ben final case study osmak

8/13/2019 BEN Final Case Study OSMAK

1/24

Page | 1

CHAPTER I

INTRODUCTION

Normal micturition (urination) requires proper function of both the bladder and the

urethra, including normal compliance within the bladder detrusor muscle and a

physiologically competent urinary sphincter. Dysfunction in voiding can result from

mechanical or physiologic abnormalities in the urinary tract that lead to an inability of the

sphincter to appropriately increase or decrease its pressure when bladder pressure is

increased. Damage to or diseases of the CNS or within the peripheral or autonomic nervous

system may lead to neurogenic bladder dysfunction. Retrieved from

http://www.ajmc.com/publications/supplement/2013/ACE012_jul13_NGB/ACE012_jul1

3_NGB_Ginsberg1_S191#sthash.N5zsbhZN.dpuf.

Neurogenic bladder is impaired bladder function resulting from damage to the nerves

that govern the urinary tract. Various nerves converge in the area of the bladder and serve to

control the muscles of the urinary tract, which includes the sphincter muscles that normally

form a tight ring around the urethra to hold urine back until it is voluntarily released.

Retrieved from http://www.healthcentral.com/encyclopedia/408/391.html.

There are two major types of bladder control problems that are associated with a

neurogenic bladder. Depending on the nerves involved and nature of the damage, the bladder

becomes either overactive (spastic or hyper-reflexive) or underactive (flaccid or hypotonic).

Retrieved from (http://my.clevelandclinic.org/disorders/neurogenic_bladder/hic-

neurogenic-bladder.aspx).


2/24

Page | 2

Risk factors for neurogenic bladder include various birth defects, which adversely

affect the spinal cord and function of the bladder, including spina bifida or sacral agenesis

and other spinal cord abnormalities.

Symptoms including a dribbling urinary stream, straining during urination or inability

to urinate may also be associated with neurogenic bladder. Urinary retention may result either

from loss of bladder muscle contracting performance or loss of appropriate coordination

between the bladder muscle and the external urethral sphincter muscle. In addition, symptoms

of repeated UTIs or new findings of hydronephrosis (dilation of the kidneys) can be initial

symptoms of a neurogenic bladder. Patients with increased bladder pressures are at an

increased risk for UTIs.

Retrieved from (http://www.urologyhealth.org/urology/index.cfm?article=9).

A variety of techniques can be used depending on gender and age of the patient and

social environment. In most cases, intermittent bladder catheterization is necessary to obtain

complete evacuation of the bladder. Bladder capacity can be increased by anticholinergic

drugs, injection of botulinum toxin into the bladder, and augmentation cystoplasty. Retrieved

from (http://www.ncbi.nlm.nih.gov/pubmed/22182847).

Overall, the inability to control urination (incontinence) affects 8.5% of women and

1.6% of men between 15 to 64 years old. In the US, the incidence in individuals with multiple

sclerosis is 40% to 90%, Parkinson's disease 37% to 72%, and stroke 15% Retrieved from

(http://www.mdguidelines.com/neurogenic-bladder).

Purpose and objectives

This case study aims to present the different nursing care plans of a pediatric patient

diagnosed with UTI secondary to neurogenic bladder. This case study also aims to construct


3/24

Page | 3

personalized nursing care plans to meet the needs of the patient in order to promote healing

and recovery. This study seeks to accomplish the following objectives:

1. Identify the core problem and its contributing factors.

2. Formulate nursing care plans for the patient that are accurate and attainable.

3. Review if the care was beneficial to the client.

4. Acquire added knowledge on the disease process and improve on giving care.

5. Identify appropriate nursing diagnosis based from the significant findings

from the assessment

Significance of study

This study is intended to benefit the following:

To the patient,as the primary recipient of care, would improve health condition as a

response to the nursing interventions rendered.

