Patient s Profile: Name: Labbot, Jocelyn Dalay-on Date of Birth: October 14, 1991 Age: 19 yrs.

old Place of birth: Tuba-an Norte Tuba Benguet Home Address: Tuba-an Norte Tuba Benguet Gender: Female Civil Status: Single Religion: Baptist Date of Admission: March 3, 2011 Admitting Diagnosis: Acute Pyelonephritis Admitting Physician: JoAnne E. Braga M.D. Lic # 0115458 Chief Complaint: Fever

History of Present Illness: Condition of patient started 2 weeks prior to admission as fever and RLQ pain. No consult done with medicines taken. Two days PTA, consult done at OPD wherein patient was diagnosed with UTI and Cefuroxime 50mg 1 tablet PRN was prescribed and taken, persistence of fever and RLQ pain promulgate consult done hence admission.

Previous Hospitalization/Surgery: S/P NSD January 2011 (Home Delivery)

LABORATORY RESULTS Sample: Serum Test Creatinine Full Name BS CREA Test Date: 3/7/11 Concentration Unit 79.01 Umdf/ Result Normal Remark 62.00 Reference 132.00

Urinalysis Test Date: 3/7/11 Physical Examination: Color: Yellow Transparency: Slight Turbid Reaction (PH): 50 Sp. Gravity: 10.30 Chemical Examination: Sugar: Negative Protein: Negative Serum Electrolytes Result: Sodium= 143.3 mmd/L Potassium=3.55 mmol/l Chloride=110.2 mmol/L Method: Easylyte Plus Na/K/CL Analyzer Date: 3/6/11 Reference Range: 135.148 mmd/L 3.5-5.3 mmol/l 98-107 mmol/l Microscopic Exam: WBC: 12-15 / HPF RBC: None / HPL Epithelial Cells: Moderate / LPF Amorphous Urates/PO4: Moderate / LPF Yeast Cells: Moderate / LPF Others: Pregnancy Test= Negative

Drug Study Medication Action Indication Contraindication Adverse Effects -Hypersensitivity -Alcohol -Dizziness -Headache -Fatigue -Vomiting Nursing Responsibilities -Check input and output ratio of patient -Obtain initial vital signs of patient. -Monitor for possible adverse reactions. Monitor vital signs of patient regularly.

Generic Name: -Paracetamol Dosage: 500mg 1Tab every 4 hours for fever Route: Per Orem Classification: -Analgesic -Antipyretic

-Decreases fever by inhibiting the effects of pyrogens on the hypothalamic regulating centers and by a hypothalamic action leasing to sweating and vasodilation. -Relieves pain by inhibiting prostaglandin synthesis at the CNS but does not have anti inflammatory action because of its minimal effect on peripheral prostaglandin synthesis.

-Relief of mild to moderate pain, treatment for fever.

Medication

Action

Indication

Contraindication Adverse Effects

Nursing Responsibilities -Instruct the patient not to take Ciprofloxacin with dairy products such

Generic Name: Ciprofloxacin Dosage:

-It kills bacteria by interfering with the enzymes

Ciprofloxacin is an antibiotic that is used to treat

-Ciprofloxacin is contraindicated in persons with a history of hypersensitivity to ciprofloxacin,

-nausea -vomiting -stomach pain -heartburn -diarrhea -feeling an urgent

-1 g 1 tab OD

that cause DNA to Classification: rewind -Antibacterial after being copied, which stops synthesis of DNA and of protein.

bacterial infections. -It is used to treat infections of the skins, lungs and urinary infections caused by e. coli.

any member of the quinolone class of antimicrobial agents, or any of the product components. - Pregnancy, nursing mothers, and in patients with epilepsy or other seizure disorders.

need to urinate -headache -vaginal itching and/or discharge -joint or muscle pain -extreme tiredness -lack of energy of appetite

as milk or yogurt. They could make the medicine less effective. -Tell patient that Ciprofloxacin can cause side effects that may impair her thinking. Tell patient to be careful if she plans to do anything that requires her to be awake. -Instruct patient to take ciprofloxacin with full glass of water. -Instruct the patient to stop taking ciprofloxacin and call the doctor at once if she has sudden pain, swelling, tenderness, softness, or movement problems in any of your joints.

Medication

Action

Indication

Contraindica tion

Adverse Effects

Nursing Responsibilities

GENERIC NAME: Ketorolac BRAND NAME:

