INTRODUCTION Nurses are patient advocates.

To become a successful and effective nurse, you do not only need to acquire the necessary education and licenses to practice but you also have to posses certain qualities and skills to help you perform in this fast paced industry. Nursing is a very demanding job physically, mentally, emotionally, and psychologically. Commitment and dedication is a must in every nurse. To become an effective nurse, you need to be equipped with determination and perseverance in order to endure difficulties that may come into our lives as we continue to pursue this profession. Although the days are busy and the workload is always growing, there are still those special moment, when someone says or does something and you know youre made different in someones life, and that makes the reason why despite of the difficult challenges weve encountered still we stand through it for we believe that nursing is not only a job, it is more than a job! Empowering the skills, knowledge and attitude that I had, as the student nurse of Saint Joseph Institute of Technology I had my affiliation at Butuan Medical Center (BMC) wherein I am able to have our clinical exposure in Medical Ward .As a matter of fact, it was Novenber 28, 2012 wherein I chose a case for individual case study presentation, and the patient Id chose was diagnosed with urinary tract infection (UTI). I were able to render holistic care to my patient in order to alleviate her pain felt and to build rapport in order to gain her cooperation for thorough assessment. A urinary tract infection (UTI) is a bacterial infection that affects part of the urinary tract. A urinary tract infection may involve only the lower urinary tract, in which case it is known as a bladder infection. When it affects the lower urinary tract it is known as a simple cystitis (a bladder infection) and when it affects the upper urinary tract it is known as pyelonephritis (a kidney infection). Symptoms from a lower urinary tract include painful urination and either frequent urination or urge to urinate (or both), while those of pyelonephritis include fever and flank pain in addition to the symptoms of a lower UTI. Cystitis is a urinary bladder inflammation that can result from any one of a number of distinct syndromes.[1] It is most commonly caused by a bacterial infection in which case it is referred to as a urinary tract infection. Pyelonephritis is an inflammation of the kidney and upper urinary tract that usually results from noncontagious bacterial infection of the bladder (cystitis). The most common cause of pyelonephritis is the backward flow (reflux) of infected urine from the bladder to the upper urinary tract. Bacterial infections also may be carried to one or both kidneys through the bloodstream or lymph glands from infection that began in the bladder. Kidney infection sometimes results from urine that becomes stagnant due to obstruction of free urinary flow. A

blockage or abnormality of the urinary system, such as those caused by stones, tumors, congenital deformities, or loss of bladder function from nerve disease, increases a person's risk of pyelonephritis E. coli is the cause of 8085% of urinary tract infections, with Staphylococcus saprophyticus being the cause in 510%. Rarely they may be due to viral or fungal infections. Other bacterial causes include: Klebsiella, Proteus, Pseudomonas, and Enterobacter. Escherichia coli is a Gram-negative, rod-shaped bacterium that is commonly found in the lower intestine of warm-blooded organisms (endotherms). Most E. coli strains are harmless, but someserotypes can cause serious food poisoning in humans, and are occasionally responsible for product recalls due to food contamination. E. coli and related bacteria constitute about 0.1% of gut flora,[7] and fecaloral transmission is the major route through which pathogenic strains of the bacterium cause disease.

DEFINITION OF TERMS

NURSING HEALTH HISTORY Nursing health history is the first part and one of the most significant aspects in case studies. It is a systematic collection of subjective and objective data, ordering and step-by-step process inculcating detailed information in determining clients history, health status, and functional status and coping pattern. These vital in formations provide a conceptual baseline data utilized in developing nursing diagnosis, subsequent plans for individualized care and for the nursing process application as a whole. Part of the nurses responsibility is to take care of patients records and keeping their private life confidentially, so her give her a pseudonym of Patient Y. She is 18 years old, female and a Filipino citizen residing at P-5 Dulag, Butuan City. It was Novenber 28, 2012. Wednesday, at 8:00am in the morning, wherein I chose a case for our Individual Case Presentation. First contact to my patient is that, she is lying on bed awake with IVF of PNNS 1L at the level of 790cc, regulated at 30 gtts/min., hooked at right metacarpal vein, infusing well. PRE-NATAL AND BIRTH Patient Y was born on August 17, 1994 through a normal spontaneous vaginal delivery with the help of a midwife in Provincial Hospital Butuan City .She was the 2nd of the 4 children in their family. Her mother was a housewife while his father was a business man in which it was their main source of living.