To the family,as the secondary recipient of care, the results of this study will

enhance their awareness about the present disease and give them more knowledge about the

prevention of the care needed for maintaining health. They will also be able to utilize the

appropriate nursing interventions that will be rendered by the researcher.

To the researchers,the result of this study will improve knowledge and information

regarding the disease not common in the pediatric ward and to the problems identified. This

will also enhance their skills in rendering quality nursing care to families with the same

condition.


4/24

Page | 4

To the community, the study will be able to spread awareness and knowledge about

the said disease that can be community acquired. They will be able to utilize the appropriate

nursing interventions that will be rendered by the researcher.

To the health care providers, the result of this study will serve as a guide in

improving the delivery of professional health care to the families and this will also improve

collaboration of the health care team members on their discussion caring for a client with

similar condition.

Scopes and limitations

This study was conducted from January 23, 2014 to Januray 24, 2013 at the 3rdfloor

annex pedia ward of a tertiary hospital run by the city government of Makati. This study was

done on the researchers Pediatric Wardrotation from 0600H1400H during the 2013-2014

academic school year under the supervision of their clinical instructor. Information about the

patient was attained through care and assessment of the patient as well as review of the

patients chart and information. The researches, however, were only able to attain a small

amount of information from the client as the client was either unable to fully communicate

due to young age and condition experiencing. Also, information attained by the researchers

from the clients significant other was not enough to contribute to the formulation of the

clients nursing care plans.

Background of study

The study was conducted at selected tertiary hospital. A 717 bed capacity and has 814

staff physicians with different areas of medical specialty. The hospital offers state of the art

diagnosis, therapeutic and intensive care facilities and leads the way in the Philippines in


5/24

Page | 5

cardiac care, organic transplants and surgery, cancer treatment, neurology and neurosurgery,

and many other specialties of surgery.

Its vision is to be an internationally recognized medical center dedicated to excellence

in health care and to provide high- quality health care services through integrated specialty

centers operated by highly qualified physicians and nurses, as well as technical management

and staff which are professional in handling equipment and tools.

Specifically, the study was conducted in Pediatric Infectious Ward located on 3rd

floor Annex Building.


6/24

Page | 6

Chapter III

Client Presentation

This is a case of patient D.L.A. an 8 years old female who is Catholic and resides at

Makati City. She was admitted with the diagnosis of Urinary Tract Infection secondary to

neurologic bladder.

On January 14, 2014 patient was admitted to a tertiary hospital. History of present

illness showed that 6 days prior to hospitalization, patient had 2-4 episodes of vomiting, no

fever and good appetite. One day prior, patient had more than 5 episodes of vomiting, with

poor appetite and no fever. Patient was given oral rehydration solution. Few hours prior,

patient had 7 episodes of vomiting and was brought to the institution for consult. Also 6 days

prior, patient had seizure described as upward rolling of eyeballs, stiffing of extremities

which lasted for 1 minute. 4 days prior, another episode occurred with same characteristics

and one episode again yesterday.

On January 22, first day of the patient in a government hospital, vital signs were

temperature: 36.9C, PR: 68bpm, RR: 20cpm and BP: 90/60. Physician ordered IV fluid of

D50 3NaCl, 585ml x 6hrs at 32-33gtts/min. Physician ordered to place patient on nothing per

orem diet, stand by diazepam 4mg was ordered for acute seizure. Patient weight was 19.5kg,

hemoglobin was ordered to be monitored every 6hrs while on nothing per orem diet.

Complete blood count showed WBC: 14.8 x 10^g/L, Segmenters: 0.75, Lymphocytes: 0.14,

Monocytes: 0.07 and Platelet count 563 x 10^g/L. Urine test shows sodium (Na)

131mmol/Lt, chloride (Cl) 74 mmoL/Lt.

