M.P., a 19-year-old African American male, has a spinal cord injury following a gunshot wound 2 weeks ago. The gunshot injury occurred during a hunting accident when his best friend’s gun accidentally discharged. His injury is at the T5 level. The goal is to prepare him for transfer to a rehabilitation unit in the next few days.
Case Study Progress
M.P. did not have any signs of autonomic dysreflexia. He had a large bowel movement after receiving a PRN suppository. Antibiotic therapy was initiated after results of a urinalysis with culture and sensitivity indicated a urinary tract infection. After 3 days of medication and fluid therapy, he is being transferred
1.Give 3 nursing dx to match the patient's condition with 3 intervention and goal outcomes.
2.Give a SBAR to the oncoming nurse in change of shift report.
Impaired Urinary Elimination related to Frequent urination, urgency, and hesitancy.
goal outcomes :
* The client will have a normal pattern of urine disposal, as evidenced by the absence of signs of urinary tract disorders (urgency, oliguria, dysuria).
* The client will demonstrate behavioral techniques to prevent urinary tract infections.
* Assess the patient’s pattern of elimination
* Encourage increased fluid intake
* Encourage the client to void every 2-3 hours.
Infection related to Improper toileting ,Indwelling catheter, Instrumentation or catheterization, Urinary retention
goal outcomes :
The client will be free from UTIs as evidenced by the absence of fever, chills, groin pain and suprapubic tenderness; Clear urine without a foul odor and a normal number of white blood cells.
* Assess for signs and symptoms of urinary tract infection.
* monitor WBC count.,Urinalysis., Bacteria in the urine., Urine culture and sensitivity
* Encouraged the client to void often every 2 to 3 hours a day and completely empty the bladder.
* Encouraged increased oral fluid intake
Acute Pain related to Inflammation and infection of the urethra, bladder, and other urinary tract structures.
goal outcome :
* The customer will use both medicinal and non-pharmacological pain relief strategies.
* Customer will report satisfactory pain control below level 3 to 4 on a scale of 0 to 10.
* Assess client’s description of pain such as quality, nature and severity of pain.
* Encouraged the use of a sitz bath.
* Apply a heating pad to the suprapubic area or lower back.
* Encouraged the use of analgesic
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