Health Medical
NU 371 GCU White Discharge from Penis Care Plan Template

NU 371

Grand Canyon University

NU

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Georgian Court University-Hackensack Meridian Health School of Nursing NU 371 Evidenced-based Nursing Care of the Adult Guidelines for Clinical Case Study Grading Guidelines COMPONENT ELEMENTS Pathophysiology Narrative explanation (6) • Related to patient’s diagnosis • Pathophysiological explanation of signs & symptoms • Diagram (5) • Risk factors, medical history • Signs & symptoms Nursing Process • Emphasize related lab and/or diagnostic test results (6) • Current medications, doses & indications for taking it (6) INDICATOR Focused Relevant Comprehensive Clear POINTS 11 Focused Relevant Comprehensive Clear 73 Nursing Diagnosis (6) Total of 3 Nursing diagnosis) • Two Actual; One Potential Nursing Plan (15) (1 short and 1 long term goal for each diagnosis) Nursing Interventions (30) (1 intervention from each category below for each of your 3 Nursing diagnosis) • • • • • References which support these interventions should be included Evidence based interventions Culturally based interventions Age appropriate interventions Patient and family teaching interventions Safety interventions Interdisciplinary plan of care (10) • Integration of recommendations from other care providers and why Evaluation of interventions Grammar, APA Summarize the effectiveness of your nursing care, and the interventions that you chose (10) Abstract, 5 references; Nursing Journals or text books ONLY Focused Relevant Comprehensive Clear No source older than 5 yrs 10 6 Georgian Court University-Hackensack Meridian School of Nursing CLINICAL CASE STUDY Case Study is on a 75-year-old male patient who was taken to the Emergency Room by his son because of an increase of white discharge from the penis on urination, patient was admitted on the 26th of January 2020 for further evaluation. Patient was experiencing a UTI prior to the ED visit, but was being treated with antibiotics for it. Patient has a history of end stage kidney disease, ischemic heart disease, diabetes mellitus hypertension, hyperlipidemia, dementia, dialysis. BIOGRAPHICAL DATA Patient Initials: _S.M. _ Unit: __3East @ Bayshore_ Date of Admission: __01/26/2020__ Age: _75_ Sex: _M_ Race: _Arabic_ Referral: _Family____ (Self, Family, physician) FAMILY HISTORY Diabetes – Mother Diabetes - Father HISTORY OF PRESENT ILLNESS End Stage Kidney Disease Need for Dialysis Intractable Constipation Absence of sensation Toxic Metabolic Encephalopathy Moderate malnutrition Ischemic Heart Disease CURRENT MEDICAL DIAGNOSIS Urinary Tract Infection: Serratia Marcescens End Stage Kidney Disease PAST MEDICAL HISTORY PSYCHOSOCIAL HISTORY Hypertension Hyperlipidemia End Stage Renal Disease Chronic Kidney Disease Depression – Dementia Diabetes Mellitus BS89 Dialysis Patient Dementia Depression Past Surgery: Cholecystectomy Right Hip replacement Vascular Surgery – Left Arm Fistula DEFINITION OF DISORDER ESRD : PATHOPHYSIOLOGY Head to Toe Assessment General LOC Patient is in bed, resting with eyes closed, no apparent distress at the moment. ¾ side rails up, with AVASYS video monitoring in place, call bell within reach, bed alarm on. Full level of consciousness. Orientation AAO x 1 to Self. Patient is confused, and follows commands sometimes. Vitals Pain Blood Pressure: 123/63 Heart Rate: 99 Respiratory Rate: 18 O2 Saturation: 95% on Room Air Temperature: 98.2 F - Axillary No Pain. Monitor Heart Monitor in place. Alarms set at 50 and 150. Head Pupils are pinpoint, round and reactive to light. Neck No distended neck veins, carotid palpable, no bruits. Chest No abnormalities. Heart sounds S1 and S2 present. No murmur noted. Respiratory Respirations 18bpm. Breathing is even, regular, and unlabored. Equal chest expansion. Capillary refill – 2 seconds. Abdomen Abdomen is flat, nondistended. Bowel sounds present and active in all 4 quadrants, Upper Extremities Full movement, pulses present, no edema. Lower Extremities Full movement, pulses present, no edema. ROM Range of Motion x4, Full movement, weakness. Nonambulatory. Skin Skin is intact. No breakdown. Appropriate even skin tone. Skin turgor, return in 1 second. Pulses All pulses in all 4 extremities are present, bounding +2. Tubes/Drains No tubes or drains present. IV IV and IV dressing is Clean, dry and intact. Flushed, Infusing. (Right Posterior Forearm) Other Lab Values LAB /NORMAL VALUE WBC RBC HGB HCT Glucose Creatinine Calcium PATIENT’S CURRENT VALUE RELATED TO WHICH PRIORITY DIAGNOSIS? 5.9 3.3 9.7 32.4 285 6.14 8.2 Pharmacological Agents DRUG NAME Generic/Trade Classification Acetaminophen Apixaban Aspirin Calcium acetate Carvedilol Ceftriaxone Insulin Lispro Ondansetron Pravastatin Quetiapine Sertraline Trazadone DOSE ROUTE FREQUENCY 650mg 2.5mg 81mg Oral Oral Oral Q 6 hrs PRN b.i.d. DAILY 667mg Oral t.i.d. 3.125mg 1g/D5W 50mL 100 unit/mL Oral IV Q 12 hrs Continuous SUBQ 4 times daily, before meals and nightly Q 6 hrs PRN DAILY t.i.d. Nightly Nightly PRN 4 mg 40 mg 50 mg 25 mg 150mg IV Push Oral Oral Oral Oral RATIONALE Why is the patient receiving this drug NURSING IMPLICATIONS Nursing Diagnosis Short Term Goal Long Term Goal #1 #2. Risk Nursing Interventions for each Diagnosis Dx #1 Intervention Evidence based Culturally based Age appropriate Patient and family teaching Safety Rationale Goal Reference Dx #2 Evidence based Culturally based Age appropriate Patient and family teaching Safety Intervention Rationale Goal Reference (Brief) Dx #3 Evidence based Culturally based Age appropriate Patient and family teaching Safety Intervention Rationale Goal Reference (Brief) Interdisciplinary plan of care: Summary: References: (COMPLETE APA FORMAT OF ALL REFERENCES) CUT/COPY/PASTE Pathophysiology Diagram of Disease HERE: ...
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Georgian Court University-Hackensack Meridian School of Nursing
CLINICAL CASE STUDY
Case Study is on a 75-year-old male patient who was taken to the Emergency Room by his son because of an increase of white discharge
from the penis on urination, patient was admitted on the 26th of January 2020 for further evaluation. Patient was experiencing a UTI prior to
the ED visit, but was being treated with antibiotics for it. Patient has a history of end stage kidney disease, ischemic heart disease, diabetes
mellitus hypertension, hyperlipidemia, dementia, and dialysis.