- Inhibits prostaglandin synthesis, producing

-Short term management of pain (not to exceed 5

Hypersensiti vity - Cross-

drowsin ess -

-Patients who have asthma, aspirin-induced allergy, and nasal

Toradol CLASSIFICATION: Nonsteroidal antiinflammatory agents, nonopioid analagesics DOSAGE: 30mg/amp 1 amp IV PRN for Pain

peripherally mediated analgesia - Also has antipyretic and anti-inflammatory properties. - Therapeutic effect:Decreased pain

days total for all routes combined)

sensitivity with other NSAIDs may existPre- or perioperativ e use - Known alcohol intolerance -Use cautiously in: 1) History of GI bleeding 2) Renal impair-ment (dosage reduction may be required) 3) Cardiovascul ar disease

dizziness headach e -asthma -dyspnea -edema - pallor vasodilat ion -GI Bleeding abnorma l taste diarrhea -dry mouth dyspepsi a - GI pain - nausea -oliguria

polyps are at increased risk for developing hypersensitivity reactions. Assess for rhinitis, asthma, and urticaria. - Assess pain (note type, location, and intensity) prior to and 1-2 hr following administration. - Ketorolac therapy should always be given initially by the IM or IV route. Oral therapy should be used only as a continuation of parenteral therapy. - Caution patient to avoid concurrent use of alcohol, aspirin, NSAIDs, acetaminophen, or other OTC medications without consulting health care professional. - Advise patient to consult if rash, itching, visual disturbances, tinnitus, weight gain, edema, black stools, persistent headche, or influenza-like syndromes (chills,fever,muscl es aches, pain) occur.

- Effectiveness of therapy can be demonstrated by decrease in severity of pain. Patients who do not respond to one NSAIDs may respond to another.

Medication

Action

Indication

Contraindication Adverse Effects -Avoid taking an antibiotic medicine within 2 hours before or after you take ferrous sulfate and folic acid. This is especially important if you are taking an antibiotic such as ciprofloxacin -Certain foods can also make it harder for your body to absorb this medication. Avoid taking this medication within 1 hour before or 2 hours after eating fish, meat, liver, and whole grain or "fortified" breads or cereals. -Avoid using -sore throat, trouble swallowing -severe stomach pain; or -blood in your stools -diarrhea -constipation -nausea, vomiting, heartburn -leg pain; or -darkened skin or urine color

Nursing Responsibilities -Take this medication on an empty stomach, at least 1 hour before or 2 hours after a meal. Avoid taking antacids or antibiotics within 2 hours before or after taking ferrous sulfate. - Ferrous sulfate can stain your teeth, but this effect is temporary. To prevent tooth staining, mix the liquid form of ferrous sulfate with water or fruit juice (not with milk) and drink the mixture through a straw. You may also clean your teeth with

Generic Name: Ferrous Sulfate + Folic Acid

-Ferrous sulfate is a type of iron. You normally Dosage: get iron -1 tab BID from the foods you Classification: eat. In your -Nutritional body, iron Supplement becomes a part of your hemoglobin (HEEM o glo bin) and myoglobin (MY o glo bin). Hemoglobin carries oxygen through your blood to tissues and organs. Myoglobin helps your muscle cells store

-Ferrous sulfate and folic acid is used to treat iron deficiency anemia (a lack of red blood cells caused by having too little iron in the body).

oxygen. -Folic acid helps your body produce and maintain new cells, and also helps prevent changes to DNA that may lead to cancer.

antacids without your doctor's advice. Use only the specific type of antacid your doctor recommends. Antacids contain different medicines and some types can make it harder for your body to absorb ferrous sulfate.

baking soda once per week to treat any tooth staining. - Do not crush, chew, break, or open the extendedrelease tablet. Swallow the pill whole. Breaking or opening the pill may cause too much of the drug to be released at one time. Nursing Responsibilities

Medication

Action

Indication

Contraindication Adverse Effects

Generic Name: Sambong Leaf Dosage: 1 tab TID Classification: Herbal Medicine

-It is an antiurolithiasis (kidney stones) and work as a diuretic.

-It is used to aid the treatment of kidney disorders. -The Sambong leaves can also be used to treat colds and mild hypertension. -Since it is a diuretic, this herbal medicine helps dispose of excess water and sodium (salt) in the body. -It functions as an astringent and as an expectorant, and has been found to be antidiarrhea and anti-spasm. -As an astringent, preparations made of

sambong leaves may be used for wounds and cuts. - It is also suggested to be incorporated to post-partum baths, as well as considerable immersion of particular body areas that are afflicted with pains caused by rheumatism. - Its expectorant properties make it as a popular recommendation to be taken in as tea to treat colds.

Medication

Action

Indication

Contraindication Adverse Effects Constipation, dry mouth, trouble urinating, or rash, itching, swelling of the hands or feet, trouble breathing, increased pulse, dizziness, diarrhea, vision problems, eye pain

Nursing Responsibilities -Be alert for adverse reactions and drug interactions. -Assess for eye pain -Assess for urinary hesitancy -Encourage the patient to void. -Monitor BP for possible hypertension

Generic Name: Hyoscine NButylbromide Dosage: -10 g 1tab TID Classification: Antispasmodic

-This medication is used to relieve bladder or intestinal spasms.

-Spasms of the stomach, intestines or bile duct (gastrointestinal tract), including those associated with irritable bowel syndrome (IBS). -Spasms of the bladder or urinary

-People with a very fast heart rate (tachycardia). -Heart failure. -Overactive thyroid gland -People susceptible to blockages in the urinary tract and difficulty passing urine, for example men with an enlarged

system (genitourinary tract).

prostate gland. -People susceptible to blockages in the intestines. -People with a high temperature (fever).

