What are the symptoms that cause the patient to come to the hospital?

  

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Week: 6

Dates of Care:05/20/23

Patient Initials

F A

Sex

M

Age

95

Room

804

Admitting Date

05/19/23

Admitting Chief Complaint: What symptoms cause the patient to come to the hospital?

Fatigue and general weakness and experiencing pain in the lower back. The patient was brought by his son because he was too weak to get out of bed.

Attending physician/Treatment team:

Ayman M Jabr

Consults:

Present Diagnosis: (Why patient is currently in the hospital)

Acute Pyelonephritis

ER Management: (if applicable)

Allergies:

No allergies

Code Status:

Full code

Isolation: (type and reason)

Admission Height:

56 inches

Admission Weight:

62kg (136 Ib 11 oz)

Arm Band Location (colors & reasons)

Communication needs: (verbal, nonverbal, barriers, languages)

Patient speak Spanish only and

Past Medical History: (pertinent & how managed)

Significant Events during this hospitalization but not during this clinical time: (include date, event and outcome)

Tests/Treatments/Interventions impacting clinical days care (include current orders)

Assessments and interventions: (Include all pertinent data)

Vital signs: (2 sets per day)

Time

05/20/23 0735

T

99.2 F(37.3C)

P

85

R

18

B/P

132/78

Time

05/21/23 0755

T

98.6

P

75

R

18

B/P

GI:

Diet:

Swallow precautions:

Tube feedings:

NG / G tube:

Blood Glucose: (time & date)

Last bowel movement: (time & date)

Pertinent Labs/Test:

Assessments/Interventions: (stool, bowel sounds, tenderness, distention, appetite, nausea, vomiting)

Respiratory:

02 modalities:

02 Saturation:

Suction:

Resp Rxs:

Trach:

Chest Tubes:

Pertinent Labs/Test:

Assessments/Interventions: (Lung sounds, cough, sputum, SOB)

Neurosensory:

Neuro checks:

Alert & Orientated:

Follows commands:

Speech Comprehensible:

Pertinent Labs/Test:

Assessments/Interventions:

(LOC, pupils, Glascow Coma scale, dizziness, headaches, tremors, tingling, weakness, paralysis, numbness)

Cardiovascular:

Telemetry:

Pacemaker/IAD:

DVT Prevention:

Daily Weights:

Pertinent Labs/Test:

Assessments/Interventions:

(peripheral pulses, heart sounds, murmurs, bruits, edema, chest pain, discomfort, palpitations)

Musculoskeletal:

Activity:

Traction:

Casts/Slings:

Pertinent Labs/Test:

Assessments/Interventions:

(strength, ROM, pain, weakness, fractures, amputation, gait, transfers, CMS or 5 Ps

Renal:

Catheter (indwelling/external):

CBI:

Dialysis:

A/V access:

Pertinent Labs/Test:

Assessments/Interventions: (location, bruit, thrill)(urine-quality, burning with urination, hematuria, incontinent, continent, I & O)

Skin:

Braden Score:

Pertinent Labs/Test:

Assessments/Interventions:(bruising, characteristics, turgor, surgical incision, finger & toe nails, wounds, drains, bed type)

Pain:

Pain score:

Assessments/Interventions:

(scale used, location, duration, intensity, character, exacerbation, relief, interventions)

Vascular Access: (IV site)

Assessments/Interventions: (include type of fluid & access, location, dressing, date inserted, tubing change, Site Appearance)

Gyn:

Gravida/Para:

LMP:

Last Pap:

Breast exam:

Pertinent Labs/Test

Assessment/Interventions: (bleeding, discharge)

Post-operative /procedural:

Assessments/Interventions:

(immediate post procedure care)

Safety:

Call light:

Bed Rails:

Bed alarms:

Fall risk:

Assistive Devices:

Sitter use:

Restraints (type, duration & reason):

Assessment/Interventions (modifications to room, environment, Patient)

Advance Directives/Ethical considerations:

DPOA:

Hospice:

Pertinent Data (Labs, X-rays, Etc.)

