1

GENERAL OBJECTIVES:

After 3 days of exposure at medical ward students from CTS-CN will be able to

adapt, learned and to do the best care for the patients.

SPECIFIC OBJECTIVES:

After 3 days of exposure at medical ward students will:

• apply the learning and techniques taught by our clinical instructors.

• experience and learn more about the different diseases.

• gain knowledge about the prevention and treatment.

• interact with the patient as well as the significant others.

• teach family to improved health status.

1.1 ASSESMENT
 2
a. Patient’s History
• Patients Profile
 Name: B, F.G.
 Age: 22
 Sex: Female
 Civil Status: Single
 Nationality: Filipino
 Religion: Roman Catholic
 Date of Admission: June 25, 2009
 Time of Admission: 7:00 pm
 Case Number: 2190
 Ward: Medical Ward
 Bed Number: 310 A
 Chief Complaint: - On and off fever for 3 days
- Vomiting after meals
- Tonsillitis
 Impression: Urinary Tract Infection

• History of Present Illness:

A case of Ms. B,F.G, 22 years old from Singco Compound Alang-Alang, Mandaue City
was admitted for the second time at DICGH (Doctor Ignacio Cortes General Hospital) due
to on and off fever, vomiting after meals and tonsillitis. Two weeks prior to admission she
had tonsillitis and fever.

• Past Health History:

Three months ago patient had fever and was admitted at the same hospital. The
patient was non-
dyspneic, diabetic, non-asthmatic and no known food and drug allergy. She was non
alcoholic drinker and non smoker. Ms. B, F.G father has hypertension.
 3

 Genogram

legend:
Male - Paternal Maternal
Female -
Hypertensive
Deceased -

PATIENT on and
off fever,
vomiting and
tonsillitis
b. Gordon’s 11 Functional Health Pattern
1. Pattern of Health Perception and Health Management
Ms. B, F.G describes herself as good, fine and no problem but since she was
admitted she said that it’s fair. She doesn’t have any regular physical examination and
exercise program, she completed her immunization. She drinks vitamins (Multivitamins +
Iron) every day and she wanted to have anti-flu vaccine. She cooperates well and took her
prescribed medicines on time.
2. Nutritional – Metabolic Pattern
She usually eats three times daily and with snacks. Her meal consists of rice,
vegetables, fish and meat. She usually drinks 4-6 glasses of water per day. During her stay
at the hospital, DAT diet was ordered, and the patient drinks a lot of water every day and
minimized intake of sweets.
3. Elimination Pattern
She has no problem regarding her defecation and she usually defecates
every morning around 5 – 7 am every other day, also consist of tan color with small light
yellow and not so sticky. She usually urinates 2-3 times a day and feels pain upon
urinating and has dark pale yellow. During her stay at DICGH, patient verbalized “dili
nakaayo sakit inig pangihi pero sige ko balik2 sa CR”. She doesn’t use any assistive device
in order to defecate and urinate well.
4. Pattern of Activity and Exercise
 4
Ms. B, F.G said that she usually goes to work every day and walked towards her
work place. She does many things in order to burn calories and fats like work outs. Since
Ms. B, F.G was hospitalized she has limited work due to her present condition.
5. Cognitive – Perceptual Pattern
Patient has no problem or any deficit in sensory perception and has no complaints
of vertigo, insensitivity to cold and heat during her stay. She was able to talk and
communicate well and write well.
6. Pattern of Sleep and Rest
She usually sleeps at around 10:30 – 12 midnight and usually wakes up at 5:30 am
and in afternoon she usually sleeps 1 – 2 hours. When she wakes up, she usually does her
daily chores. She doesn’t use any assistive device in order to sleep and rest well. During
her stay her rest pattern was altered due to her present condition and uncomfortable
environment. Also she was monitored every four hours as ordered by the doctor.
7. Role – Sexuality Reproductive Pattern
Ms. B, F.G hasn’t used any kinds of contraceptives. Patient complaints due to pain in
urinating, she has normal menstrual cycle (2-3 days).
8. Pattern of Self – Perception and Self Concept
Patient is very concerned about getting well and has positive outlook in her life. As
what I observed, Ms. B, F.G responded and reported what she feels during her illnesses
and asks what are the other ways to cure her.
9. Relationship Pattern
She has good family relationship and has good relationship towards the medical
team. She was the youngest among their siblings. She was loved by her family to take
care of her. She can speak clearly.
10. Pattern of Coping and Stress Tolerance
She said whenever she had stressors in life she usually watches movies with her
family and sometimes she sleeps to relieve stress. Now the only thing she can do is to
sleep due to her present illnesses.
11. Pattern of Values and Beliefs
She usually prays everyday, during and after eating meal. She has a strong faith in
God and she goes to church every Sunday. Ms. B, F.G is respectful, patient and courteous.

c. Review of Systems (Draw the anatomical position of the human body anterior
and posterior, then mark the affected area)
Anterior Posterior

TONSILITIS
 5

URINARY TRACT
INFECTION

1) Integumentary System
a. Skin: patient has light brown skin; smooth and warm (38.8°c); (-) (dry)
moisture; no presence of lesions and scar noted.
b. Hair: she has black hair; thick and straight; no lice noted.
c. Scalp: her scalp was symmetrical; no presence of lesions and scar noted.
d. Nail: her nails were symmetrical; good capillary refill in 1-2 seconds; long
nails; clean.

