Nifedipine (Procardia chronic medical

XL) 30 mg PO BID condition: cancer Dehydration

Chronic medical condition: HTN
Azilsartan 40mg PO recent severe chronic medical
illness or Diabetes condition: lung KEY
hospitalization disease Patient Demographics:
Tamsulosin (Flomax)
BPH
Pt Initials: GW NANDA
0.4 mg PO BID chronic medical Primary Medical
Urinary retention like Age: 87 Risk Factors
condition: kidney
neurogenic bladder
Infections
Gender: Male
Diagnosis Goal
disease
Ethnicity: white Nursing intervention
Shingles older adult >65
weak immune Code status: Full Pathophysiology Mediactions
recurrent UTI
years old
system due to DOA: 10.20.23 Rationale
aging
AD: No
Paitent's Data
Brimanidine Fall Risk: High Labs and Diagnostics Possible
Glaucoma Allergies: Penicillin Complications
(ALPHAGAN) 0.2%
1drop/eye Isolation: standard Evaluation/modification
Admitting diagnosis: Sepsis and Clinical Manifestation
Dorzolamide HCL- Patient Related=
timolol, one drop/eye Pneumonia Yellow highlight
Erickson's level: Integrity vs
Despair
Sepsis Cefepime 2g/50ml past medical History
Current surgery (NA)

bacteremia MINI NANDA #1: Unstable blood pressure R/T infection, age, and increase
in systolic pressure AEB patient blood pressure is 154/96, patient 2-3 cups
of coffee/day, the patient gets stressed and anxious easily.
Interventions:
Priority problem: Impaired gas exchange R/T decreased lung capacity and decreased 1- administer Azilsartan 40mg PO daily at 9:00.
functional lung tissue AEB, crackles heard at the bases of both lungs, X-ray for the chest release of endotoxins 2- administer Nifedipine 30mg PO BID at 9:00.
shows bilateral atypical pneumonia/atelectasis, CT chest w/o contrast suggests 3- Educate the patient about coffee intake and nonpharmaceutical
pulmonary fibrosis. The patient has edematous lower RLE and LLE. techniques, like guided imagery and deep breathing techniques, to
release of pro- decrease stress and anxiety.
inflammatory: cytokines
Goal: by the end of the shift patient will have improved exchange AEB, the patient will (TNF, IL-1 alpha &
have no signs of respiratory distress or complications, the O2 saturation after each beta, IL-6)

check will be more than 95%, patient will know how to use the incentive spirometer. Mini NANDA #2: risk for DVT R/T unstable blood
activation of: pressure, patient's decreased mobility,
-coagulation system comorbidities, Edema in lower extremities.
Nursing Interventions: -complement system Interventions:
-Kinin system 1- Apply elastic stocking to prevent edema.
-Neutrophil, endothelial and mono- 2- Administer Enoxaparin 80mg SQ daily at 11:00 a.m.
Assessment/intervention: macrophage cell activity 4- Educate the patient to exercise an active range of
1- I: Asses the pulse oximeter reading Q4 hrs and report O2 sat less than 90%. motion in bed.

Rationale: Oxygen saturation of less than 90% can indicate a sign of impaired gas Release of anti-inflammatory cytokines:
-LPS binding protein
exchange and possible complications. The patient might require oxygen -IL-1 receptor antagonist
therapy (Swearingen, 2016, p. 119). Mini NANDA #3: risk of Myocardial Infarction R/T
-IL-10
comorbidities, age, unstable blood pressure.
PR: patient oxygen saturation is 98%. -Nitric acid
Interventions:
2- I: Monitor the patient for signs of respiratory distress. 1- Educate the patient to take blood pressure and heart
Rationale: signs and symptoms of respiratory distress include decreased LOC, endothelial cell every day simultaneously and take them before and after
decreased mental status, restlessness, RR less than 10 breaths per minute, use of dysfunction medication administration.
2- educate the patient to take their blood pressure
accessory muscles, and anxiety (Swearingen, 2016, p. 119).
medication on time.
RR: The patient did not have signs of respiratory distress; his RR was 18, A&OX4, and 3- Educate the patient to eat healthy, decrease fatty food,
he had no signs of anxiety, restlessness, or confusion. tissue microvascular cell programmed free radical and exercise.
hypoxia thrombus adhesion cell death damage

Management/Intervention:
3- I: adminitser Metromidazole (FLAGYL) 500mg IVPB q 8hrs. multiple organ
Rationale: Metronidazole binds and disrupts PNA structure, thereby blocking bacterial nucleic damage
acid synthesis, and early administration of antibiotics decreases inflammation in the lungs
(Skidmore, 2021, p. 846) (Swearingen, 2016, p. 119)
PR: the patient was given Metronidazole (FLAGYL) 500mg IVPB at 11:00.
poor metabolic acidosis 2 or more of SIRS criteria:
4- I: auscultate the patient's breath sounds q2-4 hours or as indicated by the patient's decreased altered mental
capillary thrombocytopenia causes increase fatigue
-Temp 101.3F on admission
urination status
refil lactate
health condition. -WBC count: 18.72k on admission
- Confusion
Rationale: absent or adventitious lung sounds like crackles and wheezing can signal the - HR > 90BPM
nurse about airway obstruction, hypoxia, fluids or air trapping (Swearingen, 2016, p. -RR > 20 breath/min
119).
PR: the patient has a clear lung. Sounds throughout except at the bases where crackles
are heard in the RLL and LLL. decreased UA:
mobility d/t -protein in the urine 30mg/dl - normal<30mg/dl
Hospitalization -Nitrate: positive - normal is negative or trace
Patient education: -WBC UA: 11-20 - normal is 0-5
5- I: Educate the patient on how and why they must use the IS four times/day -RBC UA: 3-5 - normal is 0-2
Lung sounds: Swollen legs (Edema in the -Squamous epithelial: 6-10 - normal is 0-5
Rationale: IS maximizes the expansion of the lungs and alveoli to help resolve the fluids in the -bacteria in urine: few - normal is none seen
Pneumonia Crackles at RLE & LLE) d/t pneumonia
atelectasis caused form pneumonia and mobilizes secretions (Swearingen, 2016, p. 47). lungs
the bases and hospitalization
PR: The patient used the IS two times a day during the 12-hour day of care.