Results

Normal Lab Values

Significance to your patient

WBC

11.5

4.0-11.k/mm

RBC

3.55

3.6-5.04

HGB

11.5

HCT

MCV

90.3

MCH

29.3

MCHC

32.5

Platelets

260

RDW

15.9

MPV

8.3

PT

INR

APTT

Glucose

90

BUN

24

Creatinine

1.0

Sodium

3.5

Potassium

3.8

Cloride

1.08

Calcium

7.7

T Protein

6.1

Albumin

3.4

SGOT

SGPT

Alk Phos

98

Magnesium

1.6

Amylase

Lipase

CPK

LDH

34

Cholestrol

105

CK

CK-MB

Troponin I

Myoglobin

LDI

Urinalysis

Color

Character

Spec. Grav.

pH

Protein

Glucose

Acetone

Bilirubin

Blood

Nitr

Urobili

RBC

WBC

Epithelium

Urine Culture

Chest X-ray

MRI

CT Scan

Others test:

Psycho/Social: Assessment/Interventions:(mental illness, social history, living arrangements, primary care giver, substance abuse, maternal/infant bonding, family dynamics)

Cultural/Spiritual needs: Assessment/Interventions: (religious preference, adaptations & modifications, end of life decisions)

Growth & Development: (physical, psychosocial, cognitive, moral, spiritual using various theorist) What stage of development evident with patient:

Current overall plan of care: (A short statement that summarizes the anticipated plan of care)

Discharge plans and needs:

Teaching needs:(Disease process, medications, safety, style, barriers)

Pathophysiological Discussion: Discuss the current disease process at the
cellular level (in your own words). Explain why this patient is encountering this particular health deficit. What is the relationship of this current health alteration to the patients other medical conditions? Describe the current disease process the patient is encountering
etiology, epidemiology,
pathophysical mechanism,
manifestations and treatment (medical and surgical). Also note the complications that may occur with these treatments and the patients overall prognosis. Include appropriate references and use APA format.

Attach a research article pertaining to diagnosis of patient. Write a summary about the article.
List of nursing diagnoses (NANDA format). Place diagnoses in priority order and provide rationale for priority setting. May only list one nursing diagnosis that is a
Risk For diagnosis.

Priority

Nursing Diagnosis

Related to

As Evidence By

Rationale (reason for priority)

1

Acute Pain

Inflammation and infection of the urinary tact

Report of pain/ burning discomfort when urinating

The patient experienced severe pain during urination.

2

Hyperthermia

Inflammation process secondary to pyelonephritis

Increasing body temperature above the normal range

The patient always has fever symptoms

3

Impaired Urinary elimination

Kidney infection and inflammation

Urinary retention

The patient experienced frequency and hesitancy urine

4

5

Medications

Classification

Dose

Route

Freq

Purpose/Mechanism of Action

Significant Side Effects / Adverse Reactions

Nursing Implications

Lipitor

Atorvastatin

40mg

oral

daily

Inhibits HMG -COA retake enzyme which reduces cholesterol synthesis high dose lead to plaque regression

Feeling sick (nausea), Headaches, diarrhea, runny nose, sore throat, constipation

Rocephin

Ceftriaxone

1g

oral

daily

Inhibits cell wall biosynthesis by

Black tarry stool. Chest pain, shortness of breath. Sore throat, Swollen glands, and weakness

Plavix

Clopidogrel

75mg

oral

daily

Headaches, dizziness Nausea, Diarrhea, constipation, nosebleeds

Vasotec

Enalapril

10mg

oral

Daily

Blurred vision itching or mild rash, diarrhea, Headaches

Tylenol

Heparin

Acetaminophen

650mg

650mg

oral

6 hours

Red, peeling or blistering skin, rash , hives, itching, and difficulty breathing

Nursing Diagnosis: Identify the top two nursing Diagnoses and expand

Assessment as evident by (AEB) or data collection relative to the nursing diagnosis (Appropriate for chosen diagnosis. Includes objective & Subjective historical data that support actual or risk for nursing diagnosis)

Patient Goal(s)

Statement of purpose for the patient to achieve

Patient Outcome (Should be measurable, attainable, realistic and timed, all criteria should be present and specific to the patient Dx.)

(Must have at least two short term outcomes and two long term outcomes)

Interventions/Implementations (Must have at least four nursing interventions for each outcome written that directly relate to the patients goal statement and help to reach the patient outcomes. They should be specific in action, frequency, and contain a rationale.