Nursing Care Plan Assessment Pathophysiology Objective Nursing Intervention -Perform a comprehensive assessment of pain (Pain, Quality, Radiation, Severity, and Time) as well as the precipitating factors. -Encourage verbalization of feelings and concerns. -Encouraged to do divertional activities such as reading newspaper or listening to music -Encourage to do deep breathing exercises. -Encourage to have adequate Rationale Evaluation

Subjective: Nasakit ditoy ko as verbalized by the patient. -with pain rated as 6/10 at abdominopelvic area characterized as burning pain. Objective: -weak in appearance -restlessness noted -facial grimaces at times -guarding behavior note upon movement -with initial vital signs of: BP: 100/80 mmHg PR:79 Bpm RR:21 Cpm

Damage or disease process Inflammation Pain

Short Term: After 4 hours of nursing intervention The client will be able to verbalize relief of pain from the rate of 6 to at least less than the rate of 3.

-To establish baseline data that will be useful in managing pain.

After 4 hours of nursing intervention the client verbalized relief and pain rated as 4/10.

-To promote relaxation and comfort and reduce anxiety. -To help client shift her focus of attention to other things.

-To promote relaxation and comfort. To prevent fatigue and

Temp: 36.5 Nursing Diagnosis: -Acute Pain Related to Inflammation Process

rest and sleep.

prevent further stimulation of pain.

Assessment

Pathophysiology

Objective

Nursing Intervention -Determine client s previous elimination pattern. - Assessment of the bladder area. -Determine the clients input and output. -Encouraged to increase fluid intake up to 2-3 liters per day (water). -Instruct to the client to void every 2-3 hours

Rationale

Evaluation

Subjective: Medyo marigatan ak nga agisbo ken no mamingsan ket basit-basit lang ti rumwar , as verbalized by the patient Objective: - Bladder is visible and palpable -Bladder is tender on palpation - with lower

abdominal pain as verbalized by the patient

-with initial vital signs of: BP: 100/80 mmHg PR:79 Bpm RR:21 Cpm Temp: 36.5 Nursing

Urinary retention can be caused by an obstruction in the urinary tract or by nerve problems that interfere with signals between the brain and the bladder. If the nerves aren t working properly, the brain may not get the message that the bladder is full. Even if you know that your bladder is full, the bladder muscle that squeezes urine out may not get the signal that it is time to push, or the sphincter muscles may not get the signal that it is time to relax. A weak bladder

Short term: -After 6 hours of nursing intervention the client will be able to improve urinary elimination.

-To assess degree of inference or disability. -To assess retention. -To determine effectivity of elimination.

Goal unmet because the patient is still unable to void properly.

-To promote renal function and prevent infection and formation of renal stones. -To prevent bladder distention and to prevent further infection. -Provide -To help intermittent alleviate pain cold and hot ,reduce compress on inflammation the and promote abdominopelvic urination area.

Diagnosis: Impaired Urinary Elimination

muscle can also cause retention. Urinary retention is characterised by poor urinary stream with intermittent flow, straining, a sense of incomplete voiding and hesitancy (a delay between trying to urinate and the flow actually beginning). As the bladder remains full, it may lead to incontinence, nocturia (need to urinate at night) and high frequency. Acute retention causing complete anuria is a medical emergency, as the bladder may distend (stretch) to enormous sizes and possibly tear if not dealt with quickly. If the bladder distends enough it will begin to become painful. The increase in pressure in the bladder can also prevent urine

entering from the ureters or even cause urine to pass back up the ureters and get into the kidneys, causing hydronephrosis, and possibly pyonephrosis, kidney failure and sepsis. A person should go straight to an emergency department as soon as possible if unable to urinate when having a painfully full bladder.

Assessment

Pathophysiology

Objective

Nursing Intervention -Obtain previous eating pattern and weight. -Provide small frequent feeding. -Encourage to increase fluid intake up to 23 liters per day. -Encouraged to choose foods that are appealing. -Encouraged to increase intake of foods rich in Iron and Vit. C

Rationale

Evaluation

Subjective: Medyo awan ganak nga mangan , as verbalized by the patient. Objective: -pale in appearance lips and conjunctiva -with capillary refill of 2-3 seconds -with medium body built -with good skin turgor -verbalization

Ventricular dysfunction reduced arterial flow

- To establish baseline data that will be useful in managing eating habits. -To promote hydration.

- To stimulate appetite that aids in eating. -To promote

of weight loss -with initial vital signs of: BP: 100/80 mmHg PR:79 Bpm RR:21 Cpm Temp: 36.5 Nursing Diagnosis: Altered Tissue Perfusion Related to Decreased Oxygen Carrier

such as liver and citrus foods. -Instructed to avoid salty foods and gastric irritants such as sodas.

-To prevent

Assessment

Pathophysiology

Objective

Nursing Intervention

Rationale

Evaluation