Case Study About "Bladder Stones" - Tanta University PDF

**Tanta University** **Faculty of Nursing** **Medical surgical Nursing Department** **Operation Area** **Case Study about:**  **" Bladder stones"** **" آلاء مجدي عبد العزيز عبد العزيز"** **Section/ operation department** **Group:2C Under Supervision: Dr: Nada Ebrahim.**...

**Tanta University** **Faculty of Nursing** **Medical surgical Nursing Department** **Operation Area** **Case Study about:**  **" Bladder stones"** **" آلاء مجدي عبد العزيز عبد العزيز"** **Section/ operation department** **Group:2C Under Supervision: Dr: Nada Ebrahim.** **Outlines :-** - **Demographic Data.** - **Physical Examination.** - **Signs and Symptoms.** - **Complication.** - **Investigation.** - **Medication.** - **Nursing Care Plan.** **\*Demographic Data\* \_Patient name: ابراهيم فهمي احمد الشافعي** **\_Age: 59 Y. \_Sex: Male** **\_Marital Status: married. \_Education: litrated** **\_Occupation:Free work** **\_Date of admission: 16/11/20204 and admitted from: emergency** **\_Weight: 82 Kg. \_Hight: 165Cm** \*History\* =========== **\_Chief complain on admission: Acute Pain , frequent Difficult urinating with burning sensation ,Nausea ,Urinary retention** **\_Current complaint: pain, unpaired physical mobility, impaired urinary elimination** **\_Diagnosis: kidney stones , begin prostatic hyperplasia** **\_Name of Operation: Cystoilthotomy** **\_Past medical history: \-\-\-\-\-\-\-\-\--** **\_Family History : \-\-\-\-\-\-\-\-\-\-\-\-\-\-\--** **\_Past surgical history: \_\_\_\_** \*Physical Examination\* ======================== **\*Vital Signs:** +-------------+-------------+-------------+-------------+-------------+ | **.** | **83b/m | **120/80mmh | **Site** | **95** | | | Site** | g** | | | | | | | **Chest** | **%** | | | | **Site** | | | | | | | **nt** | | | | | **Brichal | | | | | | monitor** | | | | | | | | | | | | **device** | | | +-------------+-------------+-------------+-------------+-------------+ \*Signs and Symptoms\* ====================== - **Sever pain in the side and back** - **Pain, pruning sensation during urinating** - **Nausea and vomiting** - **Urinary retention** - **Difficult urinating** - **Pain worse with movement** \*Complication\* ================ - **Urinary tract infection** - **Renal damage** - **Obstruction** - **Chronic kidney failure** \*Investigation\* ================= **Patient's value** -- ---------------------------------- -- **\...\...\...\...\...\...\...** **\...\...\...\...\...\...\...** **........................** **.......................** **.......................** **.......................** +-----------------------------------+-----------------------------------+ | **Name of diagnostic** | | +===================================+===================================+ | **Non contrast CT Of urinary** | **\*Urinary bladder stones (3.6 × | | | 2.5 cm).** | | | | | | **\*Enlarged size prostata.** | +-----------------------------------+-----------------------------------+ **\*Medication\*** +-------------+-------------+-------------+-------------+-------------+ | | **Dose** | **Frequenc* | | **Remarks** | | | | * | | | | | | | | | | | | **y** | | | +=============+=============+=============+=============+=============+ | | **1am** | **Once** | | Monitor | | | | | | | | | **p** | | | PB**,**O2** | | | | | | ,**H | | | | | | | | | | | | R | +-------------+-------------+-------------+-------------+-------------+ | | **4 mg** | **Once** | | | +-------------+-------------+-------------+-------------+-------------+ | | **1** | **Once** | | Monitor | | | | | | | | | **amp** | | | PB**,**O2** | | | | | | ,**H | | | | | | | | | | | | R | +-------------+-------------+-------------+-------------+-------------+ | | **10 mg** | **Once** | | Monitor | | | | | | | | | | | | PB,O2,H | | | | | | | | | | | | R | +-------------+-------------+-------------+-------------+-------------+ -- -------------------- ------------ -- -- **\*Nursing Care** **Plan\*** -- -------------------- ------------ -- -- **The patient will maintain joint mobility and prevent complication s associated with immobility** -- ---------------------------------------------------------------------------------------------------- -------------------------------- -- **range-ofmotion exercises.** **\*Nursing Care Plan\*** +-----------------+-----------------+-----------------+-----------------+ | | **Nursing | **Nursing** | **Evaluatio n** | | | Outcomes** | | | | | | **Intervention* | | | | | * | | +-----------------+-----------------+-----------------+-----------------+ +-----------------+-----------------+-----------------+-----------------+ | | **The patient | **Monitor the | **The gool | | | will report | amount,** | was** | | | relief from | | | | | discomfort or | **color, odor, | **partly met.** | | | pain related to | and clarity of | | | | urinary** | urine. Check | | | | | for signs of | | | | **elimination** | urinary tract | | | | | infection. | | | | **.** | Encourage the | | | | | patient to | | | | | drink 2-3 | | | | | liters of fluid | | | | | per day. | | | | | Provide a | | | | | comfortable** | | | | | | | | | | **and private** | | | | | | | | | | **environmen** | | | | | | | | | | **t for | | | | | urination. | | | | | Administer | | | | | prescribed | | | | | analgesics if** | | +=================+=================+=================+=================+ | | | **pain is | | | | | present.** | | +-----------------+-----------------+-----------------+-----------------+ **\*Nursing Care Plan\*** +-----------------+-----------------+-----------------+-----------------+ | | | **Nursing** | | | | | | | | | | **Intervention* | | | | | * | | +-----------------+-----------------+-----------------+-----------------+ +-----------------+-----------------+-----------------+-----------------+ | | | **1. Maintain | | | | | Sterility:** | | | | | | | | | | **Strictly | | | | | adhere to | | | | | aseptic | | | | | techniques | | | | | during the | | | | | procedure.** | | | | | | | | | | **Minimize** | | | | | | | | | | **traffic in | | | | | the operating | | | | | room to | | | | | prevent** | | | | | | | | | | **contamination | | | | | ** | | | | | | | | | | **.** | | | | | | | | | | **2. Monitor | | | | | Patient:** | | | | | | | | | | **Continuously | | | | | monitor the | | | | | surgical site** | | +=================+=================+=================+=================+ | | | **for breaches | | | | | in sterility.** | | | | | | | | | | **Use sterile | | | | | dressings to | | | | | cover the | | | | | surgical site | | | | | after | | | | | completion.** | | +-----------------+-----------------+-----------------+-----------------+