Evaluation. (Was the outcome met, partially met or not met and why? And is the plan of care revised or continued and new evaluation date/time is set)

Nursing Diagnosis: Identify the top two nursing Diagnoses and expand

Assessment as evident by (AEB) or data collection relative to the nursing diagnosis (Appropriate for chosen diagnosis. Includes objective & Subjective historical data that support actual or risk for nursing diagnosis)

Patient Goal(s)

Statement of purpose for the patient to achieve

Patient Outcome (Should be measurable, attainable, realistic and timed, all criteria should be present and specific to the patient Dx.)

(Must have at least two short term outcomes and two long term outcomes)

Interventions/Implementations (Must have at least four nursing interventions for each outcome written that directly relate to the patients goal statement and help to reach the patient outcomes. They should be specific in action, frequency, and contain a rationale.

Evaluation. (Was the outcome met, partially met or not met and why? And is the plan of care revised or continued and new evaluation date/time is set)

PAGE
1 2/9/23, 2:46PM Week 6: MH Care Plan – NUR4020-01:Nursing Care of Mental Health Patients (2023 Spring Term 1)-15902 – Resurrection University

https://oakpoint.brightspace.com/d2l/lms/dropbox/user/folder_submit_files.d2l?db=44247&grpid=0&isprv=0&bp=0&ou=19761 1/9

Mental Health Care Plan (Updated)
Course: NUR4020-01:Nursing Care of Mental Health Patients (2023 Spring Term 1)-15902

Part I Criteria
Level 4
6 points

Level 3
4 points

Level 2
2 points

Level 1
0 points

Criterion Score

Demographics

and Brief

History

/ 6Demonstrates a

mastery level of

understanding in

completion of

section & all of the

following areas:

– Diagnosis

extracted from

DSM-V manual.

– Provides relevant

data regarding past

medical history

(pertinent & how

managed).

– Significant events

during current

hospitalization with

times & dates.

– All sections

completed.

Demonstrates a

satisfactory level of

understanding in

completion of

section &/or is

deficient in 1 of the

following areas:

– Diagnosis

extracted from

DSM-V manual.

– Provides relevant

data regarding past

medical history

(pertinent & how

managed).

– Significant events

during current

hospitalization with

times & dates.

– All sections

completed.

Demonstrates a

basic level of

understanding in

completion of

section &/or is

deficient in 2 of the

following areas:

– Diagnosis

extracted from

DSM-V manual.

– Provides relevant

data regarding past

medical history

(pertinent & how

managed).

– Significant events

during current

hospitalization with

times & dates.

– All sections

completed.

Does not

demonstrate

understanding in

completion of

section &/or is

deficient in 3 or

more of the

following areas:

– Diagnosis

extracted from

DSM-V manual.

– Provides relevant

data regarding past

medical history

(pertinent & how

managed).

– Significant events

during current

hospitalization with

times & dates.

– All sections

completed.

2/9/23, 2:46PM Week 6: MH Care Plan – NUR4020-01:Nursing Care of Mental Health Patients (2023 Spring Term 1)-15902 – Resurrection University

https://oakpoint.brightspace.com/d2l/lms/dropbox/user/folder_submit_files.d2l?db=44247&grpid=0&isprv=0&bp=0&ou=19761 2/9

Part I Criteria
Level 4
6 points

Level 3
4 points

Level 2
2 points

Level 1
0 points

Criterion Score

Physical

Assessments

and

Interventions

/ 6

Psychosocial

Assessment

/ 6

Demonstrates a

mastery level of

understanding in

completion of

section & all of the

following areas:

– Vital Signs, 2 sets.

– General

appearance & ADLs.

– Review of systems,

each area

documented fully.

– Lab values.

Demonstrates a

satisfactory level of

understanding in

completion of

section &/or is

deficient in 1 of the

following areas:

– Vital Signs, 2 sets.

– General

appearance & ADLs.

– Review of systems,

each area

documented fully.

– Lab values.

Demonstrates a

basic level of

understanding in

completion of

section &/or is

deficient in 2 of the

following areas:

– Vital Signs, 2 sets.

– General

appearance & ADLs.

– Review of systems,

each area

documented fully.

– Lab values.

Does not

demonstrate

understanding in

completion of

section &/or is

deficient in 3 or

more of the

following areas:

– Vital Signs, 2 sets.