On January 23, first day of student nurse-patient interaction, patients vital signs at

1200H were temperature: refused, PR: 105bpm, RR: 20cpm and BP: refused. Physician


7/24

Page | 7

ordered ampicillin 730mg IV every 6hrs after negative skin test and gentamicin 50mg IV

every 8hrs. IV fluid was shifted to D5 1MB 1500ml to run for 24hrs. at the rate of 62

63gtts/minute. The physician ordered insertion of intermittent catheter. Patient has dry mucus

membrane, skin, poor skin turgor and weight loss from 22kg to 19.5kg. Nursing diagnosis of

Fluid volume decreases related to in adequate fluid intake as manifested by dry mucus

membrane and skin. She looks thin and malnourished and short for her age. Nursing

diagnosis formed was Imbalanced nutrition: less than body requirements related to

insufficient intake as evidenced by decrease in body weight. Patient was noticed hiding

her legs, and when she is being asked about her personal history, she doesnt give any

response. Patient was irritable and doesnt want to be touched by male student nurses. Cues

presented gives the nursing diagnosis of Impaired comfort related to present health

condition as manifested by irritability and fear.

On January 24, second day of student nurse patient interaction. Patients vital signs

at 1200H were temperature: 37C, PR: 100bpm, RR: 26cpm, BP: 90/70. Patient was awake,

active and responsive to stimulus. At 0800H, patient was still on nothing per orem diet and

medication were being continued. Intravenous fluid was still at D5 1MB 1500ml at the rate of

6263gtts/min. Urine output was 6 diapers with 2 bowel movement. Cues presented made it

possible for the researcher to come up with the nursing diagnosis of Acute urinary retention

related to neurological disease as manifested by bladder distension and difficulty

voiding.Patient was lying in bed for the whole time. She has limited ability to perform skills

and slowed movement. It made the researchers identified the nursing diagnosis of Impaired

physical mobility related to neuromuscular impairment as manifested by limited ability

to perform gross and motor skillsand nursing diagnosis of Self - care deficit related to

neuromuscular impairment as manifested by ability to perform activities of daily living.


8/24

Page | 8

With the current condition of the patient and impairment being experienced, researchers

identified the nursing diagnosis of Risk for injury related to generalized body weakness.


9/24

Page | 9

CHAPTER IV

Analysis and Interpretation

In accordance to the analysis and interpretation, necessary and appropriate interventions were

utilized to solve the problems identified and goals that are needed to be met by the client. It

aims to further discuss the problems identified by the researchers.

The Actual and Potential problems were identified to a client with Urinary tract infection

secondary to neurogenic bladder.

1. Urinary retention related to neurological disease as evidenced by bladder distentionand difficulty voiding

2. Fluid volume deficit related to inadequate fluid intake as evidenced by dry mucusmembrane and skin

3. Imbalanced nutrition: less than body requirements related to insufficient intake asevidenced by decrease in body weight

4. Impaired physical mobility related to neuromuscular impairment as evidenced bylimited ability to perform gross or fine motor skills

5. Self-care deficit related to neuromuscular impairment as evidenced by inability toperform activity of daily living

6. Impaired comfort related to present health condition as manifested by irritability andfear

7. Risk for injury related to generalized body weakness

Nursing Diagnosis #1 Total urinary incontinence r/t neuropathy preventing

transmission of reflex indicating bladder fullness.

Inability of usually continent person to reach toilet in time to avoid unintentional loss of

urine. NANDA (2012)


10/24

Page | 10

Several muscles and nerves must work together for your bladder to hold urine until

you're ready to empty it. Nerve messages go back and forth between the brain and the

muscles that control bladder emptying. If these nerves are damaged by illness or injury, the

muscles may not be able to tighten or relax at the right time. The muscles and nerves of the

urinary system work together to hold urine in the bladder and then release it at the appropriate

time. Nerves carry messages from the bladder to the spinal cord and brain and from the

collections of nerves in the peripheral nervous system to the muscles of the bladder telling

them either to tighten or release. In a neurogenic bladder, the nerves that are supposed to

carry these messages do not work properly. Urine retention often happens if the muscles

holding urine in do not get the message that it is time to let go.

