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General Objectives

At the end of my duty in GABMMC, I, Lyndon L. Santos 3rd year Bachelor of Science in

Nursing student of San Beda College, Mendiola, will be to impart my knowledge and skills

towards the patient, through promoting and maintaining, physiologic and psychologic stability,

and health restoration.

Specific Objectives

• To gain new information about the patient’s disease and its etiology, pathophysiology,

clinical manifestations as well as the standard medical and nursing management so that

we may apply this newly acquired to our patient as well as similar situations in the future.

• To learn new clinical skills as well as sharpen our current clinical skills required in the

management of the patient with AGN.

• To develop our sense of unselfish love and empathy in rendering nursing care to our

patient so that we may be able to serve future clients with a higher level of holistic

understanding as well as individualized care.

• Establish a trusting relationship to client and his family.

• Perform the assigned task efficiently and dynamically.

• Formulate an effective nursing care plan for the client regarding UTI.

• Acquire necessary skills in assessing the signs and symptoms of patient with UTI.

• Internalize the necessary concept or principle regarding UTI.

• Educate the family in the prevention, promotion, and maintenance of healthy lifestyle as

well as to cure and restore health.

Definiton of the Disease

A urinary tract infection (UTI) 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.

The most common type of UTI is acute cystitis often referred to as a bladder infection. An

infection of the upper urinary tract or kidney is known as pyelonephritis, and is potentially more

serious. Although they cause discomfort, urinary tract infections can usually be easily treated

with a short course of antibiotics. Symptoms include frequent feeling and/or need to urinate, pain

during urination, and cloudy urine.

Risk Factors


Women are more prone to UTIs than men because in females, the urethra is much shorter

and closer to the anus than in males, and they lack the bacteriostatic properties of

prostatic secretions. Among the elderly, UTI frequency is roughly equal proportions in

women and men. This is due, in part, to an enlarged prostate in older men. An enlarged

prostate means the gland has grown bigger. Prostate enlargement happens to almost all

men as they get older. As the gland grows, it can press on the urethra and cause urination

and bladder problems. As the gland grows, it obstructs the urethra, leading to increased

difficulty in micturition. Because there is less urine flushing the urethra, there is a higher

incidence of E. coli colonization.

Sexual activity

In young sexually active women sex is the cause of 75—90 % of bladder infections, with

the risk of infection related to the frequency of sex. The term "honeymoon cystitis" has

been applied to this phenomenon of frequent UTIs during early marriage. In post

menopausal women sexual activity does not affect the risk of developing a UTI.

Spermicide use independent of sexual frequency increase the risk of UTIs.

Urinary catheters

Indwelling urinary catheters increase the risk of UTIs. Staphylococcus epidermidis is

most common organism. Scrupulous aseptic techniques or the use of intermitent

catherterization rather than an indwelling catherter may decrease these associated risks.


A predisposition for bladder infections may run in families.


Other risk factors include diabetics sickle-cell disease or anatomical malformations of the

urinary tract such as prostate enlargement.

While ascending infections are generally the rule for lower urinary tract infections and

cystitis, the same is not necessarily true for upper urinary tract infections like

pyelonephritis which may originate from a blood born infection.

Recurrent Infections

Many women suffer from frequent UTIs. Nearly 20 percent of women who have a UTI

will have another and 30 percent of those will have yet another. Of the last group, 80

percent will have recurrences.

Usually, the latest infection stems from a strain or type of bacteria that is different from

the infection before it, indicating a separate infection. Even when several UTIs in a row

are due to E. coli, slight differences in the bacteria indicate distinct infections.

Research funded by the National Institutes of Health (NIH) suggests that one factor

behind recurrent UTIs may be the ability of bacteria to attach to cells lining the urinary

tract. A recent NIH-funded study found that bacteria formed a protective film on the

inner lining of the bladder in mice. If a similar process can be demonstrated in humans,

the discovery may lead to new treatments to prevent recurrent UTIs. Another line of

research has indicated that women who are "non-secretors" of certain blood group

antigens may be more prone to recurrent UTIs because the cells lining the vagina and

urethra may allow bacteria to attach more easily. Further research will show whether this

association is sound and proves useful in identifying women at high risk for UTIs.

Infections in Pregnancy

Pregnant women seem no more prone to UTIs than other women. However, when a UTI

does occur in a pregnant woman, it is more likely to travel to the kidneys. According to

some reports, about 2 to 4 percent of pregnant women develop a urinary infection.

Scientists think that hormonal changes and shifts in the position of the urinary tract

during pregnancy make it easier for bacteria to travel up the ureters to the kidneys. For

this reason, many doctors recommend periodic testing of urine during pregnancy.


• The mortality associated with acute uncomplicated cystitis among women aged 20-60

years appears to be negligible. A longitudinal cohort study of Swedish women showed a

higher mortality among women with a history of UTI compared with age-matched

women without this history (37% versus 28% in 10 y, P <0.001).1 These cohorts were not

matched for other mortality-related factors, making it difficult to attribute the increased

mortality to UTIs.

• In contrast, the morbidity in terms of quality of life and economic measures is

tremendous. Each episode of UTI in a young woman results in an average of 6.1 days of

symptoms, 1.2 days of decreased class/work attendance, and 0.4 days in bed.

• Groups at risk for UTIs associated with calculi include those with dysfunctional voiding,

urinary intestinal diversion, indwelling urinary catheters, and vesicoureteral reflux.

Reason for Choosing the Case for Presentation

I chose this case study out of curiosity as it was my first time to encounter such case and because

of that, I was interested in it. I was willing to undergo new experiences which would bring new

learnings for me. Another reason was that it was one of the suggestions of our clinical instructor

to be used in making our case study.

Patient’s Profile
Rama, Esmeralda 22/F

Date admitted: April 27, 2010

Admitting Diagnosis: UTI; Anemia r/o Typhoid Fever; G1P0

Chief Complaint: Fever

History of present illness: Fever, cough, colds

Address: 1219 Kagitingan st., Tondo, Manila

Date of Birth: July 18 1987

Birthplace: Cavite

Status: Single

Nationality: Filipino

Religion: Christian (Born Again)

Mother: Ma. Lolita T. Rama

Father: Renato Rama

Socioeconomic and Cultural Factor
• Education:

Patient X is a high school graduate from Manila.

• Income and occupation:

Patient X works in a casino. She earns roughly up to 10,000-20,000 pesos every month.

But since she was diagnosed with UTI, she works less and naturally earns less.

• Place of residence:

Patient X lives in Kagitingan St. Tondo Manila.

• Cultural/Ethnicity:

Patient X is Tagalog, she was raised and born in Manila.

• Religion: Christian Born Again

Environmental Factor
No data

History of Past Illness

• History of accidents or injuries: none

• History of known allergy to foods and medication: none

• History of previous confinement.

o Patient X has no previous confinement. This was the first time the patient was


• Any known medical problem and medication taken: none

History of Present Illness
• A week before the patient was brought to the hospital she had fever for one week;

she also experienced suprapubic pain and discomfort. She also reported that she

frequently feel urinated and experiencing pain in urination. She also noticed an unusual

darker color of her urine.