2) Head and Neck

a. Head: her head is symmetrical; no lesions and scar found.
b. Face: symmetrical; oval shape; smooth texture; (+) moisture.
c. Neck: no presence of lesions, masses and lumps noted.
d. Lymph Nodes: no visible lymph nodes but it can be palpated at about .3cm
but not tender.

3) Eyes
Her both eyes were symmetrical and she can clearly see and read near or far;
brown color eyes; no signs of irritation nor inflammation seen; (+) PERRLA (pupil
equally round reactive to light accommodation).

4) Ears
Both of her ears were in line with the eye level; symmetrical; no amount of
serum discharges noted; no signs of inflammations and lesions noted. Patient can
hear clearly.

5) Nose and Sinus

Her nose is in line at the middle part of the face; no signs of inflammation
seen and tendernes. Patient can smell normally.
 6

6) Mouth and Oropharynx

a. Lips: pinkish color; (+) moisture; no inflammations and lesions noted.
b. Buccal Mucosa: pinkish color; (+) moist; no signs of inflammations and
lesions noted.
c. Gums: healthy; pinkish color; no inflammations seen.
d. Teeth: yellowish color; has 29 tooth; no decayed tooth seen.
e. Tongue: at middle part; pinkish color; no inflammations and lesions seen.
f. Soft Palate: light pink; no inflammations noted.
g. Hard Palate: light pink; no inflammations noted.
h. Tonsils: pinkish color; swollen tonsils seen.

7) Respiratory System
I- her thoracic part was equal and symmetrical.
P- intercostals spaces of the patient were even.
P- (+) resonance.
A- normal breath sounds; 21 cpm.

8) Cardiovascular System
I- (-) palpitations.
P- non tender.
P- (+) resonance.
A- (-) murmur sounds; 110/60 mmHg.
Pulse sites
Radial - 78 bmp

9) Breast
I-her breasts were symmetrical; no lesions and deformities noted; no discharges
noted; nipples were not
inverted.
P- no tenderness;

10) Abdomen
I- equal color; smooth texture; no deformities noted; no inflammations and lesions
noted.
A- bronchovesicular sound found at the mid part of 1st - 2nd interspaces on the
anterior chest and in medium pitch.
 7
P- according to the patient she hasn’t noted lumps and masses.
P- Not performed

11) Genito-Urinary Reproductive System

I- according to the patient, she has no discharges, painful at a scale of 9 (in which 1
is not painful and 10 is the painful) upon urinating due to her present condition.
P- unable to assess

12) Anus and Rectum

According to the patient her rectum is patent, no deformities.

13) Musculoskeletal System

ROM: moderately firm; no deviations; can move her upper and lower extremities
and functions well.
GAIT: limited due to her present condition; steady
STRENGTH: she is able to manage herself; equal hand grasp.

14) Neurologic System

GAIT: limited due to her present condition
STRENGTH: she’s able to manage herself; semi-normal strength due to her present
condition.
GRIP: well coordinated; normal grip.
COORDINATION: well coordinated.
 8

1.2 DIAGNOSTIC EXAM (laboratory results should have its significance)

DATE EXAMINATION DONE NORMAL ACTUAL SIGNIFICANCE
VALUES FINDINGS
6/25/0 URINALYSIS
9
Transparency:  Presence of Protein and (+)
Cloudy in UTI (urinary tract
Color: Yellow infection)
Volume
 if it decreases it signifies
ph 4.5 – 7.5 7.0
bleeding / hemorrhage
 if positive occur it signifies
Protein Negative (+) malfunction of the kidneys.
(proteinuria)
if positive occur it signifies
Glucose Negative (-)
malfunction of the kidneys
HEMATOLOGY
Leukocytes 5.0 – 10.0 20.3
if it increases it signifies
Segmenters 0.50 – 0.70 .86 chronic infection, viral
infection.
RBC 3.80 – 5.80 4.01
 if it increases it signifies
polycythemia, dehydration
and COPD. If it decreases it
HCT 37.0 – 47.0 40.5
signifies anemia,
hyperthyroidism, and
hemorrhage.
WBC 4.2 – 5.4 20.7  if it increases it signifies
infection, inflammation and
 9
trauma.

