Nursing Diagnoses of patients with Urinary tract infection and Deep Vein Thrombosis
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Nursing Diagnoses of patients with Urinary tract infection and Deep Vein Thrombosis
The Concept Map
-619125266065Assessment
Subjective – urgency and lower abdominal pain, frequent urination, pain with urination
Objective data-UTI 30month, 14months and 8 month ago, gonorrhea 2 yrs. ago
Body Systems- no nausea, no vaginal bleeding but having pelvis discomfort. Ears clear, no swelling and pain,
Neurologic-Alert with normal reflexes.
Pulmonary- clear
Cardiac: regular rate and rhyme.
Gastrointestinal- normal bowl movement
Urinary- Showed pus and bacteria. Bad smell from urine.
Reproductive: Clear
Skin: Dry not swollen
00Assessment
Subjective – urgency and lower abdominal pain, frequent urination, pain with urination
Objective data-UTI 30month, 14months and 8 month ago, gonorrhea 2 yrs. ago
Body Systems- no nausea, no vaginal bleeding but having pelvis discomfort. Ears clear, no swelling and pain,
Neurologic-Alert with normal reflexes.
Pulmonary- clear
Cardiac: regular rate and rhyme.
Gastrointestinal- normal bowl movement
Urinary- Showed pus and bacteria. Bad smell from urine.
Reproductive: Clear
Skin: Dry not swollen
Cause Study: Urinary Tract Infection
643890042545Patient’s Name: K.N.
Demographic info: Gender female and is 24 years old
00Patient’s Name: K.N.
Demographic info: Gender female and is 24 years old
380047513970Factors affecting patient’s health (cultural, beliefs, resources, lifestyle)
Lifestyle of keeping multiple partners might be the cause of UTI.
0Factors affecting patient’s health (cultural, beliefs, resources, lifestyle)
Lifestyle of keeping multiple partners might be the cause of UTI.
208597513969Gordon Pattern and supporting data
1-Elimination: normal bowl movement, no bladder discharges and skin is also dry.
2- Sexuality: Multiple partners
3- Coping: Cooperative
0Gordon Pattern and supporting data
1-Elimination: normal bowl movement, no bladder discharges and skin is also dry.
2- Sexuality: Multiple partners
3- Coping: Cooperative
210502592075Priority NSg Diagnoses
1. Pelvic pain
2. Strong smelling urine
3. Lack of knowledge about the causing factors of UTI
0Priority NSg Diagnoses
1. Pelvic pain
2. Strong smelling urine
3. Lack of knowledge about the causing factors of UTI
2066925252730Interventions for #1 priority problem
Restrictions on sexual activities and birth control pills.
00Interventions for #1 priority problem
Restrictions on sexual activities and birth control pills.
right9525Goal/outcome: To minimize the frequently happening UTI
00Goal/outcome: To minimize the frequently happening UTI
30289518890Educational plan: Will be guided about the cause of UTI
00Educational plan: Will be guided about the cause of UTI
Cause Study: Deep Vein Thrombosis
-619125266700Assessment
Subjective – swelling in left foot, pain in left calf
Objective: 24 hours pain, rating 8/10, doing treatment from 1 year.
Body Systems: Clear ear, nose,
Neurologic: Alert and no numbness
Pulmonary- clear
Cardiac: regular rate
Gastrointestinal- normal bowel sounds no blood found in stool.
Urinary- clear
Reproductive: normal organs
Skin: normal
00Assessment
Subjective – swelling in left foot, pain in left calf
Objective: 24 hours pain, rating 8/10, doing treatment from 1 year.
Body Systems: Clear ear, nose,
Neurologic: Alert and no numbness
Pulmonary- clear
Cardiac: regular rate
Gastrointestinal- normal bowel sounds no blood found in stool.
Urinary- clear
Reproductive: normal organs
Skin: normal
2057400280670Gordon Pattern and supporting data
1-Elimination: normal bowl movement, no blood in stool
2- Relationship: lives alone
3- coping: acute distress from pain in leg
0Gordon Pattern and supporting data
1-Elimination: normal bowl movement, no blood in stool
2- Relationship: lives alone
3- coping: acute distress from pain in leg
603885027940Patient’s Name: JB
Demographic info: Gender male and is 57 years old
00Patient’s Name: JB
Demographic info: Gender male and is 57 years old
359600513970Factors affecting patient’s health (cultural, beliefs, resources, lifestyle)
Lifestyle of eating and not taking care of his weight.