The John Hopkins University. (2014). Retrieved from

http://www.hopkinsmedicine.org/healthlibrary/conditions/kidney_and_urinary_system_

disorders/neurogenic_bladder_85,P01487/

The interventions rendered to the patient are the following:

Monitor vital signs, assess amount, frequency, and character (color, odor, and specific

gravity) of urine, monitor urinalysis, urine culture, and sensitivity because urinary tract

infection can cause retention, but is more likely to cause frequency, encourage clients to

urinate every 2 to 4 hours to minimize excessive retention of urine in the bladder, supervise

and record time, the number of each micturition to note the decrease in spending and changes

in urine specific gravity because urinary retention increases the pressure in the upper urinary

tract that can affect the kidneys,percuss/palpate suprapubic area because a distended bladder

can be felt in the suprapubic area and instruct patient or caregiver on measures to help

voiding.
http://www.hopkinsmedicine.org/healthlibrary/conditions/kidney_and_urinary_system_disorders/neurogenic_bladder_85,P01487/http://www.hopkinsmedicine.org/healthlibrary/conditions/kidney_and_urinary_system_disorders/neurogenic_bladder_85,P01487/http://www.hopkinsmedicine.org/healthlibrary/conditions/kidney_and_urinary_system_disorders/neurogenic_bladder_85,P01487/http://www.hopkinsmedicine.org/healthlibrary/conditions/kidney_and_urinary_system_disorders/neurogenic_bladder_85,P01487/


11/24

Page | 11

At the end of the shift, the patient usually urinates through catheter, her urine was

color dark yellow. Her bladder was distended and her mother usually palpates her bladder to

induce urination.

Nursing Diagnosis # 2: Fluid volume deficit related to inadequate fluid intake as

evidenced by dry mucous membrane and skin

At risk for experiencing vascular, cellular, or intracellular dehydration. NANDA

(2012)

Fluid volume deficit, or hypovolemia, occurs from a loss of body fluid or the shift of fluids

into the third space, or from a reduced fluid intake. Common sources for fluid loss are the

gastrointestinal (GI) tract, polyuria, and increased perspiration. Fluid volume deficit may be

an acute or chronic condition managed in the hospital, outpatient center, or home setting. The

therapeutic goal is to treat the underlying disorder and return the extracellular fluid

compartment to normal. Treatment consists of restoring fluid volume and correcting any

electrolyte imbalances. Early recognition and treatment is paramount to prevent potentially

life-threatening hypovolemic shock. Elderly patients are more likely to develop fluid

imbalances.

Elsevier. (2014). Retrieved from

http://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Constructor/gulanick21.

html


Monitor vital signs, record the intake and output accurately, assess skin turgor,

mucous membranes and complaints of thirst, assess neurological status, encourage to drink

plenty of fluids, monitor IVF every hour, Instruct the significant others to report immediately

for signs of dehydration such as poor skin turgor, slow capillary refill, and dry mouth and

xxplain importance of maintaining proper nutrition and hydration


12/24

Page | 12

At the end of 8 hours shift, patient was still on nothing per orem diet with the output

of 6 diapers and 2 bowel movement. She has dry mucous membrane, skin and poor skin

turgor. Intravenous fluid was D5 1MB 1500cc, regulated at 62-63 gtts/min for 24 hrs at the

left hand infusing well.

Nursing Diagnosis # 3: Imbalanced nutrition: less than body requirements related to

insufficient intake as evidenced by decrease in body weight

Impaired ability to perform or complete feeding, bathing/hygiene, dressing and

grooming, or toileting activities for oneself. NANDA (2012).

