November , 2023
Priority #__1__
Nsg. Dx:
Deficient Knowledge related to frequent
bacterial infections as evidenced by frequent
hospitalizations.
Assessment Data:
11/26
BP 112/71
HR-75
Respiration 17
Temp 97.4
SPO2 98%
Weight for 44.7 kg
11/27
BP 109/66
SPO2 100%
BP 112/71
HR-75
Patient states she has been admitted several times
for A UTI infection.
Supporting medications:
Levofloxacin
Iv fluids
Supporting
Labs/Diagnostics:
none
Client initials PE
PMH- The patient has a past medical history of
constipation, lactose intolerance, non-functioning,
otitis media.
Vesicoureteral reflux
Reflux nephropathy
DX: UTI infection
Clinical Situation:
The 17-year-old patient underwent a right
nephrectomy and is currently presenting with a
UTI. She reports no nausea or vomiting but
complains of left flank pain, fever, and reduced
appetite. The patient resides with her boyfriend
and his mother, as her own mother is not present.
During the ER visit, she expressed concerns about
her left kidney and a potential bacterial infection.
Patient is sitting in bed. Patient complains that
mom is not being supportive and does not provide
the resources that she needs to maintain patient
states she spoke to a social worker about her eating
disorder. patient complains of being small for her
age. Patient also complains of flank pain and
headaches and migraines. Patient also states that
she cannot keep food down that she has no desire,
or her body has no desire to keep food down or to
digest food. The patient also expresses concerns
about frequent hospital visits, attributing the loss
of her right kidney to recurrent urinary tract
infections.
Labs
CBC,
Hemoglobin, 14.0
Hematocrit, 41.2
MCH 30.8
RDW 11.1
RBC
Priority #___2_
Nsg. Dx: imbalance nutrition, less than body
requirements, related to inadequate interest in
food as evidence by decreased BMI less than
body requirements for patient's age.
Assessment Data:
Patient is sitting in bed. Patient complains that
mom is not being supportive and does not provide
the resources that she needs to maintain patient
states she spoke to a social worker about her eating
disorder. patient complains of being small for her
age.
Supporting medications:
Zofran
Iv fluids
Supporting Labs/Diagnostics:
BMI 17.46
Priority #___3_
Nsg. Dx: Acute pain related to bacterial
infection as Evidenced by patient state and pain
level was 15 out of 10.
Priority #__4__
Nsg. Risk for dehydration related to inadequate
fluid intake as evidenced by nausea and
vomiting and patient stating that she cannot
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