andreaganoza
Can you help me with doing a SBAR for this patient: -She is a young…
Can you help me with doing a SBAR for this patient:
-She is a young woman is 28 years old coming to the ER for recurrent UTI, and was found to have urosepsis
Subjective Data
The patient states “I had yeast infections in the past and they usually go away but this time it didn’t”
The patient states “I don’t think the infection is that bad because I had yeast infections before and they’re like UTI’s; The infection should go away with antibiotics.”
Objective Data
Vital signs:
Tempt 99.2
RR 18
Pulse 113
BP 108/68
Sat 96%
Intake: 1000
Output: 300 ml
Hospital medications:
Acetaminophen tablet tylenol, genapap & Cefepime IV
no known allergies
High WBC of 12,000/mm3
Positive gram negative for RODS
Fever of 99.2 F
Dysuria/flank pain of 3
CLIENT INITIALS: DATE: 2/10/23
NURSING DIAGNOSIS: Risk for anxiety
RT: unfamiliar medical diagnosis and treatments
AEB:.
NURSING CARE PLAN
PRIORITY CONCEPT: Infection
PSYCHOLOGICAL
Assessment
Planning Goal
Desired Outcome (Specific/Measurable)
Implementation
Nursing Interventions
Rationale
Reason for Interventions
Evaluation Goal Met? *
Pertinent Data: Patient Will: Nurse Will: Why: What Happened: Yes No
Subjective:
The patient states “I had yeast infections in the past and they usually go away but this time it didn’t”
The patient states “I don’t think the infection is that bad because I had yeast infections before and they’re like UTI’s; The infection should go away with antibiotics.”
Objective:
High WBC of 12,000/mm3
Positive gram negative for RODS
Fever of 99.2 F
Dysuria/flank pain of 3
.
Short Term Goals:
The client will verbalize an understanding of her medical diagnosis and treatment plan within 12 hours of initial consultation.
Long Term Goals:
The client will demonstrate an improved level of comfort and confidence in managing her medical condition with minimal levels of anxiety within 2 weeks.
1) Provide the client with knowledge regarding her diagnosis and treatment plan.
2) Encourage the client to ask questions and share any concerns regarding her medical diagnosis and treatment plan.
Rationale:
3)Allow the client to discuss her feelings and experiences connected to her medical diagnosis and treatment plan.
1) Provide the client with resources and support to help her manage her medical condition.
2) Encourage the client to practice relaxation techniques such as deep breathing and progressive muscle relaxation to lessen anxiety.
3) Provide the client with a systematic plan for controlling her medical condition.
1) Education can help to lessen anxiety by providing the client with an understanding of her disease and the treatment approach
2) This can allow the client to acquire insight into her health and offer her with an opportunity to share any issues or fears she may have.
3)This can allow the client to express her emotions and provide her with a sense of support and understanding.
1) Resources and support might help the client to acquire confidence in managing her disease.
2) Relaxation techniques can enable the client to reduce anxiety and generate a sense of serenity.
3) A planned strategy can allow the client to feel organized and in charge of her illness.
Short Term Goals:
The patient shows her ability to verbally communicate her grasp of her medical diagnosis and treatment plan at the end of the 12 hour shift.
Long Term Goals:
The patient shows her ability to verbally communicate her increased comfort and confidence in being able to manage her medical condition with a minimum amount of worry.
The patient has shown her capacity to talk about her emotions and experiences in relation to her medical diagnosis and treatment regimen, as well as her usage of relaxation techniques like deep breathing and progressive muscle relaxation in her 2 week patient visit.
Yes
Yes
CLIENT INITIALS: DATE: 2/10/23
NURSING DIAGNOSIS: Infection
RT: Urinary Tract Infection
AEB: positive bacteria urine culture result, temperature of 99.2 degrees Fahrenheit, and increased white blood cell count
NURSING CARE PLAN
PRIORITY CONCEPT: Infection
MEDICAL
Assessment
Planning Goal
Desired Outcome (Specific/Measurable)
Implementation
Nursing Interventions
Rationale
Reason for Interventions
Evaluation Goal Met? *
Pertinent Data: Patient Will: Nurse Will: Why: What Happened: Yes No
Subjective:
The patient states “I been having some abdominal pain and pain when urinating. ”
The patient states “I don’t have a headache but some fever, it’s been going away”
The patient states “I had yeast infections in the past and they usually go away but this time it didn’t”
Objective:
High WBC of 12,000/mm3
Positive gram negative for RODS
Fever of 99.2 F
Dysuria/flank pain of 3.
Short Term Goals:
The client will demonstrate improved health status as evidenced by absence of signs and symptoms of infection (e.g. fever, chills, abdominal pain, dysuria) within 12 hours of initiating treatment.
Long Term Goals:
The client will demonstrate sustained improvement in health status with absence of signs and symptoms of infection for a minimum of 2 weeks following completion of treatment.