INFANCY TO ADOLESCENCE According to patient Y, she was breastfeed by her mother after birth. She was a friendly person and active in playing volleyball, badminton and basketball during her childhood. Patient Y was 12 years old when she was graduated in elementary at Dulag Elementary School last 2006. He had continued her studies at Dulag National High School and graduated at year 2010. And she is a 2nd year college student at Dulag with the course of criminology.

FAMILY HEALTH HISTORY Patient Ys family were both Cebuano. Her father was a busness man and a good provider to his family. His father and her mother was in a good condition pertaining to health. According to patient Y, she is the one who had that kind of disease in their family.

PAST HEALTH HISTORY Patient Y was a very active and have a positive attitude. She like to eat junk foods and soft drinks. At first she didnt feel any discomfort to her health condition. She always get drunks when shes with his boyfriend and friends. When she was a 1st year college student she felts discomfort in urinating on her vagina and pain at the RQ on her abdomen, she take a medication that was given by her friend and she forgot the name of the said drug and she was cure at that time. After 1 year, now when she was in 2nd year college. The pain that she felts before was worsen for about 2 weeks that make her parents decide to go to the hospital for admission. PRESENT HEALTH HISTORY November 24,2012 at 9:45p.m, Patient Y with her parents decided to admit her to Butuan Medical Center (BMC) due to inability to abdominal pain colichy 2 weeks tolerated (+), dysuriaterminal (+), hypogastric pain and 1 week PTA onset of fever and chills. The nurse has done a procedure of catheterization with as further stated by patient M. After they went home. At the same day, admission and they arrived at 11:00p.m and attended by Dr. Barriga, with Patient M chief complain of inability to urinate and defecate for 3 date. 11:00 p.m Dr. Barriga ordered to admit him at room no. 101 Medical Ward. On that night, Patient M doctor ordered temperature, pulse rate,respiratory rate every 4 hours to monitor his vital signs accordingly and to be able to have baseline data. Monitor BP,I and O every shift. IVF of Plain LR 1L at 20gtts/min. During admission patient M vital signs are as follows: T;36.7, PR: 86bpm, RR:21cpm and blood pressure :110/70mmHg. July 3, 2011 at 1:00pm, doctor ordered for laboratory: Complete blood count (CBC) Platelet

Lipid Panel Creatinine Blood Urea Nitrogen Ultrasound for whole abdomen include prostate 12 Leads ECG Chest X-ray

Hematology performed during July 3, 2011 and came at 6:00pm

POST WBC RBC Hemoglobin Hematocrit MCV MCH MCHC Platelet Diff. count Neutrophils Lymphocytes Monocytes Eosinophils

RESULT 8:00 4.67 138 0.40 86.7 29.5 341 163 0.66 0.23 0.10 0.01 Pg g/L

UNIT 10^g/L 10^12/L g/L

REFERENCE 5.0-10.0 M 4.5-5.2 F 3.5-5.6 M 135-175 F 125-155 M 0.40-0.52 F 0.36-0.48 82-92 27-32 320-380 150-400 0.50-0.70 0.20-0.40 0.02-0.06 0.02-0.05