She took paracetamol to relive her fever and pain. After a week of taking medications she

decided to consult the doctor because she still experienced fever and pain. She then was

admitted to GABMMC upon diagnosing Urinary Tract Infection

Family Health Illness History
Grandfath Grandmother
er  Grandfath
 er  
Px’s mother
father 

Sibling Sibling 6
1 Sibling Patien 
tX Sibling Sibling 7 Sibling 8
 2
Sibling 5

  


Female – Alcoholic - 
Male – Hypertensive- 

Diabetic -  Asthma - 

Smoker -  Deceased - 

UTI - 
Gordon’s Health Pattern of Functioning
Health Perception and Management
Before: During/After:
• Health is given a high priority; • Patient’s hemoglobin, hematocrit count
• If possible, patient visits the doctor for is below normal; causing the patient to
check-up if experiencing illnesses. be weak and pale
• Usual illnesses: cough, colds, • The patient’s V/S is monitored every 2
fever(seldom) hrs.
• Treatment/management: paracetamol • Patient’s intake and output is being
for fever; takes vitamins measured accurately
• The patient is being checked by the
physician during rounds
• The patient responds well and
cooperates with interventions
Analysis: Patient X cannot function normally like before because of her
confinement and her hospital condition.
Interpretation: UTI refers to the infection of the urinary tract of a person. Due to this infection.
The patient experiences pain which inhibits her to move normally.

Nutritional/Metabolic Pattern
Before: During/After: 3 meal/3 day recall
• Likes to eat fried chicken, porkchop,Day 1: Breakfast-Sandwich Lunch-rice,
sinigang dinner-vegetables
hotdogs, sinigang(these are the typical
meal/seldomely eats vegetables) Day2: Breakfast-Soup Lunch- Chopsuey
• Eats mostly at home; sometimes clientDinner- nilaga and banana
eats at fast foods when at work Day3: hotcake/champorado Lunch- sandwich
Analysis: Patient X’s nutritional and metabolic status has been changed due to
her confinement and her medical health condition. Her preconfinement
status is totally affected.

Interpretation: An individual’s health status greatly affects eating habits and

nutritional status (Fundamentals of Nursing by Kozier p. 1178) UTI cases
requires a low salt diet and restricts bladder irritants like coffee, tea,
Before: During/After:
• Bowel- 2x a day (regularly)
• Bowel- 0-2x a day(irregular)
• Urinates- usually 3-4x a day
• Urinates- 3 up to 10x a day(yellowish
color and has no pain on urination)

Analysis: Patient X’s bowel and urination pattern is altered; her bowel comes irregularly. She is
also required to increase her oral fluid intake which results to much more frequent urination.

Activity and Exercise Pattern

• The patient’s activities are
• Works at casino
ambulation, deep breathing
• Not much of activities at home
exercises, personal hygiene,
1. Watching TV
and texting
2. Texting
Analysis: The patient’s activities during hospitalization are limited; leisure and recreational
activities are also disrupted.
Interpretation: because of pain experience by the patient she difficulty in doing her normal daily
activity unlike before she had UTI

Sleep/Rest Pattern
Before: During/After:
• Hrs. of sleep- 6-7 hours • Patient X complains difficulty in
• Client has no sleeping habits; does not sleeping
take afternoon naps • The patient usually is able to sleep for a
• Texting and watching TV is his/her short period of time
form of relaxation • The patient doesn’t feel rested from
time to time
Analysis: Patient X is not used to the hospital environment. She is not used to the hot
temperature of her room which makes it difficult for her to sleep.
Interpretation: the patient is having a hard to rest and sleep because of the environment.
Self-Perception and Cognitive Pattern
Before: During/After:
• Professional at work • The patient experiences on and off
• Has a strong personality fever
• Gives self high respect and confidence • Patient X feels a little scared and
disappointed about her recurrent fever
• She fears that she might have a longer
Analysis: Because of her present health status, her self concept had changed. She is very
disappointed that she isn’t able to work and not able to contribute to the family’s needs.
Interpretation: “Events or situations may change the level of self concept over time. Illness and
trauma can also affect self concept.” (Fundamentals of Nursing 7th edition by Barbara Kozier
p.959 & 962)

Cognitive Perception
Before: sensory During/After:

Roles and Relationship

Before: During/After:
• Role-worker(breadwinner) • Mother ,sister, and partner regularly
• Relationship-encounters family w/ visits and stays
other working siblings • Some other relatives also frequently
• Describes the family as happy and visits
healthy in general
Analysis: Patient X’s family and so as her other relatives are very supportive. She enjoys seeing
visitors; they tell jokes and share ideas regarding her hospitalization.

Values and Beliefs

Before: During/After:
• Religion-Born Again • Patient X and her mother says a short
• Rarely attends mass prayer of thanksgiving in the morning
• Parents has strong faith and at night during her hospitalization
• She says that she rarely prays, but still
believe that her faith will always help
Analysis: Patient X’s faith is revived after what happened. She realized that together with her
medical needs attended, she also needs her faith to improve her current health status

Sexual and Reproductive Pattern

Before: During/After:
• Patient X is not married and has a • Patient X refuses to talk about her
boyfriend sexual practices
• Has engaged to sexual activities with • Patient X is excited regarding her
her current boyfriend and is currently 7 pregnancy
mos. pregnant to her first baby • Talks to her baby from time to time
Analysis: Patient X is not comfortable talking about her sexual practices, instead, she shows
great joy and excitement with her pregnancy.

Coping stress Pattern

Before: During/After:



Physical Assessment

• Observe body Observation Proportionate, Height: 5ft., 6 Body built is

build, height, varies with lifestyle inches proportionate
and weight in Weight: 160 lbs.
relation the
client’s age
lifestyle and
health pattern.

• Observe the
client’s posture
and gait, Observation Relaxed, erect Relaxed; Normal
standing, posture; erect/proper
sitting, and coordinated posture; walks
walking. movement without any

• Observe the
over all
hygiene and
grooming. Observation Clean, neat Clean, hygiene- normal
Relate these to conscious
the person’s
activities prior
to the

• Note body and

breath odor in
relation to
activity level. no body and
No body odor, or breath bad odor normal
minor body odor
• Observe for relative to work or
signs of exercise; no breath
distress in odor
posture or
facial Shows no signs of
expression distress
Observation No distress noted Patient is relaxed
• Note obvious
signs of health
or illness
looks a bit weak,
but shows no signs
• Asses the of obvious illness
clients attitude Healthy appearance
responds well and
• Note the attentively
affect/mood; client responds
assess the appropriately
s of the clients Cooperative Normal

• Listen for Appropriate to Normal

quantity of situation
speech, quality, Speaks in a
Areas to Assess Techniques Normal Findings Actual Findings Analysis

• Note for color Inspection Varies from light Skin is pale- Hemoglobin count
and uniformity to deep brown; looking; generally is low
Best assessed from ruddy pink to uniform
under natural light light; from yellow
and on areas not over tones to olive.
exposed to sun. Generally uniform
expect in areas
exposed to sun;
area of lither
(palm, lips, nail
beds in dark
skinned people)

No edema
No edema
• Assess presence
of edema

Moisture in the
• Assess skin skin folds and in Normal
moisture. Inspection/ the axillae, perspiration Normal
• Note skin Palpation freckles, some
lesions birthmarks, some No lesions
according to flat and raised nevi Normal
location, (moles); no
distribution, abrasion or any
color, other lesion.
size, shape,
type or
structure Uniform, within
normal range.