1.3 ANATOMY and PHYSIOLOGY (drawing of the affected area)

• Kidneys are responsible for urine production

as well as the homeostatic function.
• Renal Pelvis is the funnel-like dilated proximal
part of the ureter in the kidney.
In humans, the renal pelvis is the point of
convergence of two or three major calyces.
Each renal papilla is surrounded by a branch
of the renal pelvis called a calyx.
The major function of the renal pelvis is to act
as a funnel for urine flowing to the ureter.
• Ureters are the ureters are muscular tubes
that propel urine from the kidneys to the
urinary bladder. In the adult, the ureters are usually 25–30 cm (10–12 in) long and ~3-4 mm
in diameter.
In humans, the ureters arise from the renal pelvis on the medial aspect of each kidney before
descending towards the bladder on the front of the psoas major muscle. The ureters cross
the pelvic brim near the bifurcation of the iliac arteries (which they run over). This
"pelviureteric junction" is a common site for the impaction of kidney stones (the other being
the ureterovesical valve). The ureters run poster inferiorly on the lateral walls of the pelvis
They then curve anterior medially to enter the bladder through the back, at the
vesicoureteric junction, running within the wall of the bladder for a few centimeters. The
backflow of urine is prevented by valves known as ureterovesical valves.
In the female, the ureters pass through the mesometrium on the way to the urinary bladder.
 10
• Urinary Bladder is the organ that collects urine excreted by the kidneys prior to disposal
by urination. A hollow muscular, and distensible (or elastic) organ, the bladder sits on
the pelvic floor. Urine enters the bladder via the ureters and exits via the urethra.
Embryologically, the bladder is derived from the urogenital sinus and, it is initially continuous
with the allantois. In males, the base of the bladder lies between the rectum and the pubic
symphysis. It is superior to the prostate, and separated from the rectum by the rectovesical
excavation. In females, the bladder sits inferior to the uterus and anterior to the vagina. It is
separated from the uterus by the vesicouterine excavation. In infants and young children,
the urinary bladder is in the abdomen even when empty.
• Urethra is a tube which connects the urinary bladder to the outside of the body. In males, the
urethra travels through the penis, and carries semen as well as urine. In females, the urethra
is shorter and emerges above the vaginal opening.
The external urethral sphincter is a striated muscle that allows voluntary control
over urination.

1.4 PATHOPHYSIOLOGY
• UTI (urinary tract infection) is a bacterial infection that affects any part of the urinary
tract. The main cause agent is Escherichia coli. Although urine contains a variety of
fluids, salts, and waste products, it does not usually have bacteria in it. When bacteria
get into the bladder or kidney and multiply in the urine, they may cause a UTI.
MANIFESTATIONS
• Dysuria (painful urination)
• Urgency (the need to urinate
• without
Schematic
delay)Diagram
• Increased frequency of
urination UTI
• Suprapubic tenderness, (URINARY TRACT
PREDISPOSING FACTORS INFECTION)
pelvic discomfort especially DISEASE CONDITION
CAUSE
• Improper Hygiene Bacteria called
pre- and immediately
• Low intakeOccurs
of water and of Urethritis - The inflammation and Escherichia Coli lived in
postvoid. in 20%
vitamins infection is limited to the urethra. the bowel (colon and
women with uncomplicated
• Children and Adults Cystitis - Results from an irritation around the anus0).
UTI.
•• Patient with AIDS and of the lower urinary tract mucosa.
Small volume voiding. • Poor Hygiene
Hemorrhagic Cystitis -
• Increased numberwho
Diabetes / People take
of white • Sexual Intercourse
immunosuppressant Characterized by large quantities
blood cells in the urine
medication. of visible blood in the urine. It can
(pyuria)
be caused by an infection
•• One of the most
Suprapubic common
tenderness REPRODUCTIVE
(bacterial or adenovirus types 1-
• sources of infection
Urinary urgency andis SYSTEM
47) or as a result
ORGAN of radiation,
AFFECTED
frequency may be present or cancer chemotherapy, or
absent. immunosuppressive medication.
• Fever Hemorrhagic cystitis is often
• Flank pain and tenderness confused with glomerulonephritis,
(back pain) but hypertension and abnormal
• Costovertebral angle renal function are absent in MANIFESTATIONS (PATIENT)

tenderness (CVA hemorrhagic cystitis. • Pain in Urination

tenderness)Nausea and
vomiting
• Peripheral leukocytosis
• Urine contains white blood
cell casts- elongated
Pyelonephritis - This infection • Fever(38.8°c)
usually results from ascension of • Vomiting
the bacteria to the kidney from the • Urgency
lower urinary tract, but also can
arise by hematogenous spread
 11

