Nursing Care Plan

N.C.P 1

Nursing Care Plan

Catherine Traylor

F.H.

January 31,2007

Karen Ruffin

Mercer County Community College

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Abstract

F.H. is an 83 year old male, whom was cared for on January 31,2007 by the writer. He was

admitted to Capital Health System at the Mercer Campus with diagnoses of an Urinary

Tract Infection and Generalized Weakness. F.H. also had pre-existing medical condition

prior to being admitted. Plan of care for F.H. had to be designed to accommodate his

existing and pre-existing medical conditions.

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Nursing Care Plane

Demographic

F.H. is a 83 year old white male, whom was admitted to the hospital with a diagnoses of

Urinary Tract Infection and Generalized Weakness. He also has Chronic Obstructive Pulmonary

Disease, Degenerative Joint Disease, Neurogenic Bladder, Chronic Renal Dysfunction,

Depression, and age related Dementia. F.H. is a widower, who retired from his profession about

20 years ago. His primary and only spoken language is English. F.H. lives in his home located in

the Central part of New Jersey with a 24 hour caregiver.

Upon entering F.H. room he was calmly sitting in a chair working on a crossword puzzle

from a newspaper. He appeared to be relaxed and comfortable, dressed in a hospital gown. As the

writer observed F.H., it was noted that the client was awake, alert, and oriented times three, he

was receiving 2L of oxygen via nasal cannula. Client skin appearance was dry, intact, and had an

even pink tone, as I palpated the skin it was smooth; warm with good skin turgor. F.H. blood

pressure was 139/62, pulse rate of 84, respiration rate of 18, and oxygen saturation of 99%. Upon

auscultation of his lungs there was wheezing in all fields of the left lung and at the base of the

right lung on expiration, all of the other fields where clear. F.H abdomen was soft, round, and

non tender with positive bowel sounds in all 4 quadrants. Clients oral temperature was 97.1, and

he denied the presence of any pain stating that it was a 0 on a 0-10 scale.

F.H. was admitted to Capital Health System with medical diagnosis of a Urinary Tract

Infection and Generalized Weakness. Normally, urine is sterile, it is usually free of bacteria,

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viruses, and fungi. An infection occurs when tiny organisms, usually bacteria from the digestive

tract, cling to the opening of the urethra and begin to multiply. The urethra is the tube that carries

urine from the bladder to outside the body. Most infections arise from one type of bacteria,

Escherichia coli, which normally lives in the colon. In many cases, bacteria first travels to the

urethra and multiplies, causing an infection. An infection limited to the urethra is

called urethritis. The urinary system is structured in a way that helps ward off infection. The

ureters and bladder normally prevent urine from backing up toward the kidneys, and the flow of

urine from the bladder helps wash bacteria out of the body. In men, the prostate gland produces

secretions that slow bacterial growth. In both sexes, immune defenses also prevent infection. But

despite these safeguards, infections still occur.

A common source of infection is catheters, or tubes, placed in the urethra and bladder. A

person who cannot void or who is unconscious or critically ill often needs a catheter that stays in

place for a long period time (www.niddk.nih.gov). In F.H. particular case, he has a surgical

insertion of a suprapubic cystostomy due to a nervous system disorder, that caused him to lose

bladder control. Often time if the catheter is not properly care for bacteria can invade the catheter

and cause an infection in the bladder (Potter & Perry 2006).

The Generalized weakness is one of the most common medical complaints of Seniors.

F.H. weakness is possibly due to poor diet and/or renal dysfunction. Generalized weakness can

be the result of many illness, so to assign this symptom to one disease process is difficult to do,

but overall It is characterized by muscle