• Note skin Palpation Uniform

temperature, Skin temp. within Normal
compare the normal range
two feet and
two hands When pinched,
using the skin springs back
to previous state
backs of your
Skin springs back
fingers to normal range
• Note skin Normal/good skin
turgor turgor
(fullness and

• Note evenness Inspection Evenly distributed Hair is thick and Normal

of growth over hair, thick, silky evenly distributed;
and resilient hair. curly
the scalp,
thinness or
thickness of
scalp, texture
and oiliness. No infection or No infection;
Note presence of infestation. No infestation Normal
infections or

Fine. fine
• Palpate for Palpation
texture. Normal


• Note finger Inspection Convex curvature; Good convex Normal

nail plate angle of nail plate curvature of nail
shape to about 160°. plate
determine its
curvature and Smooth texture.
angle. Smooth Normal
• Note finger
nail and Highly vascular
toenail texture. and pink in light Pinkish in color Normal
• Note toenail skinned clients;
bed color. dark skinned
clients may have
brown or black
pigmentation in

Intact epidermis
Intact epidermis Normal
• Note tissue Prompt return of
surrounding pink or usual Prompt return of normal
nails. color. (Generally pinkish color; 1-2
• Perform less than four secs
blanch test of seconds.)
capillary refill.
Size and symmetry INSPECTION Normocephalic, Symmetrical Normal symmetry
and shape symmetrical

Presence of PALPATION No presence of No nodules, normal

nodules, masses nodules, masses masses;
and depressions and depressions depressions
Color, appearance INSPECTION White in color, no Whitish color normal
flakes and Presence of flakes abnormal; due to
infestations and inability to wash
masses, no scars hair
Tenderness PALPATION No presence of No tenderness normal
Evenness, color, INSPECTION Hair should be Hair color is With hair dye
distribution even, presence of unevenly
gray hair is normal distributed

Oiliness of scalp PALPATION Moderately oily Moderately oily normal

Body Parts To Be Technique Normal Actual Findings Analysis

Assessed Findings
Ears and Hearing
Inspect the Inspection Color same as The same color as normal
auricles for color, facial skin facial skin;
symmetry of size symmetrical, aligned with outer
and position auricle aligned with cantus
the outer cantus of
Palpate The Palpation Mobile, firm, and Firm, no normal
auricles for not tender; pinna tenderness; pinna
texture, elasticity, recoils after it is recoils back after
and areas of folded folded
Using an otoscope, Inspection Distal third Unable to
inspect the contains hair perform; without
external ear canal follicles and glands otoscope
for cerumen, skin Dry Cerumen, No sticky normal
lesions pus , and Grayish-tan color; secretions
blood or sticky wet
cerumen in various
shades of brown

Inspect the Inspection Pearl gray color, Unable to

tympanic Semitransparent perform; without
membrane for otoscope
color and gloss

Hearing Acuity

Assess client’s Inspection Normal voice tones Normal voice normal

response to normal audible tones
voice tones.
Perform the watch Inspection Able to hear ticking Able to hear in normal
tick test ticking of in both ears both ears
a watch has a
higher pitch than
the human voice.

Tuning Fork Test Able to hear in normal

both ears
Perform Weber’s Inspection Sound is heard in Able to hear in normal
test to assess bone both ears or is both ears
conduction localized at the
center of the head

Nose and Sinuses

Inspect the Inspection Symmetric and Symmetric and normal
external nose for straight no straight; uniform
any deviations in discharge or flaring in color
shape, size, or uniform color
color and flaring
or discharge from
the nares.
Lightly palpate the Palpation Not tender; no No tenderness; no normal
external nose to lesions lesions; no
determine any displacements of
areas of tenderness bone cartilage
masses and
displacements of
bone and cartilage

Determine Patency Inspection Air moves freely as Breathes freely normal

of both nasal the client breathes with both nares
cavities through the nares

Inspect the nasal Inspection There should be no No swelling normal

cavities using a swelling, redness or
flashlight or a any tenderness
nasal speculum

Observe for the Inspection Mucosa pink clear, No lesions, normal

presence of watery discharge pinkish mucosa,
redness swelling, no lesions presence of some
growths, and hair

Inspect the nasal Inspection Nasal septum intact Nasal septum normal
septum between and aligned in the intact; aligned in
the nasal chambers midline the midline
Bone and cartilage Palpation There should be no none
masses and
Palpate the Inspection and There should be no none
maxillary and Palpation inflammation and
frontal sinuses for tenderness
Mouth and Oropharynx

Inspect the outer Inspection Uniform pink color Soft, pinkish in normal
lips for symmetry Soft, moist, smooth color, dry texture,
of contour, color texture symmetry has the ability to
and texture of contour, ability purse lips
to purse lips

Inspect and Inspection Uniform pink Has elastic normal

palpate the inner color, moist, texture; uniform
lips and buccal smooth, glistening pinkish color
mucosa for color, and elastic texture
moisture , texture,
and presence of
Inspect the teeth Inspection 32 adult teeth, Shiny tooth normal
and gums while smooth, white, enamel; complete
examining the shiny tooth enamel, Pinkish gums
inner lips and pink gums, moist
buccal mucosa firm texture to
gums, no retraction
of gums
Inspect the Inspection Smooth, intact No dentures
dentures dentures

Inspect the surface Inspection Central position

of the position
color and texture

Inspect the base of Inspection Smooth tongue Smooth tongue Normal

the tongue, the base with base
mouth floor, and prominate veins
the frenulum

Palpate the tounge Palpation Smooth with no Smooth; no

and floor of the palpable nodules palpable nodules
mouth for any
nodules, lumps, or
excoriated areas.
To palpate the
tongue use gauze
to grasp its tip.

Inspect salivary Inspection Same as color of Same color Normal

duct openings for buccal mucosa and
any swelling or floor of mouth
Inspect the hard Inspection Light pink, smooth, Light pink; normal
and soft palate for soft palate lighter smooth
color, shape, pink hard palate,
texture, and the more irregular
presence of bony texture.