10^gL

GORDONS FUNCTIONAL PATTERN

I.Health Perception and Health Management Past: When Pt. Y was asked about her health before she was admitted, she verbalized okay kaayo arang man gani nako kalaagan. Pertaining to Pts Y diet if she has any allergy to foods, she exclaimed that there is only one the eggplant that makes her felts ithcy. Actually she ates what is served in their table, she is not that kind of person that is choosy with regards to the food being served to her. Everytime she was ill, first in line in her intervention was to have a check-up in Santos Hospital. Present: Staying in hospital makes Pt. Y more ill, as she explained. Whatever maybe the result of hes condition, she is ready for that, and she always prayed to God to help her ease the pain she felt.Lahe ra gyud ang akong situation sa karon ug sauna. Pt. Y verbalized as I let her compare her health before until to the present. II. Nutrition and Metabolic Pattern Past: Patient Y was in good shape before she was admitted. She definitely ates 4 to 5 times a day not include the snack for twice in a day and she didnt feel any pain. For her, having 4 to 5 meals in a day is already enough to give her enough energy to her study. And she also didnt missed any of her meal. Mainly she liked to ate fruits, vegetables, rice, meat, fish and her favorite is afritada. Present: Since she was diagnosed that she had an Acute Pyelonephritis, Pt. Y was restricted not to ate foods that may aggrevate or worsen her condition. Now, it is too far different from what she ate before. Salty foods is a very no-no for her. There are changes in her meals, she ates 3 meals in a day due to her condition. III.Elimination Pattern Past: She usually voids 3-4 times in a day which considered to be normal. wala may sakit kung mangehi ko Pt. Y said, as I asked her if she felt any discomfort or pain during urination. Pt. Y also defecate twice in a day with no discomfort or pain felt upon defecation. Present: Pt. Y usually voids more than 3-4 times in a day. tungod man jud sa tambal ni Doctor na gipa take nako mao sige ko ug ihi patient Y said, as I asked her during interview. And she also said that sakit akong vagina pagmangihi ko as verbalized by the patient. Pt. Y defecate once in a day without discomfort or pain felt upon defecation.

IV. Pattern of Activity and Exercise Past: Before Pt. get ill, she was very active and enthusiast in their place. She had been into different sports such as volleyball, badminton, basketball and etc. Her favorite sport is volleyball. She is a 2nd year criminology student and they have an exercise everyday as her daily routine and sometimes there punishments. Present: Pt. Ys activity and exercise affected a little bit due to her condition. dili na kaayo ko maka ki.at unlike before as verbalized by the patient when I let her compare her activity before until to the present. V: Cognitive Perceptual Pattern Past: Pt Y joined a contest when she was in high school in their place and she is a talented person. Present: Pt Y is a 2nd year criminology student. Pt. Y was educated enough to understand things, she was able to write, read, calculate a mathematical problem. VI.Pattern of Sleep and Rest Past: Pt. Y actually sleeps at 10pm in the evening and wakes up at 6am in the morning, as if it was already her routine everyday. Sometimes she was able to have her nap time in the afternoon if she had no clases.Okay kayo akong pagtulog, walay problema Pt. Y explained as I asked her to describe his sleep pattern and if she has no difficulty with it. Present: Since Pt. Y undergone to his present condition right now, it disturbs her a little bit due the pain and excessive urination. This makes her more sick as what she said. Her condition makes her free uncomfortable whenever she had her sleep and rest period. VII.Pattern of Self-perception and Self-control Past: Pt. Y was indeed healthy and merely got sick. Though she smoke and drink liquor she still manages to be healthy through minimizing the use vices. Present: Pt. Y admits that she is now unhealthy and this is because of her unhealthy practices in life. She regrets so much of being careless on her health. But on the other hand, she said that ready na ko sa tanan na mahitabo sa ako.a as I asked her if she is ready whatever the result of her health condition. VIII.ROLES AND RELATIONSHIP

Past: Pt. Y as a daughter was loving and caring to her family. She is the 2nd daughter of Mr. D and Mrs. A . silhig,bantay tindahan ra man ug kaon akong trabaho sa balay as I asked her if what is her duties in their house. Present: Since Pt. Y was admitted in the hospital the one who perform her duties in their house is her two sister, since she is sick and cant perform her duties. Her mother is the one who takes care of her. While his father is the one who find ways to sustained the needs for her and to pay the bills.