Adequate nutrition is necessary to meet the body's demands. Nutritional status can be

affected by disease or injury states (e.g., gastrointestinal [GI] malabsorption, cancer, burns),

physical factors such as muscle weakness, poor dentation, activity intolerance, pain,

substance abuse, social factors such as lack of financial resources to obtain nutritious foods,

or psychological factors such as depression or boredom. During times of illness (trauma,

surgery, sepsis, burns) adequate nutrition plays an important role in healing and recovery.

Cultural and religious factors strongly affect the food habits of patients. Women exhibit a

higher incidence of voluntary restriction of food intake secondary to anorexia, bulimia, and

self-constructed fad dieting. The elderly likewise experience problems in nutrition related to

lack of financial resources, cognitive impairments causing them to forget to eat, physical

limitations that interfere with preparing food, deterioration of their sense of taste and smell,

reduction of gastric secretion that accompanies aging and interferes with digestion, and social

isolation and boredom that cause a lack of interest in eating.


http://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Constructor/gulanick36.

html
http://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Constructor/gulanick36.htmlhttp://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Constructor/gulanick36.htmlhttp://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Constructor/gulanick36.htmlhttp://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Constructor/gulanick36.html


13/24

Page | 13


Determine attitude toward eating and foods, weigh patient weekly, discourage

beverages that are caffeinated or carbonated, encourage passive exercise to enhance

metabolism and utilization of nutrients, reinforce the following to the patients parents: the

basic four groups, as well as the need for specific minerals and vitamins and importance of

maintaining adequate caloric intake because food high in calories and proteins that promote

weight gain and nitrogen.

At the end of the shift, the patient was as recorded was 19.5kg from 22kg. Her mother

verbalized understanding about the importance of having a balanced meal equipped with the

necessary vitamins and minerals

Nursing Diagnosis # 4: Impaired physical mobility related to neuromuscular

impairment as evidenced by limited ability to perform gross or fine motor skills

State in which an individual has a limitation in independent, purposeful physical

movement of the body or of one or more extremities. (NANDA, 2012).

Alteration in mobility may be a temporary or more permanent problem. Most disease

and rehabilitative states involve some degree of immobility, as seen in strokes, leg fracture,

trauma, morbid obesity, multiple sclerosis, and others. With the longer life expectancy for

most Americans, the incidence of disease and disability continues to grow. And with shorter

hospital stays, patients are being transferred to rehabilitation facilities or sent home for

physical therapy in the home environment. Mobility is also related to body changes from

aging. Loss of muscle mass, reduction in muscle strength and function, joints becoming

stiffer and less mobile, and gait changes affecting balance can significantly compromise the

mobility of elder patients. Mobility is paramount if elder patients are to maintain any


14/24

Page | 14

independent living. Restricted movement affects the performance of most activities of daily

living (ADLs).

Elsevier. (2014). Retrieved fromhttp://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Constructor/gulanick40.

html


Monitor and record vital signs to establish baseline data, note for skin turgor /oral

Mucous membranes for signs of dehydration, determine patients mental status for baseline

data, maintain IVF for hydration, instruct the patient to wear light clothing to avoid

perspiration, encourage adequate intake of fluids and nutritious foods like: fruits and

vegetables to maximize energy production and aides in fast recovery, situate the patient in a

position of comfort, reposition patient frequently, or at least every 2 hours, instruct significant

others to assist with feedings as appropriate proper nutrition and hydration and document

nursing procedures done and endorse accordingly for further assessment and management.

At the end of 8 hours shift, the patient partially participated in activity of daily living

and (-) foot drop and (-) bedsore.

Nursing Diagnosis # 5: Self-care deficit related to neuromuscular impairment as

evidenced by inability to perform activity of daily living

Impaired ability to perform or complete activities of daily living, such as feeding,

dressing, bathing, toileting. (NANDA, 2012).