Inspect the uvula Inspection Positioned in Position in the normal

for position and midline of soft midline
mobility while palate
examining the

Inspect the Inspection Pink and smooth Smooth and normal

oropharynx for posterior wall pinkish posterior
clor and texture wall
inspect one side at
a time to avoid
eliciting the gag

Inspect the tonsils Inspection Pink and smooth, Pinkish; no normal

for clor, discharge, no discharge of discharge or
and size normal size inflamation

Elicit the gag Inspection Present Gag reflex present normal

reflex by pressing
the posterior
tongue with a
tongue blade

Neck and Glands

Inspect the neck Palpation Muscles equal size; Head centered; no normal
muscles for head centered swelling
swellings or
Observe head Inspection Coordinated, Coordinated normal
movement. smooth movements movements; no
with no discomfort discomfort
Move the chin to Inspection Head flexes 45 Able to flex 45 normal
the chest degree degrees

Move the head Inspection Head hyperextends Able to normal

back so that the 60 degree hyperextend 60
chin points upward degrees

Move the head so Inspection Head laterally Able to flex 40 Normal

the ear is moved flexes 40 degree degrees
toward the
shoulder on each

Turn the head to Inspection Head flaterally Able to rotate 70 normal

the right and to the rotates 70 degree degrees
Muscle strength Inspection Equal strength equal normal
turn the head to
one side against
the resistance of
your hand repeat
on the other side

Shrug the Inspection Equal strength equal normal

shoulders against
the resistance of
your hands

Palpate the entire Palpation No lymph nodes None palpable normal

neck for enlarged should be palpable
lymph nodes,

Palpate the trachea Papation Central placement Placement of neck normal

for lateral in midline of neck is at midline
deviation. spaces are equal on
both sides
Inspect the thyroid Inspection Not visible on Not visible normal
gland stand in inspection
front of the client,
observe the lower
half of the neck
overlying the
thyroid gland for
symmetry and
visible masses

Hyper extend the Inspection Glands ascends Not visible normal

head and swallow during swallowing
but not visible

Breast Unable to perform; patient refuses to underwent breast

1. Inspect the shape, INSPECTION Anteroposterior Chest symmetric Normal
symmetry of the thorax to transverse
from posterior to lateral diameter in ratio
views. Compare the of 1:2.
anteroposterior diameter to Chest symmetric
the transverse diameter.
2. Inspect the spinal INSPECTION Spine vertically Spine is vertically normal
alignment for deformities. aligned. aligned
3. Place the palms of both PALPATION Full and Full chest normal
your hands over the lower symmetric chest expansion;
thorax with your thumbs expansion (when move apart an
adjacent to the spine and the client takes a equal distance
your fingers stretched deep breath, your and at the same
laterally. thumbs should time;
move apart an
equal distance
and at the same
time; normally
the thumbs
separate 3-5 cm
(1.5-2 inches)
during deep

4. Palpate the chest for PALPATION 1. Bilateral Vibrations felt normal

vocal (tactile) fremitus, the symmetry of through chest
faintly perceptible vocal fremitus. wall
vibration felt through the 2. Fremitus is
chest wall when the client heard most of
speaks. clearly at the apex
of the lungs.
3. Low pitched
voices of males
are more readily
palpated than
higher pitched
voices of females.

5. Percuss the thorax PERCUSSION Percussion notes Normal normal

resonate, except
• Ask the over scapula.
client to bent
the head and
fold the arms
forward across
the chest. This
separates the
scapula and
exposes more
lung tissue to
• Percuss
in the
spaces about
5cm (2 in)
intervals in a
• Compare one
side of the
lung with the
6. Percuss the PERCUSSION Excursion is 3 to 3 to 5 cm normal
diaphragmatic excursion. 5 cm bilaterally in bilaterally
women and 5 to 6
cm in men.
7. Auscultate the chest AUSCULTATE Vesicular and Vesicular and normal
using the flat-disc bronchovesicular bronchovesicular
diaphragm of the breath sounds breath sounds
stethoscope. heard


8. Inspect breathing pattern INSPECTION Quiet, rhythmic, respirations;
(respiratory rate rhythm) and effortless relaxed and exerts
respirations. not much effort

Simultaneously inspect Inspection & No pulsation No pulsation Normal

and palpate the Palpation
Precordium for the
presence of abnormal No pulsation
pulsation, lifts, or heaves No lifts or heave

Location: Should
occupy only one
interspace, the 4th
or 5th, and be at
or medial to the
1cm x 2cm;
Normally a short,
gentle tap;
Duration: short,
occupies only 1st
half of systole.
No lift or heave
Auscultate the Heart in all
four anatomic sites: aortic, Aortic pulsation
pulmonic, tricuspid, and
apical (mitral). Auscultation S1: usually at all S1 heard heard at Normal
sites all sites
Usually louder at
apical area S2 heard at all
S2: usually heard sites normal
at all sites
Usually louder at
case of heart
Systole: silent
interval; slightly
shorter duration
than diastole at
normal heart rate
(60-90 beats per
Diastole: silent
interval; slightly
longer duration
than systole at
normal heart
S3 in children
and young adults
S4 in many older


Carotid Arteries

- Palpate the carotid artery Palpation Symmetric pulse

using extreme caution volumes.

Full pulsation Full pulsation Normal

thrusting quality

Quality remains Quality changes Normal

same when client when client lies on
breather turns bed from sitting
head, and
changes from
sitting to supine
- Auscultate the carotid position. No sound
artery to determine the Elastic arterial
presence of a bruit Auscultation wall Normal

Jugular Veins No sound heard

-Inspect the jugular veins on auscultation.
for distention while the No visible veins
client is placed a semi-
fowler’s Inspection normal
position(30degrees to 45°)
Veins not visible
(indicating the
right side of heart
is functioning
Peripheral Vascular System
Palpate the peripheral Palpation Symmetric pulse Symmetric Normal
pulses on both sides of the volume.
client’s body individually, Full pulsations. Full pulsation normal
simultaneously, and
systematicallyto determine
the symmetry of pulse
Inspect the peripheral Inspection In dependent No presence of normal
veins in the arms and legs position, superficial veins
for the presence and/or presence of
appearance of superficial distension and
veins when limbs are nodular bulges at
dependent and when limbs calves.
are elevated. When limbs
elevated, veins

Assess the peripheral legs Inspection Limbs not tender. Limbs are not normal
veins for signs of phlebitis Symmetric in tender
size. symmetric
Inspect the skin of the Inspection Skin color pink. Skin is pinkish in normal
hands and feet for color, color; temp is
temperature, edema, and within normal
skin changes. range; no edema
Assess the adequacy of Inspection Buerger’s test:
arterial flow if arterial original color
insufficiency is suspected. returns in 10
secs.; veins in
feet or hands fill
in about 15 secs. 1-2 secs capillary normal
Capillary refill refill
test: immediate
return of color.


Inspect the abdomen for Unblemished Uniform skin normal
skin integrity Inspection skin color
Uniform color No surgical scars
striae or surgical
Flat rounded No evidence of normal
Inspect the abdomen for Inspection (convex), or enlargement
contour and symmetry. scaphoid Symmetric
(concave). contour
No evidence of
enlargement of
liver or spleen.