IX.SEXUAL ACTIVITY PATTERN Past: Agrisibo jud kaayo ko makipaghilawas sa akong uyab sugod sa kadtong iyang nakuha akong virginity as Pt.Y humorously explained as I asked her if she is active into sex during coitus. She didnt feel any discomfort or pain. Present: Pt. Y is no longer active in sex due to her present condition. panagsa nalang kay magsakit akong vagina as I asked her if she still want to have entercourse with his boyfriend. X. Stress and Coping Tolerance Past: Everytime Pt. Y had a problem she go to her friends and share her problems to make her feelings comfortable and ligther. Present: Since Pt. Y has been hospitalized she is dependent to her physicians order and everytime she has loses hope she offers her problem to our almighty god. And despite of her problem she still have the courage to fight and handle things that she sacrifices.

XI. Values and Beliefs Pattern Past: Pt. Y believed that a Doctor was a good healer, sometimes whenever she felt sick or anyone of her family they would prefer to go to the hospital for check-up. Present: Pt. M still believed that a Doctor is a good healer and she still prefer for it.

PHYSICAL ASSESSMENT An accurate physical assessment requires an organized and systemic approach using the technique of inspection, palpation, percussion, and auscultation. It also requires a trusting relationship and rapport between the nurse and the patient to decrease the stress of the patient may have being physical exposed and vulnerable. The patient much more relaxed and cooperate if you explain what will be done and the reason for doing it. While the findings of a nursing assessment do sometimes contribute to the identification of a medical diagnosis, the unique focus of a nursing assessment is on the patients responses to actual or potential problems. Physical assessment had been done to my patient last November 28, 2012 at the Medical ward of Butuan Medical Center, 1pm in the afternoon. The patient was lying on bed awake as I saw her and do further assessment to his body parts.

GENERAL SURVEY: Patient Y is coherent and attentive upon conversation. She was able to answer question correctly and speaks fluently. She can move independently without any assistance, well groomed and dont have any foul odor; Vital signs as follows T: 36.5C BP: 90/60 mmhg PR: 75 bpm RR: 22 cpm

HEAD Upon inspection Patient Y has white and oily sculp, without any lices. Her hair is black, long and straight. No lesions and no mass upon palpation.

EYES

Patient Y had no defect on her both eyes and is able to see letters and read presented to her at a distance of about 20 feet, she has symmetrical shape of eyes, eyelids, eyelashes, and eyebrows. She had also white sclera, pinkish conjunctiva with visible capillaries. Her pupils are equally round and reactive to light accommodation. Patient Y also sees object in his periphery as I asked her if she sees the penlight in his side, she can also follows the six cardinal gaze were in her eyeballs can move in six directions. EARS Patient Y can hear whisper words and can relay the message, both ears are symmetrical in shape. No ear discharges upon inspection. She cant maintain balance of her body as I asked her to stand straight and closed her eyes while holding both hands.

NOSE Patient Y had visible vibrissae with bougar seen upon inspection. Nares are symmetrical and able to smell odor such as vanilla and coffee then she had a brown nare without any abrasion and lesions.

MOUTH Patient Y had cracked lips, she had a total number of 28 teeth composed of *molars, * upper incision. Upon inspection, her gums was color pink, as well as her tongue. Her tonsils were not inflamed, with positive gag reflex.

NECK Upon inspection she has no lesion or any abrasion noted on her neck. Her sternocleidomastoid muscle is active for she can resist the force of my hand on her cheek and told to resist it. Her trapezius muscle is also active for she can resist the force applied by my hand to her shoulder as I instructed her to raise her shoulder.

CHEST

Patient M chest was symmetrical and upon inspiration there is equal chest expansion, and equal recoil upon expiration, bronchiole sounds heard over bronchus site. Tactile fremitus observed upon palpation at the back of the chest.

ABDOMEN Patient Y skin was dark brown. No masses or any lesions noted., upon auscultation, she had a normal bowel sound of 8 which is normal with the range of 5-35. Upper extremities Skin color is brown, oily to touch. Brachial pulse palpated as well as the radial pulse with equal, regular in beat. No mass and any lesion. Nails are dirty and untrimmed. She has a good skin turgor and capillary refill returns after 2 seconds. Brachial reflex appreciated and it is active. Arm circumference is 26cm and both arm are symmetrical. Clubbing of fingers were noted. Thorax and Lungs: Chest circumference is 89 cm by using tape measure. Skin color is the same to the other parts of the body. Chest expands during inspiration and relaxed when patient exhale. No adventitious sound heard, RR: 22cpm. Heart : Apical pulse heard upon auscultation and has 75 bpm recorded.