Self-care is the practice of activities that mature person initiates and performs

independently within time frame, to promote and maintain personal well-being, healthful

functioning and continuing development throughout life. Orem's (1985) self- or dependent-

care deficit theory is a useful basis from which the care of the chronically ill pediatric

population can be planned. Attention is given to a caring relationship in which there is a
http://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Constructor/gulanick40.htmlhttp://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Constructor/gulanick40.htmlhttp://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Constructor/gulanick40.htmlhttp://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Constructor/gulanick40.html


15/24

Page | 15

dependent person in need of care and an individual who serves as that dependent person's

agent of care.

US National Library of Medicine: National Institue of HElath. (2014). Retrieved from

http://www.ncbi.nlm.nih.gov/pubmed/2133143


Determine age affecting ability of individual to participate in own care, note

concomitant medical problems/existing conditions that may be factors for care, identify

degree of individual impairment/ functional level according to scale, determine individual

strengths and skills of the client, perform/assist with meeting clients needs when he or she is

unable to meet own needs, identify preferences, food, personal care items, and other things,

and encourage family to provide assistance to the needs of the patient.

At the end of the shift, patient can move her hand and fingers, she was not able to

stand and sit on his own. The patient was assisted by her mother when changing clothes and

diapers as observed by the student nurse. The family verbalized understanding on providing

assistance for the care of the patient.

Nursing Diagnosis # 6: Impaired comfort related to present health condition as

manifested by irritability and fear

Perceived lack of ease, relief, and transcendence in physical, psychospiritual,

environmental, and social dimensions. (NANDA, 2012).

A highly subjective state in which a variety of unpleasant sensations and a wide range

of distressing factors may be experienced by the sufferer. Pain may be acute, a symptom of

injury or illness such as a myocardial infarction, or chronic, lasting longer than 6 months, the

result of a long-term illness such as arthritis. Pain may also arise from emotional,

psychological, cultural, or spiritual distress. Pain can be very difficult to explain, because it is

unique to the individual; pain should be accepted as described by the sufferer. Pain
http://www.ncbi.nlm.nih.gov/pubmed/2133143http://www.ncbi.nlm.nih.gov/pubmed/2133143


16/24

Page | 16

assessment can be challenging, especially in the elderly, where cognitive impairment and

sensory-perceptual deficits are more common.


http://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Constructor/gulanick39.html


Monitor vital signs and note for any significant changes, determine the location,

characteristic, duration, frequency, quality, intensity, and aggravating factors of pain, observe

patients skin texture and temperature, encourage of verbalization of feelings and deep

breathing exercise, encourage mother to keep the patients nail short to prevent skin trauma

when scratching, provide a non-pharmacological methods for promoting comfort: back rubs,

slow rhythmic breathing, and repositioning and provide a quiet environment conducive for

rest and sleep.

At the end of the shift, patient was repositioned and engaged with diversional

activities like eating. Patient had adequate rest period

7. Risk for injury related to generalized body weakness

The risk of injury as a result of the interaction of environmental conditions with

individual adaptive response and defense sources. NANDA (2012)

Safety, often defined as freedom from psychological and physical injury, is a basic

human need. Health care, provided in a safe manner, and a safe community environment are

essential for a patient s survival and well-being. A safe environment reduces the risk for

illness and injury and helps to contain the cost of health care by preventing extended lengths

of treatment and/or hospitalization, improving or maintaining a patient s functional status,

and increasing the patient s sense of well-being.


17/24

Page | 17

Elsevier. (2014). Retrieved from:

http://www.us.elsevierhealth.com/Nursing/Fundamentals-and-Skills/book

/9780323079334/ Fundamentals-of-Nursing/


Assess patients condition to note if there are signs of injury. Assess mood, coping

abilities, personality styles that may result in carelessness to determine the level of

cooperation. Encourage companion not to leave the patient to prevent injury by a close.

Make use of pillows as cushion from side rails to prevent injury. Keep side rails raised to

prevent injury.