1) Monitor vital signs
2) Monitor intake and output
3) Perform sponge bath as needed
4) Provide comfort measures such as blanket if patient is having chills, lowering down room temperature as needed
5) Administer pain and antipyretic medications as needed
1) Provide health teachings on medication adherence, pain management, diet if indicated and what to watch out as signs of infection
2) Instruct for follow up visits and tests as indicated
1) Monitoring body temperature and pulse rate can determine if the body temperature is becoming normal hence indicates effective treatment or can indicate worsening of conditions
2)This determines if the patient status is deteriorating, if further treatment is required and prevent any complications
3) To lower down body temperature
4) Promoting and providing comfort helps the patient rest and recuperate
5) This can help in easing pain and lowering down fever
1) Early detection of complication and help lessen worsening of the patient’s condition and should be reported immediately. Teaching patient on medication adherence specially on antibiotics ensures the patient adheres to an effective treatment regimen
2) For continuous evaluation of patient’s condition and to determine progress based on physical assessments and lab results (decrease in WBC count, no fever or pain)
Short Term Goals:
Patient reports no pain or discomfort or can be objective such as lowering down of body temperature to normal range, normal input, and output of urine.
There has been an absence of signs and symptoms of infection (e.g. fever, chills, abdominal pain, dysuria) at the end of the 12 hour shift.
Long Term Goals:
The patient has been following the treatment regimen as prescribed.
The patient has no UTI, no urinary retention, a negative culture for RODS for at least 2 weeks after completing treatment and sensitivity result.
The patient’s WBC count has remain within the normal range for at least 2 weeks after completing treatment
Yes
Yes
CLIENT INITIALS: DATE: 2/10/23
NURSING DIAGNOSIS: Risk for Shock
RT: unstable vital signs, compromised immune system secondary to Sepsis and UTI.
AEB:
NURSING CARE PLAN
PRIORITY CONCEPT: Infection
MEDICAL
Assessment
Planning Goal
Desired Outcome (Specific/Measurable)
Implementation
Nursing Interventions
Rationale
Reason for Interventions
Evaluation Goal Met? *
Pertinent Data: Patient Will: Nurse Will: Why: What Happened: Yes No
Subjective:
The patient states “I been having some abdominal pain and pain when urinating. ”
The patient states “I don’t have a headache but some fever, it’s been going away”
The patient states “I had yeast infections in the past and they usually go away but this time it didn’t”
Objective:
High WBC of 12,000/mm3
Positive gram negative for RODS
Fever of 99.2 F
Dysuria/flank pain of 3.
Short Term Goals:
The client will display adequate perfusion as evidenced by stable vital signs, palpable peripheral pulses, skin warm and dry, usual level of mentation, individually appropriate urinary output, and active bowel sounds. (e.g. fever, chills, abdominal pain, dysuria) within 12 hours of initiating treatment.
Long Term Goals:
The client will have decreased symptoms of infection (e.g. fever, chills, abdominal pain, dysuria) and improved laboratory parameters (e.g. WBC count, RODS) within 2 weeks of initiating treatment.
1) Monitor vital signs and perfusion parameters (e.g. heart rate, blood pressure, urine output, skin temperature, capillary refill time, mental status) every 4 hours.
2) Administer prescribed antibiotics.
3) Encourage adequate hydration.
4) Monitor urine output, urine color, and urine specific gravity.
5) Administer prescribed analgesics for pain management.
6) Monitor and report changes in the patient’s condition, such as elevated temperature, chills, and confusion.
1) Monitor laboratory parameters (e.g. WBC count, RODS) regularly.
2) Monitor vital signs, mental status, and perfusion parameters (e.g. heart rate, blood pressure, skin temperature, capillary refill time, urine output).
3) Continue to administer prescribed antibiotics.
4) Encourage adequate hydration. Administer prescribed analgesics for pain management.
5) Monitor urine output, urine color, and urine specific gravity.
6) Monitor and report changes in the patient’s condition, such as fever, chills, and confusion.
1) To identify and monitor changes in the patient’s condition and to assess the effectiveness of interventions.
2) To reduce the infection and prevent it from spreading.
3) o prevent dehydration that can lead to shock.
4) To assess renal function and effectiveness of treatment.
5) To control pain and promote comfort.
6) To identify and assess changes in the patient’s condition, which may indicate a worsening of the infection.
1) To assess the response to treatment and identify any changes in the infection.
2) To identify and monitor changes in the patient’s condition and to assess the effectiveness of interventions.
3) To reduce the infection and prevent it from spreading.
4) To prevent dehydration that can lead to shock. To control pain and promote comfort. Adequate hydration is important to maintain adequate perfusion and prevent shock. Pain management is important for comfort and promoting healing. Increasing activity level and improving nutrition helps to promote healing and prevent complications.
5) To assess renal function and effectiveness of treatment. Reduced renal perfusion due to fluid shifts and selective vasoconstriction is indicated by decreasing urinary output with high specific gravity. This condition could be a sign of a severe urosepsis complication.
6) To identify and assess changes in the patient’s condition, which may indicate a worsening of the infection.
Short Term Goals:
The patient reports decreased symptoms of infection and the objective data shows the patient’s stable v/s, palpable peripheral pulses, skin warm and dry, usual level of mentation, individually appropriate urinary output, and active bowel sounds within 12 hours at the end of the shift.
Long Term Goals:
The patient has been following the treatment regimen as prescribed for the last week.
The patient has stable vital signs (heart rate, blood pressure, skin temperature, capillary refill time, urine output), improved laboratory parameters (WBC count, RODS), decreased symptoms of infection (fever, chills, abdominal pain, dysuria), and improved mental status within the 2 weeks of initiating the treatment.
Yes
Yes
