206569099 ben-final-case-study-osmak

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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

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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).
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).

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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
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:

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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.
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 3rd floor
annex pedia ward of a tertiary hospital run by the city government of Makati. This study was
done on the researcher’s Pediatric Ward rotation from 0600H – 1400H 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

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patient’s 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 client’s significant other was not enough to contribute to the formulation of the
client’s 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
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.

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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.

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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, patient’s vital signs at
1200H were temperature: refused, PR: 105bpm, RR: 20cpm and BP: refused. Physician
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 doesn’t give any
response. Patient was irritable and doesn’t 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. Patient’s 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

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medication were being continued. Intravenous fluid was still at D5 1MB 1500ml at the rate of
62 – 63gtts/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 skills and nursing diagnosis of Self - care deficit related to
neuromuscular impairment as manifested by ability to perform activities of daily living.
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.

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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 distention
and difficulty voiding
2. Fluid volume deficit related to inadequate fluid intake as evidenced by dry mucus
membrane and skin
3. Imbalanced nutrition: less than body requirements related to insufficient intake as
evidenced by decrease in body weight
4. Impaired physical mobility related to neuromuscular impairment as evidenced by
limited ability to perform gross or fine motor skills

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5. Self-care deficit related to neuromuscular impairment as evidenced by inability to
perform activity of daily living
6. Impaired comfort related to present health condition as manifested by irritability and
fear
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)
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

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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.
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.

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Elsevier. (2014). Retrievedfrom
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
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

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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.
html
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 patient’s parents:the
basic four groups, as well as the need for specific minerals and vitamins and importance of
maintaining adequate caloric intake becausefood 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).

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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
independent living. Restricted movement affects the performance of most activities of daily
living (ADLs).
html
Monitor and record vital signs to establish baseline data, note for skin turgor /oral
Mucous membranes for signs of dehydration, determine patient’s 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.

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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
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 client’s 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

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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
assessment can be challenging, especially in the elderly, where cognitive impairment and
sensory-perceptual deficits are more common.
html
Monitor vital signs and note for any significant changes, determine the location,
characteristic, duration, frequency, quality, intensity, and aggravating factors of pain, observe
patient’s skin texture and temperature, encourage of verbalization of feelings and deep
breathing exercise, encourage mother to keep the patient’s 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

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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 physicalinjury, is a basic
human need. Health care, provided in asafe manner, and a safe community environment are
essentialfor a patient ’ s survival and well-being. A safe environment reducesthe risk for
illness and injury and helps to contain the cost of healthcare by preventing extended lengths
of treatment and/or hospitalization,improving or maintaining a patient ’ s functional status,
andincreasing the patient ’ s sense of well-being.
Elsevier. (2014). Retrievedfrom:
http://www.us.elsevierhealth.com/Nursing/Fundamentals-and-Skills/book
/9780323079334/ Fundamentals-of-Nursing/
Assess patient’s 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.

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CHAPTER V
SUMMARY OF FINDINGS, CONCLUSION, AND RECOMMENDATIONS
I. Factors that led to the development of the condition
Predisposing Factors:
Precipitating Factor:
II. Interrelationship of factors identified that led to the development of the
problem
III. Relevant interventions to be rendered to the patient
Nursing 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.

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 Monitor urinalysis, urine culture, and sensitivity. Rationale: Urinary tract
infection can cause retention, but is more likely to cause frequency
 Encourage clients to urinate every 2 to 4 hours. Rationale: Minimizing
excessive retention of urine in the bladder.
 Supervise and record time, the number of each micturition. Note the decrease
in spending and changes in urine specific gravity. Rationale: urinary retention
increases the pressure in the upper urinary tract that can affect the kidneys.
 Percuss/palpate suprapubic area. Rationale: A distended bladder can be felt in
the suprapubic area.
 Institute intermittent catheterization. Rationale: Because many causes of
urinary 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., 8
to 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.

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 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 hydration
Nursing 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
 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 patient’s 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 patient’s mental status for baseline data.
 Maintain IVF for hydration
 Instruct the patient to wear light clothing to avoid perspiration

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 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
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 to
scale:
 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.

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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 patient’s skin texture and temperature
 Encourage of verbalization of feelings and deep breathing exercise
 Encourage mother to keep the patient’s 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 sleep
Nursing Diagnosis # 7: Injury related to generalized body weakness
 Assess patient’s 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 by
a 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 interventions
The nursing diagnoses which goals were fully met are the following:

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 Impaired physical mobility related to neuromuscular impairment as evidenced
by limited ability to perform gross or fine motor
 Self-care deficit related to neuromuscular impairment as evidenced by
inability 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 bladder
distention and difficulty voiding
 Fluid volume deficit related to inadequate fluid intake as evidenced by dry
mucous membrane and skin
 Imbalanced nutrition: less than body requirements related to insufficient
intake as evidenced by decrease in body weight
 Impaired comfort related to present health condition as manifested by
irritability 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 patient’s 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
client’s 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

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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.
To the relatives and significant others, to be more aware regarding the
patient’s 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 researcher’s knowledge and nursing care will
contribute to the improvement of the patient’s 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

Page | 25
needs improvement. Provide a copy as a basis and serve as a reference with a new
innovations and developments for the future researchers.

206569099 ben-final-case-study-osmak

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206569099 ben-final-case-study-osmak