At the end of the shift, the patient had shown no sign of injury as evidenced by: (-

) Fall, (-) Confusion, (-) Scratches, (-) Bruises, and (-) Redness.
http://www.us.elsevierhealth.com/Nursing/Fundamentals-and-Skills/bookhttp://www.us.elsevierhealth.com/Nursing/Fundamentals-and-Skills/book


18/24

Page | 18

CHAPTER V

SUMMARY OF FINDINGS, CONCLUSION, AND RECOMMENDATIONS

I. Factors that led to the development of the conditionPredisposing Factors:

Precipitating Factor:

II. Interrelationship of factors identified that led to the development of theproblem

III. Relevant interventions to be rendered to the patientNursing Diagnosis # 1: Urinary retention related to neurological disease as manifested

by bladder distension and difficulty of voiding

Monitor vital signs. Assess amount, frequency, and character (color, odor, and specific gravity) of

urine.

Monitor urinalysis, urine culture, and sensitivity. Rationale: Urinary tractinfection can cause retention, but is more likely to cause frequency

Encourage clients to urinate every 2 to 4 hours.Rationale: Minimizingexcessive retention of urine in the bladder.

Supervise and record time, the number of each micturition. Note the decreasein spending and changes in urine specific gravity. Rationale: urinary retention

increases the pressure in the upper urinary tract that can affect the kidneys.


19/24

Page | 19

Percuss/palpate suprapubic area. Rationale: A distended bladder can be felt inthe suprapubic area.

Institute intermittent catheterization. Rationale: Because many causes ofurinary retention are self-limited, the decision to leave an indwelling catheter

in should be avoided.

Educate patient or caregiver about the importance of adequate intake, (e.g., 8to 10 glasses of fluids daily).

Instruct patient or caregiver on measures to help voiding.Nursing Diagnosis # 2: Fluid volume deficit related to in adequate fluid intake as

manifested by dry mucus membrane and skin

Monitor vital signs. Record the intake and out put accurately Assess skin turgor, mucous membranes and complaints of thirst. Assess neurological status. Encourage to drink plenty of fluids. Monitor IVF every hour Instruct the significant others to report immediately for signs of dehydration

such as poor skin turgor, slow capillary refill, and dry mouth

Explain importance of maintaining proper nutrition and hydrationNursing Diagnosis # 3: Imbalanced nutrition: less than body requirements related to

insufficient intake as evidenced by decrease in body weight

Determine attitude toward eating and foods


20/24

Page | 20

Weigh patient weekly Discourage beverages that are caffeinated or carbonated Encourage passive exercise to enhance metabolism and utilization of nutrients Reinforce the following to the patients parents:

o The basic four groups, as well as the need for specific minerals and

vitamins

o Importance of maintaining adequate caloric intake

o Foods high in calories and proteins that will promote weight gain and

nitrogen

Nursing Diagnosis # 4: Impaired physical mobility related to neuromuscular

impairment as manifested by limited ability to perform gross and motor skills

Monitor and record vital signs. Rationale: To establish baseline data. Note for skin turgor /oral Mucous membranes for signs of dehydration. Determine patients mental status for baseline data. Maintain IVF for hydration Instruct the patient to wear light clothing to avoid perspiration Encourage adequate intake of fluids and nutritious foods like: fruits and

vegetables. Rationale: Maximize energy production and aides in fast recovery.

Situate the patient in a position of comfort Reposition patient frequently, or at least every 2 hours Instruct significant others to assist with feedings as appropriate proper

nutrition and hydration


21/24

Page | 21

Nursing Diagnosis # 5: Self - care deficit related to neuromuscular impairment as

manifested by ability to perform activities of daily living.

Determine age affecting ability of individual to participate in own care. Note concomitant medical problems/existing conditions that may be

factors for care.

Identify degree of individual impairment/ functional level according toscale:

0-completely independent. 1-requires use of equipment/device 2-requires help from another person for assistance, supervision/teaching 3-requires help from another person and equipment device 4-dependent, does not participate activity Determine individual strengths and skills of the client Perform/assist with meeting clients needs when he or she is unable to meet

own needs.