Observe abdominal Inspection Symmetric Symmetric normal

movements associated movements movements
with respirations, caused by
peristalsis or aortic respiration.
pulsations Visible peristalsis
in very lean
Aortic pulsations
in thin persons at
epigastric area
Observe the vascular No visible None visible normal
pattern. Inspection vascular pattern.
Auscultate the abdomen Without friction normal
for bowel sounds, vascular Auscultation Audible bowel rubs
sounds, and peritoneal sounds
friction rubs. Absence or atrial
Absence of
friction rubs
Percuss several areas in Tympany over Tympany over the normal
each of the four quadrants Auscultation the stomach and stomach
to determine presence of gas-filled bowels;
tympany and dullness. dullness,
especially over
the liver and
spleen, or a full

Perform light palpation Percussion No tenderness; No tenderness; normal

first to detect areas of relaxed abdomen abdomen is
tenderness and/or or with smooth, relaxed
muscle guarding. consistent tension
Symetrically explore all
four quadrants.
Perform light palpation
first to detect areas of Percussion No tenderness; No tenderness;
tenderness and/or muscle relaxed abdomen abdomen is
guarding with relaxed

Perform deep palpation Palpation Tenderness may Tenderness normal

over all four quadrants . be present near present near
xiphoid process, xiphoid process
over cecum, and
over sigmoid

Palpate the liver to detect Palpation May not be Slightly palpable normal
enlargement and palpable.
tenderness. Border feels

Palpate the ares above the Palpation Distended and None palpable normal
pubic symphisis if the palpable as
clients history indicates smooth, round,
possible urinary retention. tense mass
(indicates urinary

Inspect the muscles for Inspection Equal size on Equal on both Normal
size and compare both both sides of the sides
sides body

Inspect the muscles and

tendons Inspection No contractures None Normal

Inspect the muscles for

fasciculations and tremors No fasciculations
Inspection None Normal

Palpate muscles at rest to

determine muscle tonicity
Normally firm

Test muscle strength Palpation Firm Normal

Equal strength on
each body side
Inspection Right muscle is Normal


Inspect the skeleton for Inspection No deformities None Normal

structure and deformities

Palpate the bones to locate

edema or tenderness
Palpation No tenderness or none normal
Areas to be Assessed Technique Normal Actual Findings Interpretation/
Findings Analysis
1.) Language Inspection The client is able to understand normal
a.) Ask client to point able to by naming the
to common objects and understand by pointed object;
ask the client to name naming the responds to verbal
pointed object and written
clearly and has commands
b.) Ask the client to the ability to
respond to simple respond to
verbal and written simple verbal
commands like ”point and written
to your toes” commands
2.) Orientation Inspection The client is Able to state normal
Ask the client the city able to state the name, date, illness
or residence, time of current time,
day, date of day, day of date, year, place,
his own name,
week, duration of
duration of
illness and names of illness and name
family members. of family
3.) Memory Inspection The average Able to repeat normal
Listen for lapses in person can
memory. Ask the client repeat a series of
about difficulty with five to eight
digits in
a) Assess immediate
recall by asking the
client to repeat a series
of three digits,

4.) Attention Span

Test the ability of the
client to concentrate by Inspection Able to focus on Focused and normal
asking the client to recite examiner’s relaxed
the alphabet or to count questions. Able Able to count
backward from 50. to recite the backward to 50
alphabet or to
count backward
from 50
5.) Calculation Inspection Able to answer Able to answer normal
Test the ability to the equation quickly
calculate by asking the quickly.
client to solve simple
Neurological System
And Vagus

1.) Throat movement

Inspection When patient Uvula and soft Normal
Instruct your patient to speaks, his or palate moves up
open his or her mouth and her uvula and
say “Ah”. soft palate move
straight up
2.) Gag reflex
Instruct your patient to
open his or her mouth. As
you depress his or her
tongue with a tongue Inspection Patient gags. Patient gags Normal
depressor, touch a cotton However,
swab to either side of his remember that a
or her pharynx. weak gag reflex
may be normal
3.) Vocalization in an elderly
Ask your patient to speak patient.
or cough.

Inspection Patient’s voice Voice is clear normal

clear and strong.
Cough strong.
XI. Spinal Accessory

1.)Shoulder movement
Inspection The client lifts Able to lift Normal
Stand facing your patient. shoulder despite shoulder
Place your hands on his or your downward
her shoulders. Ask him or pressure.
her to lift his or her
shoulders as you apply
moderate downward

2.) Neck muscle strength

Place your left hand on the

right side of your patient’s
face. Instruct him or her to
turn her head toward his or
her right side, against your Inspection Firm jaw Able to turn head normal
hand’s pressure. Repeat on pressure against
the left side of her face. your hand
XII. Hypoglossal

Ask your patient to open Inspection Tongue is Tongue centered

his or her mouth, and motionless and on mouth floor Normal
observe his or her tongue centered on
at rest. mouth floor.

Tongue Movement

Instruct your patient to Slight tongue

stick out her tongue. Inspection Protruding movement; tongue Normal
tongue appears centered
between lips.
Tongue strength Expect slight
Instruct your patient to movement.
press his or her tongue
against one cheek wall. Inspection
Apply fingertip pressure to Exerts firm
outside of cheek as patient Patient exerts pressure Normal
uses tongue to resist firm tongue
pressure. Repeat test on pressure against
other cheek. your fingertips.

1.) Reflexes

a.) Biceps

Inspection Presence of Normal
normal slight
flexion of the
elbow, and
b.) triceps reflex

Inspection Present
c.) Patellar reflexes Presence of Normal
normal slight
extension of the
Inspection Present
Presence of Normal
d.) Achilles reflex normal
extension or
kicking out of
the leg as the
Inspection muscle
e.) Plantar Reflex Present
Presence of Normal
normal plantar
Inspection (downward jerk)
of the foot)
2.) Motor function Negative Babinski
All five toes Normal
a.) Walking gait bend downward
– normal
babinski reflex


Good gait; good

The client has Normal
b.) Romberg test
upright posture
and steady gait
with opposing
arm swing;
Inspection walks unaided
c.) Standing on one Negative
foot with eyes closed Romberg: may
sway slightly
d.) Heel-toe walking but is able to
maintain upright
posture and foot
stance Maintains stance
e.) Toe or heel
walking Inspection Maintains stance Normal
for atleast 5 Has hard time
seconds performing
10. Fine motor Tests for
the upper extremities Maintains heel- Could not
Inspection toe walking Has hard time balance well
a) Finger-to-nose test along a straight performing
The client is Could not
able to walk balance well
b) Alternating several steps on able to repeatedly
toes or heels and rhythmitically
supination and The client is touch his nose Normal
pronation of hands on Inspection able to
knees repeatedly and
rhythmitically able to perform
touch his nose. rapidly
c) Finger to nose and
Inspection Normal
to the nurse’s finger

Can alternately
d) Fingers to supinate and
fingers Inspection pronate hands at Normal
rapid pace.