6- I: teach the patient to use non-pharmaceutical techniques, deep breathing, and

listening to music along with exercising and resting periods Increase/unstable
Rationale: non-pharmaceutical breathing techniques decrease anxiety dyspnea and Blood pressure
help facilitate gas exchange (Swearingen, 2016, p. 119-120)
PR: The patient loves to go to the beach with his wife to help helo relax and decrease
stress-related anxiety.
BP: 159/86 Risk for DVT

Evaluation: at the end of the shift, the goal was met. AEB, no signs of complications or
respiratory distress were present, O2 saturation was 98%, a patient used the SI and
knows how to use it, and the reason SI is used. Enoxaparin (Lovenox)
80mg SQ daily at 11:00

If untreated or
unrecognized on
time
Lactate >2mmol/L
References
Hypotension <90/60 septic shock
Harding, M. M., Kwong, J., & Hagler, D. (2020). Lewis’s medical-surgical nursing: assessment and management of clinical problems. Elsevier. HR < 60

McCance, K. L., Huether, S. E., & Rote, N. S. (2019). Pathophysiology: The biologic basis for disease in adults and children. Mosby. MAP<65

Swearingen, P. L. (2016). All-in-one nursing care planning resource: Medical-surgical, pediatric, maternity, and psychiatric-mental health. Elsevier.
Death

PRIORITY NANDA #1:Infection R/T current diagnosis, age, foreign body invasion causing bacteremia AEB, the temperature on admission of 101.3F, lack of knowledge about infection
causes, WBC count on admission is 18.72k/cmm, neutrophils count on admission was 88%, the patient was dehydrated (tenting skin, forgets to drink fluids).

Goal: at the end of the shift, will have to remain free from signs and symptoms of infection. AEB temperature will stay within a normal range (96-99F), the culture won't be positive for
the pathogen, urine will be yellow, clear, and odorless, the patient will have >500ml of fluids intake by mouth, and patient WBC will be less than 10k, BP will be less than 120/80, Temp
will be less than 99F

Nursing assessment/intervention:
Assessment/Monitoring:
1- I: Assess the patient's vital signs for SIRS criteria q4 hrs and as needed.
Rationale: SIRS criteria can be an early sign to detect infections, and if 2 out of 4 results are abnormal, the patient can develop sepsis (Swearingen, 2016, p.445).
PR: The patient's temperature is 97.8, HR is 77, BP is 108/62, and WBC is 8.5k, and he is alert and oriented x4, with no signs of confusion present.
2- I: assess the patient's mental status, LOC q 4 hours and as needed.
Rationale: LOC questions are a late sign that the patient has an infection, and a quick intervention has to be done if there is an altered LOC as part of SIRS criteria.
PR: the patient could know his name, date of birth, today's date, and why he was at the hospital.

Management/Intervention:
3- I: Administer the patient's antibiotics, Cefepime 2g in 50ml NS IVPB over 30 mins Q12hrs.
Rationale: Cefepime is an antibiotic used to treat UTIs; it inhibits cell wall synthesis by binding to essential PBP to fight infections (Lexicomp, 2023).
PR: Cefepime 2g in 50ml NS IVPB over 30 mins was administered at 15:00.
4- I: adminitser Metromidazole (FLAGYL) 500mg IVPB q 8hrs.
Rationale: Metronidazole binds and disrupts PNA structure, thereby blocking bacterial nucleic acid synthesis (Skidmore, 2021, p. 846)
PR: the patient was given Metronidazole (FLAGYL) 500mg IVPB at 11:00.

Patient Education:
5- I: Collaborate with the PCT to ensure and remind the patient to increase fluid intake.
Rationale: dehydration can increase the risk of infection, and increasing fluid intake can help the body stay hydrated and flush the body.
PR: the patient had 840ml fluids by mouth and 700ml through IV infusion.
6- I: Educate the patient to have probiotics when discharged and not to discontinue his antibiotics when she feels better.
Rationale: Prolonged antibiotic use and/or stopping antibiotics abruptly can kill the normal flora in the body, and that can cause diarrhea and Cdiff (CDAD). Probiotics help restore the
good bacteria in the GI tract (Swearingen, 2016, p. 263).
PR: the patient was not educated about antibiotics use. He will be discharged on 10.21.23. The patient does not take probiotics at home

Evaluation: by the end of the shift, the goal was met AEB, Patient urine remained clear yellow odorless, culture results came out negative, lactate lab results were 1.6, no signs of
confusion present, VS at 16:00 were BP 135/98. Tem was 98.2. HR was 77, and the patient had 840ml of fluids PO (water, juice, coffee).