Breast and Axilla: Breast is engorge, no mass or lymph nodes palpated. Nipples of the patient are protruded and have the same color with the other skin color of the body which is light brown. Axillary temperature is 36.5 degree Celsius. Lower extremities: Extremities were equal in length and color. Patellar reflex is active as well as the Achilles reflex. Popliteal , dorsalipedis, and tibialis pulse are palpated with equal, regular in beat. Nails were polished with color brown. Babinski reflex not noted. Genitalia: The patient usually voids more than 3-4 times a day with complaints of pain upon voiding due to her present condition.

Rectum and Anus:

Pt. Y defecate once in a day without discomfort or pain felt upon defecation.

S Mo sakit usahay ako ang tiyan labi na sa may too nga parte
With a pain scale of 7/10

- with guarding behavior

- Facial grimace noted - Distended abdomen - Irritable at times

NURSING DIAGNOSIS: ACUTE PAIN RELATED TO UNDERLYING DISEASE CONDITION SCI. BASIS
Acute pain indicates that damage or injury has occurred. Pain is also referred to as nociception, nociceptors are neural receptors involved in the transmission of pain perceptions to and from the brain that respond to biochemical mediators or noxious stimuli. They are free nerve endings in the skin that respond to intense, potentially damaging stimuli. The joints, skeletal muscle, tendon fascia, and cornea have nociceptors which transmit stimuli that produces pain. Visceral pain results from stimulation of pain receptors in the abdominal cavity and thorax. Visceral pain tends to appear, and diffuse, often feels like deep somatic pain that is burning, aching, or feeling of pressure. Visceral pain is frequently caused by stretching of tissues or muscle spasms. SOURCE: FUNDAMENTALS OF NURSING 7TH EDITION BY BARBARA KOZIER

NURSING GOAL:
Within 5 hours of rendering effective nursing care the patient will be able to report decrease of pain from 7 to 3.

INTERVENTIONS 1. Perform assessment of pain to include location, characteristics, frequency and severity 2. Accept clients description of pain, and acknowledge the pain experiencing 3. Position client in a supine or comfortable position with head supported with pillows 4. Provide comfort measure such as changing of position 5. Demonstrate deep breathing exercise or pursed lip breathing 6. Encourage divertional activities like talking to others 7. Suggests to listen to soothing music 8. Provide calm and quite environment 9. Instruct to have adequate rests periods

RATIONALE To provide a comparative baseline data

Pain is subjective experience and cannot be felt by others

To prevent pressure on abdominal areas

To provide non pharmacologic pain management

Relaxation technique reduces pain by relaxing tense muscle that contribute to pain To divert attention from pain

Music therapy is an inexpensive and effective therapy for the reduction of pain To relax client and to have adequate rests periods To prevent fatigue

S O

Initkaayoakopaminawsakolawas - Temp. 38.2 C - Skin is warm to touch - shivering - weak to look at

NURSING DIAGNOSIS: HYPERTHERMIA RELATED TO UNDERLYING DISEASE CONDITION SCI. BASIS

Pyrogens cause a rise in body temperature. It also acts as an antigen triggering immune system responses. The hypothalamus reacts to raise the set point and the responds by producing heat. SOURCE: SCRIBD.COM

NURSING GOAL:
Within 5 hours of rendering effective nursing care patients temp will decrease from 38.2 37.5 C.

INTERVENTIONS 1.Note presence of sweating as body attempts to increase heat loss by evaporation and conduction 2. Monitor Vital signs every hour 3. Render tepid sponge bath 4. Place ice pack on head part 5.Promote bed rests 6. Encourage to use thin clothing 7. Instruct to wrap body and extremities with blanket 8.Advice client to increase fluid intake of 6 8 glasses of water

RATIONALE Evaporation is decreased by environmental factors of high humidity and high ambient temperature To provide comparative baseline data To lower patients temperature It absorbs body heat It reduces body heat production To promote comfort Provides warmth to the body To prevent dehydration