0Factors affecting patient’s health (cultural, beliefs, resources, lifestyle)
Lifestyle of eating and not taking care of his weight.
208597463500Priority NSg Diagnoses
1. Left leg pain
2. Blood clot in the left posterior tibial vein
3. Lack of knowledge about healthy life style
00Priority NSg Diagnoses
1. Left leg pain
2. Blood clot in the left posterior tibial vein
3. Lack of knowledge about healthy life style
2076450238125Interventions for #1 priority problem
Increase the bodily movement and decrease weight
00Interventions for #1 priority problem
Increase the bodily movement and decrease weight
right185420Goal/outcome: To minimize future blood clot in the vein
00Goal/outcome: To minimize future blood clot in the vein
3000375147955Educational plan: Will be given tips to control blood clot and decrease weight.
00Educational plan: Will be given tips to control blood clot and decrease weight.
Nursing Diagnosis identified for the treatment of Urinary tract infection and Deep Vein Thrombosis
A twenty-four years women who was presented to the clinic with a quick urgency to urinate the symptoms of frequent urination and pain stated 45minutes before she was brought to the hospital.
Problem-related to Urine track infection evidenced by sudden lower abdominal; discomfort, the strong odor of urine, pain with urination and frequent urination. She had a long history of urinary tract infection and the problem related to urinary tract infection was also evidenced by the bacteria and puss in her urine.
The second case study refers to an overweight 57 years old man JB. He came to the clinic because of the swelling in his left foot for about a week. The pain was getting worse in the last 24 hours. He had marketed the pain extreme that is 8 out of 10 and has an appointment with the primary care provider.
At age 54 he had a blood clot and got treatment by a blood thinner warfarin for up to a year. He has also some symptoms of diabetics five years ago. The patient’s social history shows that he is living alone and has a 28 pack per year smoking history. He also used to drink 3-4 times bear per day and in weekends he drinks six packs. But the patient was not found with a history of illicit drug use.
The problem related to deep vein thrombosis was diagnosed due to the evidence that his left ankle and foot were swollen, his left calf was swilled as much as twice the normal size and also the lower extremity of his left side showed no flow in the tibia vein of the left posterior. The iliac vein and left common femoral were having enough flow and his right lower extremities were also showing good blood flow. His right leg has no redness, tenderness or swelling. He had no blood clot disease in his family so no family evidence of thromboembolic diseases was found. He was admitted for further treatment.
The Nursing Diagnosis that is most important to address the Problem of the Clients
Nursing Diagnosis is of three types. The first one in problem-focused nursing diagnosis and that explains the clinical judgment that concerns the behavior of the specific patients towards his or her health condition. These are the definite observable characteristics that reveal the health conditions of the patients. Those characteristics are patient behavior and physical appearance. A relative factor is identified during this diagnosis and that is a causative factor of the illness (Potter, Perry, & Hall, 2016).
The second type is risk nursing diagnosis includes a risk factor. Risk factors are the environmental, genetic, physiological, psychological and chemical elements that can worsen the health condition of the patient. The third type of nursing diagnosis is a “health promotion nursing diagnosis” which is a type of clinical judgment that checks a patient motivation for his or her wellbeing and it actualizes the potentials of human health. (Potter, et al., 2016).
The nursing diagnosis that was used in both the cases is “problem-focused nursing diagnosis”. Because patients are being assisted based on the symptom they were showing. The lady had lower abdominal pain, she was frequently urinating and her urine had a particular aroma. She also had a history of urinary tract infection. So her behavior was clear that she was having urinary tract infection.
The other patient has a swollen left foot and the patient also reported the rate of his pain as 8 out of ten. So the appearance and behavior of the patient towards his comes under the problem focused nursing diagnosis.
The second and third important nursing diagnosis in the given cases:
The second most important nursing diagnosis is “risk nursing diagnosis”. This was determined based on the facts that one of the patients can have a risk of injury and fall because he has got pain in his foot and has very high body weight. So this risk factor might occur to him if the nurse will not give him proper service.