The client with accuracy

f.) Fingers to thumb performs with
coordination and
Inspection rapidity.

able to perform Normal

11.) Fine motor tests The client
for the Lower Inspection performs with
Extremities accuracy and Normal
Ask the client to lie supine rapidity
and to perform these tests.
a.) Heel down opposite
shin The client
touches each
finger to thumb
quickly with
each hand
b.) Toe or ball of foot to
the nurse’s finger Equal

12.) Light touch Inspection

sensation Normal

Moves smoothly
13.) Pain sensation
The client
Inspection demonstrates
bilateral equal Normal
14.)Temperature sensation Light touch
Inspection Moves
smoothly, with
coordination Able to determine Normal
15.)Position of Kinesthetic
sensation Inspection
Light tickling or Able to determine Normal
touch sensation
16.) Tactile discrimination
For all tests, the client’s
eyes needs to be closed. Inspection The client is
able to Normal
a.) Stereo gnosis(Ability discriminate
to recognize objects “sharp” and
by touching them)
The client is
b.)Extinction Inspection able to
Phenomenon discriminate Normal
between “hot”
and “cold”
Can readily
determine the
position of the
fingers and toes.
Able to recognize Normal

The client
Inspection common objects Both points felt

Both points of
stimulus are felt


Unable to perform; patient refuses to
Prostate Gland-Unable to perform; patient refuses to
Course in the Ward
Laboratory Exam

Date performed: 04/26/10

Actual Normal
Procedure Definition Interpretation Analysis
findings Values
Complete blood count
Hemoglobin The hemoglobin test is an integral part of 74 gm/l 120-180 gm/l Decreased While the kidney is normally
your health evaluation. The test is used to: thought of as an excretory organ,
measure the severity of anemia or it is also an important endocrine
polycythemia, monitor the response to organ (ie, one that produces
treatment of anemia or polycythemia, and hormones). One of the hormones
help make decisions about blood it produces is called
transfusions if the anemia is severe. erythropoietin (EPO), which
stimulates the production of red
blood cells (RBCs). RBCs are
basically sacs of hemoglobin that
carry oxygen around. The
amount of hemoglobin varies
according to the number of
RBCs in the blood. And the
number of RBCs in the blood is
controlled by EPO. In kidney
disease, EPO production
decreases because the kidney is
malfunctioning. As a result, RBC
counts decreases, as does
Hematocrit This test is used to evaluate: anemia, 0.237 0.370-0.540 Decreased Decreased hematocrit indicates
polycythemia, response to treatment of anemia, such as that caused by
anemia or polycythemias, dehydration, iron deficiency or other
blood transfusion decisions for severe deficiencies. Further testing may
symptomatic anemias, and the be necessary to determine the
effectiveness of those transfusions. exact cause of the anemia

White blood White blood cell count or leukocyte count 4.6-10.0 Increased An elevated number of white
cell count is the number of white blood cells in the 11.6 /L blood cells (leukocytosis) can
blood. The doctor will usually measure /L result from bacterial infections,
WBC as part of the CBC, or complete inflammation, leukemia, trauma,
blood count. White blood cells are the or stress.
infection-fighting cells in the blood, and
are distinct from the red oxygen-carrying
blood cells, known as erythrocytes. All the
types of white blood cells are reflected in
the white blood cell count. A low white
blood cell count is termed leucopenia, and
a high white blood cell count is termed
Eosinophils An absolute eosinophil count is a blood No data 0-0.05 --- ---
test that measures the number of white
blood cells called eosinophils. Eosinophils
become active when you have certain
allergic diseases, infections, and other
medical conditions.
This test is done if the results of another
blood test, called a blood differential, are
abnormal. This test may also be done if the
doctor thinks you may have a specific
Lymphocytes Lymphocytes are responsible for immune 0.23 0.20-0.40 Normal
responses. There are two main types of
lymphocytes: B cells and T cells. The B
cells make antibodies that attack bacteria
and toxins while the T cells attack body
cells themselves when they have been
taken over by viruses or have become
cancerous. Lymphocytes secrete products
(lymphokines) that modulate the functional
activities of many other types of cells and
are often present at sites of chronic
Neutrophils 0.02 0-0.05 Normal
Monocytes White blood cells are evaluated by a Decreased A low number of monocytes in
differential count, which reports 0.01 /L 4.6-10 the blood (monocytopenia) can
percentages of the types of WBCs present. /L occur in response to the release
These are neutrophils which fight infection of toxins into the blood by
(also known as polys and bands, certain types of bacteria
polymorphonuclear leukocytes, PMN’s, (endotoxemia), as well as in
grans, segs and nonsegs), lymphocytes people receiving chemotherapy
which produce antibodies and other or corticosteroids. Low
immune system activities (lymphs, ly), monocyte count means that you
monocytes which also fight infection are more susceptible to infections
(mono’s), eosinophils (eos) and basophils since you don't have enough anti
(basos) which are involved with allergies. bodies that will defend you from
The red cells are also evaluated for size, viruses, bacteria and other
shape, color and the presence of any unwelcome organisms.
Segmenter abnormalities 0.74 0.60-0.70 Increased

Manual differentials are performed by

taking a drop of blood, spreading it on a
slide, staining it, and evaluating 100 cells
individually for quality and changes in
morphology. For patients with elevated
white cell counts, differentials of 200 cells
or greater might be done. Automated
differentials are performed by either testing
for specific compounds within the cells or
comparing their size, shape, and content.
Most instruments will count thousands of
cells. For both types of differentials, the
numbers are reported in percentages.
Platelet count A platelet count is a test to measure how 150-140 Increased The medical term for a high
many platelets you have in your blood. 253 /L platelet count is thrombocytosis,
Platelets help the blood clot. /L a condition in which bone
marrow cells produce too many
platelets. Thrombocytosis can be
either reactive or essential.
Reactive thrombocytosis means
that a high platelet count is a
reaction to inflammation,
infection, injury, anemia, or
cancer, and essential
thrombocytosis indicates that
genetic conditions or hormone
imbalances are causing irregular
platelet formation. Individuals
with the reactive form rarely
experience symptoms, while
people with essential
thrombocytosis may suffer from
blood clots in their extremities,
nosebleeds, bloody stools, and
unexplained bruising.
Creatinine Creatinine may be ordered routinely as part 0.40 mg/dl 0.5-1.2 mg/dl Decreased A decreased creatinine clearance
of a comprehensive or basic metabolic rate may also occur when there is
panel, during a health examination. It may decreased blood flow to the
be ordered when you have non-specific kidneys as may occur with
health complaints, when you are acutely congestive heart failure,
ill, and/or when your doctor suspects your obstruction within the kidney, or
kidneys are not working properly. acute or chronic kidney failure.
The creatinine blood test may be ordered, The less effective the kidney
along with BUN test and microalbumin, at filtration, the greater the decrease
regular intervals when you have a known in clearance.
kidney disorder or have a disease that may
affect kidney function or be exacerbated by
dysfunction. Both BUN and creatinine may
be ordered when a CT scan is planned,
prior to and during certain drug therapies,
and before and after dialysis to monitor the
effectiveness of treatments.
Blood type The results of blood typing will tell “B+” Rh(+)
determine the patient’s group A, B, AB, or
O and if she is Rh negative or positive
depending on what antigens are present on
the patients red blood cells. The results
will tell the physician treating you what
blood or blood components will be safe for
the patient to receive.
The results will tell a pregnant woman
whether she is Rh positive or negative and
whether she may be a candidate for
receiving Rh immune globulin to prevent
her from potentially developing antibodies
against her fetus’ blood cells.