MANIFESTATION
• hypothermia, poor
appetite, lethargy,
change in mental
status.
• Chills, Flank Pain,
Nausea and Vomiting.
• Cloudy, Bad Smelling
and Blood in urine.
• Delirium

COMPLICATIONS
- Sepsis - Septic Shock -
Pyelonephritis
- Damage of Kidneys - Renal
Hypertension
DEATH

• The basic pathophysiology is that once bacteria enter the bladder, local defense
mechanisms in the bladder break down and the bacteria invade the bladder
mucosa and begin to multiply. The bacteria that have lodged in the mucosa cannot
be eliminated by urination. Inflammation also occurs; it is the general response to
any bacterial invasion which results in vascular permeability. Because of the
vascular permeability, bacteria that have invaded the bladder mucosa are able to
escape into the blood stream and this is the actual start of septicemia. Once the
bacteria enters the blood stream they release endotoxins and the symptoms of
bacteremia are produced.
 12

o Acute pain related to

biological factors such as
1.5 SUMMARY OF FINDINGS (prioritizing of nursing diagnosis at least 3)
activity of disease process.

SIGNIFICANT FINDINGS o Fluid volume

NURSING deficient related
DIAGNOSIS
to excessive losses through

Patient’s History normal routes.

o ο ο Diabetic
o Alteration in
o ο ο Tonsillitis
thermoregulations related to
o ο ο Fever (38.8°C)
illness as manifested by fever
38.8°c and warm skin.
 13
o ο ο Vomiting (40ml/day)
Gordon’s 11 Functional Health Pattern
o ο ο Stress / Restless
o ο ο Pain in Urinating at a scale of 9
o ο ο Limited Exercise Pattern
Diagnostic Exam
o ο ο (+) Protein
o ο ο WBC increases

1.8 DISCHARGE PLAN (Methods)

Name of Patient: B, F.G. Date Admitted: June 25,

2009
Diagnosis: UTI (Urinary Tract Infection) Ward Number: 310

- Vitamin C once day, 8:00am.

- Co –amoxiclav (biomedis) 375mg once a day, 8:00am.
Medication
- Instruct patient to comply the medicine prescribe by the doctor.
- Take medicine regularly.
Environment - Instruct patient and significant others to clean always their surroundings so
that patient will be away from infection.
 14
- Provide proper and clean ventilation to facilitate fast healing and recovery.
- Provide safety measures.
- Instruct patient to have proper regular check-up.
- Watch for any unusualities and report to doctor immediately.
Treatment
- Never do self medication.
- Comply the medications that instructed by the physician.
- Instruct patient to have proper hygiene.
- Have proper balance diet.
Health Teaching
- Drink plenty of water.
- Proper urination pattern.
- High fever
- Cramping in the pelvic area (back).
- Pain upon urination.
- Nausea and vomiting.
Observable
- Flank pain.
Signs and
- Frequent urination.
Symptoms
- Hematuria.
- Nocturia.
- Cloudy and foul smell urine.
(this indicates as UTI) –if symptoms persist consult your doctor.
- Eat food that has rich in vitamins such a vitamin c (orange, apple, lemon…),
vitamin A (nuts, margarine…), vitamin K (green leafy vegetables, cereals,
milk…) and more.
Diet
- Minimize eating junk food and foods which contains preservatives.
- Have a proper diet.
- Encourage patient to drink plenty of water.
- Provide moral, emotional, and spiritual support for the patient.
Spiritual
- Encourage patient and significant others to pray for fast healing process.
1.9 HEALTH TEACHING PLAN

Name of Patient: B, F.G. Date Admitted: June 25,

2009
Diagnosis: UTI (Urinary Tract Infection) Ward Number: 310

OBJECTIVES CONTENT METHODOLOGY EVALUATION

General:
After 5 hours  About proper body  Lecture and  Patient will be
of nursing hygiene (perineal discussion. able to know and
interventions the care). understand
patient will be able  Proper clothing as proper hygiene
to gain knowledge well as clean and as evidence by
 15
of proper hygiene. appropriate cloths. active interaction
 Clean of the patient
environment. and the
significant
Specific:  Lecture and others.
After 2 hours  Pattern of discussion.
of nursing urination.  Patient will know
interventions the  Water intake. about the food,
patient will be able  Perineal care. beverages and
to know the factors some factors that
First - Wash, rinse
that cause the cause UTI as
and then dry the
urinary tract evidence by
urethra area being
infection (UTI). asking a lot of
sure to separate the
labia. questions about

Second - Using new the factors and

cloth or rinsed cloth, clarifications of

wash, rinse and dry some humors.

groin area outside

labia and then do
inside of thighs.
Third - Rinse cloth
Fourth -Wash, rinse,
then dry rectal area.
 Prevention of UTI.
Reference: www.altavista.com and www.url.com