The patient with Urinary tract infection might get the UTI because of her being sexually active with multiple people so they could be risk factors of immunization, pollutant, and drugs attached to those individuals. The least important nursing diagnosis in these cases is the health promotion nursing diagnosis” because none of the patients have asked to be involved in any kind of health improvement tasks but they are willing to improve their conditions. They have not promised to be the part of any spiritual group to calm their selves down and neither were they given such options so this type of nursing diagnosis is least practice in both the cases
Goals set for the Clients
Cause study: Deep Vein Thrombosis
The main goal set for the clients would be to prevent further deep vein thrombosis and urinary tract infection. Other goals for the patient with deep vein thrombosis could be preventing the clot from sizing and prevent new blood clot, and also prevent long term complications.
Blood normally move in a rapid speed through the vein and does not clot until they happened any surgery or the leg is not involved in any sort of motion. Because if the leg did not move the muscle squeeze the vein and blood get clotted (Morris, 1995).
I being a nurse can help the client to achieve his set goals. Firstly, his history shows that his problem of deep vein thrombosis is not genetically inherited neither he has got any surgery. So I will first diagnose the reason for DVT and will help him accordingly. I will identify the risk factors and will make sure that he is having enough movements because most of the time deep vein thrombosis (DVT) occurs due to lack of movement. I will make sure that the patient will not get another blood clot by giving him blood thinner materials. Because most of the time the patient with a DVT get another blood clot in his/her veins. I will watch for another swelling, leg pain or any sort of redness. The most important thing that will help the client to reach his goal is to educate him regarding his illness. He is not aware not what the cause of blood clotting is and he is not even taking care of his weight. An overweight person has high-risk factors of heart failure, stroke and other problem related to obesity. He should know that he has to take care of his weight so that he can frequently move his legs. The movement will prevent further blood clot.
If the client is able to get through the treatment and will not get the blood clot again then he has met his goal. I will make sure that the client is close to his goal of not getting deep vein thrombosis again.
Cause study regarding Urinary tract infection:
The lady has a long history of urinary tract infection and she had one 30 months ago and she was cured by using an antibiotic. She had the latest one eight months ago and she again took antibiotic for that. Her history reveals that she has been getting UTI constantly. Do the set goals for her would be not to have another UTI again and to identify the causing factors of UTI. Her medical records show that she is a non-smoker but uses occasional marijuana. She is sexually active with multiple persons.
The risk factors behind frequent urinary tract infections are the influx of bacteria in the urinary tract because of the fact that a woman’s urethra is of shorter length and bacteria will reach quickly to the bladder. Secondly sexually active women have more UTI than women who are sexually less active. She is also using a tablet for birth control.
Urinary tract infection can also be caused due to birth control techniques. Menopause is also one of the causes of increase bacterial infection in the urinary tract because due to menopause the concentration of estrogen in the uterus decrease which makes the uterus prone to infection (Hooton, 2001).The case study shows that the lady has not yet reached the point of menopause and no record of birth control has been seen. So the particular cause of bacterial infection is due to her sexual activities and hygiene issue. The main goal for her will be to minimize the rate of Urinary tract infection by restricting sexual activities and by taking care of her hygiene.
I can provide knowledge to the client regarding her frequent cause of Urinary tract invention and will let her know that her sexual activities could be the cause of the UTI. She will be guided properly on how to use the medicine. She will have to minimize her sexual activities and keep one partner in order to minimize bacterial infection in her urethra. She will be trained properly to take care of female hygiene and what to use and what not to use for birth control.
I will get to know that she has met her goal if she did not get any urinary tract infection again.
References
ADDIN ZOTERO_BIBL {"uncited":[],"omitted":[],"custom":[]} CSL_BIBLIOGRAPHY Hooton, T. M. (2001). Recurrent urinary tract infection in women. International journal of antimicrobial agents. 17(4), 259-268.
Morris, B. (1995). Nursing care for the prevention of deep vein thrombosis. 5.
Potter, P. A., Perry, A. G., & Hall, A. (2016). Fundamentals of Nursing-E-Book. Elsevier Health Sciences. (9th ed.).