– General

appearance & ADLs.

– Review of systems,

each area

documented fully.

– Lab values.

Demonstrates a

mastery level of

understanding in

completion of

section & all of the

following areas:

– General

information

(1st section).

– Stages of

development.

– Support system.

– Stressors/stress

management

practices.

Demonstrates a

satisfactory level of

understanding in

completion of

section &/or is

deficient in 1 of the

following areas:

– General

information

(1st section).

– Stages of

development.

– Support system.

– Stressors/stress

management

practices.

Demonstrates a

basic level of

understanding in

completion of

section &/or is

deficient in 2 of the

following areas:

– General

information

(1st section).

– Stages of

development.

– Support system.

– Stressors/stress

management

practices.

Does not

demonstrate

understanding in

completion of

section &/or is

deficient in 3 or

more of the

following areas:

– General

information

(1st section).

– Stages of

development.

– Support system.

– Stressors/stress

management

practices.

2/9/23, 2:46PM Week 6: MH Care Plan – NUR4020-01:Nursing Care of Mental Health Patients (2023 Spring Term 1)-15902 – Resurrection University

https://oakpoint.brightspace.com/d2l/lms/dropbox/user/folder_submit_files.d2l?db=44247&grpid=0&isprv=0&bp=0&ou=19761 3/9

Part I Criteria
Level 4
6 points

Level 3
4 points

Level 2
2 points

Level 1
0 points

Criterion Score

Pathophysical

Discussion

/ 6Demonstrates a

mastery level of

understanding in

completion of

section & all of the

following areas:

– Discussion of the

current disease

process.

– Discussion of the

etiology of the

patients illness.

– Complications that

may occur with

treatment & the

patients overall

prognosis.

– Summary of article

written using APA

format.

Demonstrates a

satisfactory level of

understanding in

completion of

section &/or is

deficient in 1 of the

following areas:

– Discussion of the

current disease

process.

– Discussion of the

etiology of the

patients illness.

– Complications that

may occur with

treatment & the

patients overall

prognosis.

– Summary of article

written using APA

format.

Demonstrates a

basic level of

understanding in

completion of

section &/or is

deficient in 2 of the

following areas:

– Discussion of the

current disease

process.

– Discussion of the

etiology of the

patients illness.

– Complications that

may occur with

treatment & the

patients overall

prognosis.

– Summary of article

written using APA

format.

Does not

demonstrate

understanding in

completion of

section &/or is

deficient in 3 or

more of the

following areas:

– Discussion of the

current disease

process.

– Discussion of the

etiology of the

patients illness.

– Complications that

may occur with

treatment & the

patients overall

prognosis.

– Summary of article

written using APA

format.

2/9/23, 2:46PM Week 6: MH Care Plan – NUR4020-01:Nursing Care of Mental Health Patients (2023 Spring Term 1)-15902 – Resurrection University

https://oakpoint.brightspace.com/d2l/lms/dropbox/user/folder_submit_files.d2l?db=44247&grpid=0&isprv=0&bp=0&ou=19761 4/9

Part I Criteria
Level 4
6 points

Level 3
4 points

Level 2
2 points

Level 1
0 points

Criterion Score

Medications / 6Demonstrates a

mastery level of

understanding in

completion of

section & all of the

following areas:

– Medications

– Classification

– Dose

– Route

– Frequency

Purpose/Mechanis

m of Action

– Side Effects

– Nursing

Implications

Demonstrates a

satisfactory level of

understanding in

completion of

section &/or is

deficient in 1 of the

following areas:

– Medications

– Classification

– Dose

– Route

– Frequency

Purpose/Mechanis

m of Action

– Side Effects

– Nursing

Implications

Demonstrates a

basic level of

understanding in

completion of

section &/or is

deficient in 2 of the

following areas:

– Medications

– Classification

– Dose

– Route

– Frequency

Purpose/Mechanis

m of Action

– Side Effects

– Nursing

Implications

Does not

demonstrate

understanding in

completion of

section &/or is

deficient in 3 or

more of the

following areas:

– Medications

– Classification

– Dose

– Route

– Frequency

Purpose/Mechanis

m of Action

– Side Effects

– Nursing

Implications

Part II Criteria
Level 3
3 points

Level 2
2 points

Level 1
1 point

Level 0
0 points

Criterion Score

2/9/23, 2:46PM Week 6: MH Care Plan – NUR4020-01:Nursing Care of Mental Health Patients (2023 Spring Term 1)-15902 – Resurrection University

https://oakpoint.brightspace.com/d2l/lms/dropbox/user/folder_submit_files.d2l?db=44247&grpid=0&isprv=0&bp=0&ou=19761 5/9

Part II Criteria
Level 3
3 points

Level 2
2 points

Level 1
1 point

Level 0
0 points

Criterion Score

Nursing

Diagnosis

/ 3

Table 1

Assessment

/ 3

Demonstrates a

mastery level of

understanding in

completion of

section & all of the

following areas:

– List of nursing

diagnoses.

– Related to . . .

– As Evidenced by . .

.

– Rationale (reason

for priority).

Demonstrates a

satisfactory level of

understanding in

completion of

section &/or is

deficient in 1 of the

following areas:

– List of nursing

diagnoses.

– Related to . . .

– As Evidenced by . .

.

– Rationale (reason

for priority).

Demonstrates a

basic level of

understanding in

completion of

section &/or is

deficient in 2 of the

following areas:

– List of nursing

diagnoses.

– Related to . . .

– As Evidenced by . .

.

– Rationale (reason

for priority).

Does not

demonstrate

understanding in

completion of

section &/or is

deficient in 3 or

more of the

following areas:

– List of nursing

diagnoses.

– Related to . . .

– As Evidenced by . .

.

– Rationale (reason

for priority).

Demonstrates a

mastery level of

understanding in

completion of

section & all of the

following areas:

– Signs &

Symptoms:

a. 2 objective.

b. 2 subjective.

Demonstrates a

satisfactory level of

understanding in

completion of

section &/or is

deficient in 1 of the

following areas:

– Signs &

Symptoms:

a. 2 objective.

b. 2 subjective.

Demonstrates a

basic level of

understanding in

completion of

section &/or is

deficient in 2 of the

following areas:

– Signs &

Symptoms:

a. 2 objective.

b. 2 subjective.

Does not

demonstrate

understanding in

completion of

section &/or is

deficient in 3 or

more of the

following areas:

– Signs &

Symptoms:

a. 2 objective.

b. 2 subjective.

2/9/23, 2:46PM Week 6: MH Care Plan – NUR4020-01:Nursing Care of Mental Health Patients (2023 Spring Term 1)-15902 – Resurrection University

https://oakpoint.brightspace.com/d2l/lms/dropbox/user/folder_submit_files.d2l?db=44247&grpid=0&isprv=0&bp=0&ou=19761 6/9

Part II Criteria
Level 3
3 points

Level 2
2 points

Level 1
1 point

Level 0
0 points

Criterion Score

Table 1 Patient

Outcome

/ 3

Table 1

Intervention

/ 3

Demonstrates a

mastery level of

understanding in

completion of

section & all of the

following areas:

– SMART:

a. Specific

b. Measurable

c. Attainable

d. Realistic

e. Timely

Demonstrates a

satisfactory level of

understanding in

completion of

section &/or is

deficient in 1 of the

following areas:

– SMART:

a. Specific

b. Measurable

c. Attainable

d. Realistic

e. Timely

Demonstrates a

basic level of

understanding in

completion of

section &/or is

deficient in 2 of the

following areas:

– SMART:

a. Specific

b. Measurable

c. Attainable

d. Realistic

e. Timely

Does not

demonstrate

understanding in

completion of

section &/or is

deficient in 3 or

more of the

following areas:

– SMART:

a. Specific

b. Measurable

c. Attainable

d. Realistic

e. Timely

Demonstrates a

mastery level of

understanding in

completion of

section & all of the

following areas:

– Includes

interventions/nursin

g actions directly

relating to pt.

outcomes.

– Specific in action,

frequency, &

contain rationale.

– Minimum of 3

interventions

appropriate to help

pt./family meet

their outcomes.

Demonstrates a

satisfactory level of

understanding in

completion of

section &/or is

deficient in 1 of the

following areas:

– Includes

interventions/nursin

g actions directly

relating to pt.

outcomes.

– Specific in action,

frequency, &

contain rationale.

– Minimum of 3

interventions

appropriate to help

pt./family meet

their outcomes.