BIOGRAPHICAL DATA
Patient Initials: _S.M. _
Unit: __3East @ Bayshore_
Date of Admission:
__01/26/2020__
Age: _75_ Sex: _M_ Race:
_Arabic_
Referral: _Family____
(Self, Family, physician)

FAMILY HISTORY
Diabetes – Mother
Diabetes - Father

HISTORY OF PRESENT
ILLNESS
End Stage Kidney Disease
Need for Dialysis
Intractable Constipation
Absence of sensation
Toxic Metabolic Encephalopathy
Moderate malnutrition
Ischemic Heart Disease

CURRENT MEDICAL
DIAGNOSIS
Urinary Tract Infection: Serratia
Marcescens
End Stage Kidney Disease

PAST MEDICAL HISTORY

PSYCHOSOCIAL HISTORY

Hypertension
Hyperlipidemia
End Stage Renal Disease
Chronic Kidney Disease
Depression – Dementia
Diabetes Mellitus BS89
Dialysis Patient

Dementia
Depression

Past Surgery:
Cholecystectomy
Right Hip replacement
Vascular Surgery – Left Arm Fistula
DEFINITION OF DISORDER

PATHOPHYSIOLOGY

ESRD: Also called kidney failure. It is
the last stage of chronic kidney disease.
When the kidney of the patient fails, it
means they have stopped working well
enough to sustain good health. As such
the patient requires dialysis or kidney
transplant.

The decline of proper functioning
of the kidney may be gradual and
initially may begin to present
asymptomatically. The renal
failure may begin with early
homeostatic mechanisms
involving hyper-filtration of the

nephrons. As the nephrons are
damaged further, the rate of
filtration in the kidney increases.
At this time, the patient may not
experience any signs and may
show normal creatinine values
and the disease may not be
detected for quite some time. The
adaptive mechanism may
continue running and may
eventually cause to the glomeruli
of the remaining nephrons.

Head to Toe Assessment
General
LOC

Patient is in bed, resting with eyes closed, no appa...

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