Identify preferences, food, personal care items, and other things. Encourage family to provide assistance to the needs of the patient.

Nursing Diagnosis #6: Alteration in comfort related to present condition as evidenced

by irritability and fear

Monitor vital signs and note for any significant changes Determine the location, characteristic, duration, frequency, quality, intensity,

and aggravating factors of pain.

Observe patients skin texture and temperature


22/24

Page | 22

Encourage of verbalization of feelings and deep breathing exercise Encourage mother to keep the patients nail short to prevent skin trauma when

scratching

Provide a non-pharmacological methods for promoting comfort: back rubs,slow rhythmic breathing, and repositioning

Provide a quiet environment conducive for rest and sleepNursing Diagnosis # 7: Injury related to generalized body weakness

Assess patients condition. Rationale: To note if there are signs of injury. Assess mood, coping abilities, personality styles that may result in

carelessness. Rationale: To determine the level of cooperation.

Encourage companion not to leave the patient. Rationale: To prevent injury bya close.

Make use of pillows as cushion from side rails. Rationale: To prevent injury. Keep side rails raised. Rationale: To prevent injury.

IV. Expected responses of the patient towards the interventionsThe nursing diagnoses which goals were fully met are the following:

Impaired physical mobility related to neuromuscular impairment as evidencedby limited ability to perform gross or fine motor

Self-care deficit related to neuromuscular impairment as evidenced byinability to perform activity of daily living

The nursing diagnoses which goals were partially met are the following:

Urinary retention related to neurological disease as evidenced by bladderdistention and difficulty voiding


23/24

Page | 23

Fluid volume deficit related to inadequate fluid intake as evidenced by drymucous membrane and skin

Imbalanced nutrition: less than body requirements related to insufficientintake as evidenced by decrease in body weight

Impaired comfort related to present health condition as manifested byirritability and fear

CONCLUSION AND RECOMMENDATIONS

Conclusion

Based on the summary of findings and data gathered, the researchers therefore

concluded that the factors which led to the development of patients actual and potential

health problems are predisposing, and precipitating factors. The potential problems were

analyzed to determine the relationship of one another to create a nursing care plan based on

clients needs. The client related factors that promoted in meeting the needs of the patient and

in preventing further complication were holistic because the rendered care covered the whole

aspect of the patient. The 12 core competencies were considered the base line upon the

utilization of the nursing process including the skills, knowledge and attitude, and through

therapeutic communication, rapport has been achieved and maintained from initial

assessment until the end of the shift. The attainment of the outcome indicators and/or client

outcome as the basis for evaluation was included.

Recommendations

Based on the summary of the findings and conclusion, the researchers formulated the

following recommendations to improve findings and to provide information regarding the

disease.


24/24

To the relatives and significant others, to be more aware regarding the

patients condition. Always monitor and report immediately for any complication

seen to the patient. Encourage them to render care and always provide support to

client.

To the student nurse, acquire knowledge regarding the case before handling

the patient to assess and diagnose the patient and properly do the appropriate

interventions. They can improve their clinical skills through the application of their

learning. The application of the researchers knowledge and nursing care will

contribute to the improvement of the patients condition. They may provide education

regarding the health condition of the client based on the actual and potential problems

that they recognized through interview and observation.

To the health care staff, they should always monitor the condition of the

client. Provide health teaching and update the family regarding the current health

status of the patient. Establish rapport and use therapeutic communication so that it

could build a trusting relationship. Always respect the client.

Future Researchers, conduct a further research and study in the care of the

client with Urinary Tract Infection secondary to neurologic bladder on the areas that

needs improvement. Provide a copy as a basis and serve as a reference with a new

innovations and developments for the future researchers.

ben final case study osmak

Documents