Assignment 5: Case Study Overview
Mrs. Jones is an 83 year old female who lives with her daughter was brought to the hospital Emergency Department via personal vehicle. Mrs. Jones reports that she has “had a fever the last few days” and today her temperature was 101.0 so she thought she better see her doctor, but the office was closed today being Sunday. The daughter was worried that her mother seemed “out there at times.” Mrs. Jones also reports she has had frequency in urination the last several days and has noticed her urine to be dark in color with a foul smell, she also reports pain in the anterior lower pelvis region with urination. (Mrs. Jones Patient Chart, 2015)
The assessment in the ER reveals that Mrs. Jones is febrile with temperature …show more content…
An increase in creatinine, bun and lactic acid levels, complete blood count was all unremarkable with exception of an increase in the white blood cell count. Urinalysis reveals presence of leukocytes estrace, nitrates, bacteria, and the presence of white and red blood cells. All lab work is indicative of ER physician diagnosis of urinary tract infection. (Mrs. Jones Patient Chart, 2015)
Treatment was to increase the IV normal saline to help flush kidneys of the bacteria. IV antibiotics are ordered to treat the infection with admission into the hospital for continuation of care.(Mrs. Jones Patient Chart, 2015)
Nursing care plan: Urinary Tract Infection related to bacteria found in the urine.
Interventions: Administer IV antibiotics and normal saline as ordered. Take vital signs every 4 hours and PRN to evaluate changes. Encourage fluids by mouth to also help flush kidneys of toxins.
Goals: Temperature will be less than 100.0 within 24 hours. Patient will report no pain within 24 hours of administering IV antibiotics Repeat urinalysis will be free bacteria day of discharge from the hospital.
Evaluation: Temperature was 99.0 within 24
Mrs. Jones is an 83 year old female who lives with her daughter was brought to the hospital Emergency Department via personal vehicle. Mrs. Jones reports that she has “had a fever the last few days” and today her temperature was 101.0 so she thought she better see her doctor, but the office was closed today being Sunday. The daughter was worried that her mother seemed “out there at times.” Mrs. Jones also reports she has had frequency in urination the last several days and has noticed her urine to be dark in color with a foul smell, she also reports pain in the anterior lower pelvis region with urination. (Mrs. Jones Patient Chart, 2015)
The assessment in the ER reveals that Mrs. Jones is febrile with temperature …show more content…
An increase in creatinine, bun and lactic acid levels, complete blood count was all unremarkable with exception of an increase in the white blood cell count. Urinalysis reveals presence of leukocytes estrace, nitrates, bacteria, and the presence of white and red blood cells. All lab work is indicative of ER physician diagnosis of urinary tract infection. (Mrs. Jones Patient Chart, 2015)
Treatment was to increase the IV normal saline to help flush kidneys of the bacteria. IV antibiotics are ordered to treat the infection with admission into the hospital for continuation of care.(Mrs. Jones Patient Chart, 2015)
Nursing care plan: Urinary Tract Infection related to bacteria found in the urine.
Interventions: Administer IV antibiotics and normal saline as ordered. Take vital signs every 4 hours and PRN to evaluate changes. Encourage fluids by mouth to also help flush kidneys of toxins.
Goals: Temperature will be less than 100.0 within 24 hours. Patient will report no pain within 24 hours of administering IV antibiotics Repeat urinalysis will be free bacteria day of discharge from the hospital.
Evaluation: Temperature was 99.0 within 24