Skinwarmto
touch
V/Stakenas
follows:
BP=90/75
PR=103
RR=22
T=37.6C
Pain=8/10

NURSING
DIAGNOSIS

MUTUALGOALS

Acutepainr/t
acuteinflammation
ofrenaltissues.

After8hoursof
nursing
interventions,the
patientwill
verbalizereliefor
controlofpain.

NURSING
INTERVENTIONS

Independent:

-Assess pain, noting

location,
characteristics,
intensity (0-10 scale)
-Note urine flow and
characteristics
-Encourage patient to
verbalize concerns and
provide support by
acceptance, remaining
with patient and giving
appropriate
information.
-Provide nonpharmacologic pain
relief such as deep
breathing exercises
-Assist with ROM
exercises and
encourage ambulation

SCIENTIFICRATIONALESAND
REFERENCES

-Helpsevaluatedegreeof
discomfortandmayreveal
developingcomplications
Decreasedflowmayreflect
urinaryretentioncincreased
pressureinupperurinarytract
Reductionofanxietyorfearthat
canpromoterelaxationand
comforts
Promotesrelaxation,andmay
enhancecopingabilities
Reducesmuscleorjointstiffness.
Ambulationreturnsorgansto
normalpositionandpromotes
feelingofwellbeing
Relievespain,enhancescomfort
andpromotesrest

Collaborative:

- Administer antibiotics
and analgesics as

EVALUATIONAND
MODIFICATION

Goalmet.After8hoursofnursing
interventions,thepatientwasable
toverbalizerelieforcontrolof
pain.

prescribed

PLANOFCARE
PATIENTSINITIALS:C.G.
AGE/SEX:18/F

DATE: 060915
STUDENTNAME:VanessaSanchez
PATTERN
MANIFESTATION

Subjective:

Ihavehadpainful
urinationforthe
past3daysas,
verbalizedbythe
patient.
Objective:
Urinaryoutputof
35mL/hr

V/Stakenas
follows:
BP=90/75
PR=103
RR=22
T=37.6C
Pain=8/10

NURSING
DIAGNOSIS

MUTUALGOALS

Impairedurinary
eliminationrelated
tokidneyinfection.

Thepatternof
elimination
improves,and
patientdeniespain
uponurinationafter
8hoursofnursing
interventions.

NURSING
INTERVENTIONS

Independent
-Measure and record the
voiding of urine each
time.
-Advise to urinate every
2-3 hours
-Palpation of the bladder
every 4 hours
-Encourage increased
fluid intake

SCIENTIFICRATIONALESAND
REFERENCES

To investigate the change of

color, and to determine the
input/output
To prevent the buildup of
urine in the urinary vesicles
To determine the presence of
bladder distention
Increased hydration rinse
bacteria
Monitoring of renal
dysfunction

Collaborative:
- Perform laboratory tests;
electrolytes, BUN,
creatinine.

EVALUATIONAND
MODIFICATION

After8hoursofnursing
interventions,thepatient
verbalizedimprovementin
painfromurination
describedasarateof2/10