BETHLEHEM UNIVERSITY

FACULTY OF NURSING & HEALTH SCIENCES

NURS 334-335
Nursing Care Plan (20%)
STUDENT NAME: MALAK ZUGHAYYER___SETTING:ALAHLI DATE:14/3/2023__________

DEMOGRAPHIC DATA: (3%)

Patient's Initials: R.I Date of Admission:24/2/2023 Ward: surgical
Medical DX: Urosepsis PYONEPHROSIS
Diet: normal IV Fluids type and amount/24 hours):
IV Fluid Type: perfalgan Amount: 1000mg Output: In the morning 700cc At the end of the shift:
100cc
Vital Signs: T= 37.8 P=80 BP=127/60 Sat=90%
Pain: Assessment Tool :numerical scale Pain Score=no pain
Pain management_____

LAB. Tests: (1.5%)

BUN , Creatinine, Na, K, Chloride .
Indicate if pt. has abnormal results in labs test with rational and treatment for this
abnormality. BUN are high than normal limit due to presence of infection
Treatment : treatment of urosepsis and prescribing antibiotics.
Major DX. Tests: (1.5%) : LT upper-uritric stone ( imbacted uritiric ston 9mm ) severe hydrourtral
nephrosis.
DRUGS (NAME, DOSE, AND ROUTE & RATIONAL): (4%)
NO NAME DOSE & ROUTE RATIONAL
. FREQUENCY
1. GENTAMICIN 7.5MG/ 1*3 IV ANTIBIOTIC
2. LASIX 40MG IV DIURETIC

Care Plan (10%)

Write down 3 Nursing Diagnosis According to the Priority and start with actual one:

NURSING ACTION RATIONAL EVALUATION

1
 DIAGNOSIS
(NANDA FORMAT)
DX. (1):
Hyperthermia related 1. Administer 1. Antipyretics Ongoing.
to dehydration as antibyretics as can help
manifested by skin indicated regulate body
warm to touch and . temperature.
flushed skin . 2. Institute cooling 2. Removing
measures. extra clothing
and linen can
help reduce
body
temperature.
3. Increase fluid 3. Hyperthermia
intake. can cause
rapid
dehydration,
to
compensation
of lost fluids.
Planning/Goals
Expected outcome
After 1 day of nursing
intervention the pt
will maintain a core
body temperature
within normal limit.
DX. (2):
Septic shock related to 1. Monitor the 1. Urine
unstable vital signs. patient’s intake production is
and output. evidence of
how well the
kidneys are
perfusing.
2. Provide adequate 2. Iv fluids are
fluid. necessary to
manage
hypotension.

2
 3. Continuous
3. Continues monitoring of
monitoring the pt. V/S is
necessary to
monitor the
effectiveness
of treatment
and the status
of the pt.
Planning/Goals
Expected outcome
After 2 days of nursing
interventions,the pt
will have stable V/S
and palpable peripheral
pulses.

DX. (3):
Impaired Urinary Ongoing
Elimination related to 1. Educate on proper 1. Appropriate
infections as manifested hygiene. cleansing
by dysuria. will
decrease
risk of
infections
which can
further
contribute to
impaired
urinary
elimination
2. Promote continued 2. To decrease
mobility. risk of
developing
UTI..
Planning/Goals After 2 days of nursing
Expected outcome intervention ,the pt will
achieve normal urinary
elimination pattern .

3
4