Demonstrates a

basic level of

understanding in

completion of

section &/or is

deficient in 2 of the

following areas:

– Includes

interventions/nursin

g actions directly

relating to pt.

outcomes.

– Specific in action,

frequency, &

contain rationale.

– Minimum of 3

interventions

appropriate to help

pt./family meet

their outcomes.

Does not

demonstrate

understanding in

completion of

section &/or is

deficient in 3 or

more of the

following areas:

– Includes

interventions/nursin

g actions directly

relating to pt.

outcomes.

– Specific in action,

frequency, &

contain rationale.

– Minimum of 3

interventions

appropriate to help

pt./family meet

their outcomes.

2/9/23, 2:46PM Week 6: MH Care Plan – NUR4020-01:Nursing Care of Mental Health Patients (2023 Spring Term 1)-15902 – Resurrection University

https://oakpoint.brightspace.com/d2l/lms/dropbox/user/folder_submit_files.d2l?db=44247&grpid=0&isprv=0&bp=0&ou=19761 7/9

Part II Criteria
Level 3
3 points

Level 2
2 points

Level 1
1 point

Level 0
0 points

Criterion Score

Table 1

Evaluation

/ 3

Table 2

Assessment

/ 3

Table 2 Patient

Outcome

/ 3

Demonstrates a

mastery level of

understanding in

completion of

section & all of the

following areas:

– Effectiveness/

Successful How.

– Not Effective

Why.

Demonstrates a

satisfactory level of

understanding in

completion of

section &/or is

deficient in 1 of the

following areas:

– Effectiveness/

Successful How.

– Not Effective

Why.

Demonstrates a

basic level of

understanding in

completion of

section &/or is

deficient in 2 of the

following areas:

– Effectiveness/

Successful How.

– Not Effective

Why.

Does not

demonstrate

understanding in

completion of

section &/or is

deficient in 3 or

more of the

following areas:

– Effectiveness/

Successful How.

– Not Effective

Why.

Demonstrates a

mastery level of

understanding in

completion of

section & all of the

following areas:

– Signs &

Symptoms:

a. 2 objective.

b. 2 subjective.

Demonstrates a

satisfactory level of

understanding in

completion of

section &/or is

deficient in 1 of the

following areas:

– Signs &

Symptoms:

a. 2 objective.

b. 2 subjective.

Demonstrates a

basic level of

understanding in

completion of

section &/or is

deficient in 2 of the

following areas:

– Signs &

Symptoms:

a. 2 objective.

b. 2 subjective.

Does not

demonstrate

understanding in

completion of

section &/or is

deficient in 3 or

more of the

following areas:

– Signs &

Symptoms:

a. 2 objective.

b. 2 subjective.

Demonstrates a

mastery level of

understanding in

completion of

section & all of the

following areas:

– SMART:

a. Specific

b. Measurable

c. Attainable

d. Realistic

e. Timely

Demonstrates a

satisfactory level of

understanding in

completion of

section &/or is

deficient in 1 of the

following areas:

– SMART:

a. Specific

b. Measurable

c. Attainable

d. Realistic

e. Timely

Demonstrates a

basic level of

understanding in

completion of

section &/or is

deficient in 2 of the

following areas:

– SMART:

a. Specific

b. Measurable

c. Attainable

d. Realistic

e. Timely

Does not

demonstrate

understanding in

completion of

section &/or is

deficient in 3 or

more of the

following areas:

– SMART:

a. Specific

b. Measurable

c. Attainable

d. Realistic

e. Timely

2/9/23, 2:46PM Week 6: MH Care Plan – NUR4020-01:Nursing Care of Mental Health Patients (2023 Spring Term 1)-15902 – Resurrection University

https://oakpoint.brightspace.com/d2l/lms/dropbox/user/folder_submit_files.d2l?db=44247&grpid=0&isprv=0&bp=0&ou=19761 8/9

Part II Criteria
Level 3
3 points

Level 2
2 points

Level 1
1 point

Level 0
0 points

Criterion Score

Table 2

Intervention

/ 3Demonstrates a

mastery level of

understanding in

completion of

section & all of the

following areas:

– Includes

interventions/nursin

g actions directly

relating to pt.

outcomes.

– Specific in action,

frequency, &

contain rationale.

– Minimum of 3

interventions

appropriate to help

pt./family meet

their outcomes.

Demonstrates a

satisfactory level of

understanding in

completion of

section &/or is

deficient in 1 of the

following areas:

– Includes

interventions/nursin

g actions directly

relating to pt.

outcomes.

– Specific in action,

frequency, &

contain rationale.

– Minimum of 3

interventions

appropriate to help

pt./family meet

their outcomes.

Demonstrates a

basic level of

understanding in

completion of

section &/or is

deficient in 2 of the

following areas:

– Includes

interventions/nursin

g actions directly

relating to pt.

outcomes.

– Specific in action,

frequency, &

contain rationale.

– Minimum of 3

interventions

appropriate to help

pt./family meet

their outcomes.

Does not

demonstrate

understanding in

completion of

section &/or is

deficient in 3 or

more of the

following areas:

– Includes

interventions/nursin

g actions directly

relating to pt.

outcomes.

– Specific in action,

frequency, &

contain rationale.

– Minimum of 3

interventions

appropriate to help

pt./family meet

their outcomes.

2/9/23, 2:46PM Week 6: MH Care Plan – NUR4020-01:Nursing Care of Mental Health Patients (2023 Spring Term 1)-15902 – Resurrection University

https://oakpoint.brightspace.com/d2l/lms/dropbox/user/folder_submit_files.d2l?db=44247&grpid=0&isprv=0&bp=0&ou=19761 9/9

Total / 57

Overall Score

Part II Criteria
Level 3
3 points

Level 2
2 points

Level 1
1 point

Level 0
0 points

Criterion Score

Table 2

Evaluation

/ 3Demonstrates a

mastery level of

understanding in

completion of

section & all of the

following areas:

– Includes all data

that is listed as

criteria in

outcomes.

– Outcomes are

determined to be

met, partially met,

or not met.

– If outcome was

not met/partially

met, plan of care is

revised/continued &

new evaluation date

& time is set.

Demonstrates a

satisfactory level of

understanding in

completion of

section &/or is

deficient in 1 of the

following areas:

– Includes all data

that is listed as

criteria in

outcomes.

– Outcomes are

determined to be

met, partially met,

or not met.

– If outcome was

not met/partially

met, plan of care is

revised/continued &

new evaluation date

& time is set.

Demonstrates a

basic level of

understanding in

completion of

section &/or is

deficient in 2 of the

following areas:

– Includes all data

that is listed as

criteria in

outcomes.

– Outcomes are

determined to be

met, partially met,

or not met.

– If outcome was

not met/partially

met, plan of care is

revised/continued &

new evaluation date

& time is set.

Does not

demonstrate

understanding in

completion of

section &/or is

deficient in 3 or

more of the

following areas:

– Includes all data

that is listed as

criteria in

outcomes.

– Outcomes are

determined to be

met, partially met,

or not met.

– If outcome was

not met/partially

met, plan of care is

revised/continued &

new evaluation date

& time is set.

Level 4
52 points minimum

Level 3
47 points minimum

Level 2
42 points minimum

Level 1
37 points minimum

Introduction:
The following clinical decision-making worksheet provides a detailed record of a patient’s care during his hospitalization for acute pyelonephritis. The patient initially presented at the hospital with complaints of fatigue, general weakness, and back pain. The worksheet outlines the patient’s diagnosis and treatment, including assessments, interventions, and pertinent data relating to his care.

Description:
The patient data provided in the worksheet details the clinical care provided to a 95-year-old male patient who was admitted to the hospital with acute pyelonephritis. The worksheet includes relevant information such as vital signs, GI, respiratory, neurosensory, cardiovascular, musculoskeletal, renal, pain, vascular access, gyn, post-operative, procedural, safety assessments/interventions, and pertinent data. The data includes test results and their significance, including WBC, RBC, HGB, HCT, Glucose, BUN, Creatinine, Sodium, Potassium, Chloride, Calcium, T Protein, Albumin, SGOT, SGPT, Alk Phos, Magnesium, and Amylase Lipase. The worksheet provides an overview of the patient’s medical history, diagnoses, treatments, and care provided by the attending healthcare professionals. The information can help provide insights into clinical approaches, best practices, and decision-making made by healthcare practitioners.

Objectives:

– To provide optimal care to the patient based on clinical data.
– To identify the patient’s healthcare needs and recommend appropriate interventions.
– To communicate effectively with the healthcare team and patient’s family, given the communication barrier.
– To assess and document vital signs, laboratory values, and assessments of multiple body systems.
– To prioritize and manage care of the patient based on medical history and present diagnosis.

Learning Outcomes:

– Evaluate clinical data to perform an accurate and comprehensive patient assessment.
– Synthesize patient data to prioritize appropriate interventions and provide optimal care.
– Develop effective communication strategies with patients and healthcare providers.
– Utilize relevant diagnostic test results to further patient management.
– Apply clinical reasoning skills to provide patient-centered interventions.

Solution 1: Management of Acute Pyelonephritis in an Elderly Patient

Acute pyelonephritis is a bacterial infection of the kidneys that can be severe if not managed properly. In elderly patients with multiple comorbidities, it can be even more challenging to manage. Here are some possible interventions for the patient’s recovery:

1. Administer antibiotics: Prompt administration of appropriate antibiotics is crucial in treating acute pyelonephritis. Empiric antibiotic therapy with broad-spectrum antibiotics like ceftriaxone and levofloxacin, which covers common uropathogens, may be initiated. However, bacteria sensitivity testing should inform the selection of an appropriate antibiotic.

2. Increase fluid intake: Adequate hydration is essential in treating acute pyelonephritis, as it helps to flush out bacteria from the kidneys. The patient should be encouraged to drink plenty of water or other clear fluids to promote urinary output.

3. Monitor vital signs: Vital signs should be monitored frequently to assess the patient’s response to treatment. The patient’s oxygen saturation, blood pressure, temperature, and heart rate should be recorded per shift.

4. Pain management: The patient’s plan of care should include adequate pain control to manage the discomfort that comes with pyelonephritis. The most appropriate pain medication to be administered should be determined by the physician.

5. Follow-up care: Elderly patients with acute pyelonephritis require close monitoring and follow-up care to ensure complete resolution of the infection. Urine cultures should be repeated to confirm that there is no evidence of an active bacterial infection, and the patient should be advised to continue hydrating even after leaving the hospital.

Solution 2: Geriatric Nursing Care of an Elderly Patient with Limited Communication

Geriatric patients with communication barriers pose unique challenges to healthcare providers. In this case, the elderly patient speaks only Spanish, and his son brought him to the hospital. Here are some possible interventions for geriatric nursing care:

1. Language interpretation services: Appropriate language interpretation services should be engaged to facilitate communication between the elderly patient and healthcare staff. A language line may be used to connect with a medical interpreter.

2. Multidisciplinary approach: A multidisciplinary team approach should be employed in the care of the geriatric patient with limited communication. The team should consist of healthcare providers, family members, social workers, and interpreters, among others.

3. Family involvement: Family members can play a crucial role in bridging the communication gap between healthcare providers and the elderly patient. The patient’s son should be encouraged to participate in patient care and educated on his father’s condition.

4. Use of visual aids: In geriatric care, the use of visual aids like pictures, charts, and graphs can be helpful in bridging the communication gap. For example, the use of pictures to represent food choices can facilitate dietary adherence.

5. Empathetic and respectful communication: Communication with the elderly patient should be characterized by empathy, patience, and respect. Non-verbal communication, like eye contact, touch, and facial expression, should be used appropriately to enhance communication and facilitate a therapeutic relationship.

Suggested Resources/Books:
1. Clinical Decision Making in Nursing Practice by Sandra M. O’Brien
2. Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care by Betty J. Ackley and Gail B. Ladwig
3. Acute Care Nurse Practitioner Certification Study Book by Sally K. Miller
4. Manual of Medical-Surgical Nursing Care: Nursing Interventions and Collaborative Management by Frances Donovan Monahan
5. The American Nurses Association Essential Guide to Nursing Management and Leadership by Ruth Tappen.

Similar asked questions:
1. What is the typical age-range of patients suffering from acute pyelonephritis?
2. What are the typical symptoms associated with acute pyelonephritis?
3. What types of tests are commonly used to diagnose acute pyelonephritis?
4. What is the typical treatment protocol for patients with a diagnosis of acute pyelonephritis?
5. How do clinicians manage patients who speak a language they do not understand?

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