Date performed: 04/26/10

Actual Normal
Procedure Definition Interpretation Analysis
findings Values
Sodium This test is a part of the routine lab 130.8 mmol/L 135-145 Normal
evaluation of most patients. It is one of the mmol/L
blood electrolytes, which are often ordered
as a group. It is also included in the basic
metabolic panel, widely used when
someone has non-specific health
complaints, and in monitoring treatment
involving IV fluids or when there is a
possibility of developing dehydration.
Electrolyte panels and basic metabolic
panels are also commonly used to monitor
treatment of certain problems, including
high blood pressure, heart failure, and liver
and kidney disease.

A blood sodium test may be ordered when

a patient has symptoms of hyponatremia,
such as weakness, confusion, and lethargy,
or symptoms of hypernatremia such as
thirst, decreased urinary output, muscle
twitching, and/or agitation.

Potassium Serum or plasma tests for potassium levels 3.18 mmol/L 3.4-4.0 Normal
are routinely performed in most patients mmol/L
when they are investigated for any type of
serious illness. Also, because potassium is
so important to heart function, it is usually
ordered (along with other electrolytes)
during all complete routine evaluations,
especially in those who take diuretics or
blood pressure or heart medications.
Potassium is ordered when a doctor is
diagnosing and evaluating high blood
pressure (hypertension) and kidney disease
and when monitoring a patient receiving
dialysis, diuretic therapy, or intravenous
Chloride Blood chloride testing is often ordered, No data 98-106
along with other electrolytes, as part of a mmol/L
regular physical to screen for a variety of
conditions. These tests may also be ordered
to help diagnose the cause of signs and
symptoms such as prolonged vomiting,
diarrhea, weakness, and respiratory
distress. If an electrolyte imbalance is
detected, the doctor will look for and
address the disease, condition, or
medication causing the imbalance and may
order electrolyte testing at regular intervals
to monitor the effectiveness of treatment. If
an acid-base imbalance is suspected, the
doctor may also order blood gas tests to
further evaluate the severity and cause of
the imbalance.
Calcium Blood calcium is tested to screen for, No data 2.15-2.57
diagnose, and monitor a range of mmol/L
conditions relating to the bones, heart,
nerves, kidneys, and teeth. Blood calcium
levels do not directly tell how much
calcium is in the bones, but rather, how
much calcium is circulating in the blood.

Date performed: 04/26/10

Actual Normal
Procedure Definition Interpretation Analysis
findings Values
Urinalysis A routine urinalysis may be done when
you are admitted to the hospital. It may
also be part of a wellness exam, a new
pregnancy evaluation, or a work-up for a
planned surgery. A urinalysis will most
likely be performed when you see your
health care provider complaining of
symptoms of a UTI or other urinary system
problem such as kidney disease.
Color Shows degree of concentration and Yellow Yellow or Normal
depends on amount voided. amber
Transparency Normal urine is transparent. Turbid Cloudy Clear Abnormal Urine clarity refers to how clear
(cloudy) urine may be caused by either the urine is. Usually, laboratories
normal or abnormal processes. Normal report the clarity of the urine
conditions giving rise to turbid urine using one of the following terms:
include precipitation of crystals, clear, slightly cloudy, cloudy, or
mucus, or vaginal discharge. Abnormal turbid. "Normal" urine can be
causes of turbidity include the presence clear or cloudy. Substances that
cause cloudiness but that are not
of blood cells, yeast, and bacteria.
considered unhealthy include
mucus, sperm and prostatic fluid,
cells from the skin, normal urine
crystals, and contaminants such
as body lotions and powders.
Other substances that can make
urine cloudy, like red blood cells,
white blood cells, or bacteria,
indicate a condition that requires
Reaction Reflects the ability of kidney to maintain 6.0 4.6-7.5 Normal
normal hydrogen ion concentration in
plasma and extracellular fluid; indicates
acidity or alkalinity of urine.
Specific Reflects the kidney’s ability to concentrate 1.010 1.005-1.025 Normal
gravity or dilute urine; may reflect degree of
hydration or dehydration.

Date performed: 04/27/10

Procedure Definition Actual findings Interpretation Analysis
Chemical test
Albumin An albumin test may be ordered as part of Negative Negative Normal
a liver panel to evaluate liver function,
along with a creatinine and BUN (Blood
Urea Nitrogen) to evaluate kidney
function, or along with a prealbumin to
evaluate a person's nutritional status. A
physician may order an albumin test, along
with other tests, when a person has
symptoms of a liver disorder such as
jaundice, fatigue, or weight loss, or
symptoms of nephrotic syndrome such as
swelling around the eyes, belly, or legs.

Doctors may also order blood albumin

tests along with or instead of a prealbumin
test when they want to check or monitor a
person's nutritional status. Albumin
concentrations do not change as rapidly as
prealbumin, but decreases can reflect
protein deficiencies and malnutrition.

Sugar The blood glucose test is ordered to Negative Negative Normal

measure the amount of glucose in the
blood right at the time of sample
collection. It is used to detect both
hyperglycemia and hypoglycemia, to help
diagnose diabetes, and to monitor glucose
levels in persons with diabetes. Blood
glucose may be measured on a fasting
basis (collected after an 8 to 10 hour fast),
randomly (anytime), post prandial (after a
meal), and/or as part of an oral glucose
tolerance test (OGTT / GTT).
IV Fluids:


• The patient is using 1 liter of Plain Normal Saline Solution

• started at 4pm


• The patient’s IV fluid is shifted to D5LR 1 liter (bottle #1) started at 5am

• During the 2-10 shift, the patient’s IVF of D5LR 1L is at 600cc level

• IV fluid is endorsed at 400cc level


• Patient used bottle #2 of D5LR 1Liter


• The patient’s IV fluid is shifted to D5NM 1 liter, bottle #3; to run for 8° reg. @ 30-31

• Started @ 10:45am

• The patient’s IV fluid is endorsed @ 550cc level

• The patient’s IVF is bottle #4 D5NM 1L to run for 8 hours

• Started @ 10pm


• The patient used D5NM 1L (#5); to run for 8 hours

• Started @ 6am

Medications Taken:

• Cefuroxime 750 mg IV q8°

• FeSO4 Tab TID Deferred-4/28/10

• Vit. C 500 mg OD P.O

• Kalium durule Tab Bid

• Ranitidine 50 mg IV q8°

STAT Medications:


PRN Medications:

• Paracetamol


• From 4/26/10 to 4/30/10, client is on DAT

Intake and output

Date: Venoclysis Others(Blood) Oral Total Urine Bowel

• 4/26/10: 250 200 450 3x --------

850 150 1000

• 4/27/10: 300 500 800 6x --------

200 100 300

800 100 900

• 4/28/10: 650 1000 1650 10x 2x

300 350 480 1130

400 100 200 700

• 4/29/10: 100 1000 1100 7x 1x

900 1440 2340

1000 240 1240

Nurse’s Notes

4/26/10 >BP=80/50; relayed to MOD

>received patient awake; sitting on >placed on moderate trendelenburg

stretcher position

>conscious and coherent >12AM BP=90/60

>febrile T=38.5°C >needs attended

>(-) respiratory distress

>G1P0 with no signs of labor noted 4/27/10 6-2

>with IVF of PNSS 1L @ 750 mL >awake; sitting on a wheelchair

>S/E by Dr. Abioq with orders made and >with IVF D5LR 1L @ 900mL level on
carried out left hand

>on q2° temp. monitoring >febrile T=38.7°C

>advised to continue TSB until afebrile >(-) respiratory distress

>on DAT; EDCF instructed >result of CBC in @ chart

>for CBC with APC tom AM; req. @ >on DAT

>increase OFI advised

>due meds. Given

>for referral to OB as ordered by Dr. Felipe

>for BPS-done TSB

>endorsed with same IVF @ 600 mL level

4/27/10 2-10 >S/E by Dr. Felipe with orders for

admission carried out
>received on bed
>for BT of 1 unit PRBC; awaits blood
>with ongoing IVF of D5LR 1L @ 600cc typing result
>endorsed to Med NOD with IVF @
>febrile; TSB instructed 400cc level
>conscious and coherent

>kept safe 4/29/10

>BPS result=in >received patient awake on bed
>BP=70/50 referred to Dr. Felipe with >conscious and coherent
orders carried out
>with ongoing IVF of D5NM 1L to run
>endorsed to DR NOD with IVF @ 550 for 8°, reg. @ 30-31 gtts/min; received @
level full level

4/27/10 2-10 >on DAT
>received back from DR accompanied by >with good capillary refill as evidenced by
DR NOD 1-2 secs. Refill
>seen by OB with orders made
>with good skin turgir as evidenced by 1-2 >monitor v/s every 2 hours
secs. Return
>monitor I/O
>with pain on neck
>Encouraged divertional activities
>no pain upon urination
>provide quiet and relaxed environment
>light yellow urine color
>Health teachings done
>supportive care done
>morning care done
>seen @ intervals

>due meds. Given

>observe non-verbal cues/pain behaviors

>obtain clients assessment of pain to include location, intensity, and characteristics

>advised deep breathing exercises

>advised to increase oral fluid intake

>advised to have naps or adequate amount of sleep

>to secure blood culture and sensitivity result

>follow-up cross-matching

>still for BT of 2 units PRBC

>after the shift, showed signs comfort and relaxation; responding well and attentively

>endorsed to the next duty nurse with IV fluid of D5NM 1L regulated @ 30-31 drops/min; @
550 cc level

Doctor’s Order


>for blood C/S


> request for serum creatine

>defer FeSO4

>Ranitidine 50 mg q8°


>still for BT of 2 units PRBC

>kalium durule 1 tab BID

>IVF of D5NM 1L x8°

Nursing Responsibilities

• One of the most important nursing roles involved in the urinary system is keeping I & O,

(intake and output).

• The fluid intake and output must be accurately measured for all patients with any urinary

related issues. Unless a patient is on fluid restrictions they should be offered fluids

frequently and have them fresh and readily available at their bedside. Fluids should

include a variety of juices, tea, soups and most of all water. Adequate hydration keeps the

urinary system clean and prevents urine from becoming concentrated. The fluid intake

should be no less than 2500 cc every day. Unless fluids are being lost through excessive

perspiration, vomiting or diarrhea the output should be approximately 2000 cc ( if their

intake was 2500cc). There is always loss with breathing and normal body function. If the

patient is dehydrated and not receiving enough fluids these body functions cannot be

performed correctly.
• The intake part of I & O consists of any fluid taken in by the patient. This can be orally or

IV. A fluid is anything that is liquid or turns back into liquid at room temperature. Ice

cream, Jell-O, Soups. The output part of I & O is anything out of the body in liquid form.

This can be from any part of the body. Vomiting, severe perspiration, diarrhea, and of

course urine. All of these must be written down and documented as soon as it occurs.

Trying to remember what your patient drank all day or when and how much they urinated

is not OK. Many patient are too confused or just to tired or confused to remember what

they drank or how much they urinated.

• If you have a mobile patient it is best to have a hat in the commode to catch the urine. For

a man have him use a urinal. For things like excessive sweating this is more difficult to

measure, you may say a chux soaked two times this shift. This can also be used if the

patient is incontinent and uses some sort of attends (adult diaper). Some people are on

very strict I & O and the attends would have to be weighed. When doing I & O remember

to notice the color and odor and any sentiment you may see.

• Another nursing responsibility is collecting specimens related to the urinary system "A

Urinalysis". There are several different kinds of urine samples that may be needed:

1.) Clean catch, all urine specimens should be clean catch, if a urine specimen states:

2.) Routine, this means there is no special procedures for collection but bacteria collects

around the urinary meatus all the time, so if we do not clean the area prior to collection of

the specimen you are going to end up with a contaminated specimen. So be it routine or

clean catch, please clean the area prior to collection.

3.) Sterile urine specimen needs to come from a catheter. It is not OK to collect a

specimen directly from a catheter bag!!! You must clamp the catheter off for
approximately 20 - 30 minutes prior to collection and then clean the catheter tip with

alcohol and then drip the urine into a sterile cup. If it is a patient who does not already

have a catheter in place then you, (the license. nurse) must do a sterile straight catheter


4.) A 24 hour urine specimen is just that. You MUST save all urine for 24 hours to find

out if there is protein being spilled into the urine. If any of the urine is not added to the

specimen it is of no value and must be done all over again.

• All urine specimens must be labeled with the patient’s name, time and date; they must

also be refrigerated until they are given to the lab.

Anatomy and Physiology


The Urinary System is a group of organs in the body concerned with filtering out excess fluid

and other substances from the bloodstream. The substances are filtered out from the body in the

form of urine. Urine is a liquid produced by the kidneys, collected in the bladder and excreted

through the urethra. Urine is used to extract excess minerals or vitamins as well as blood

corpuscles from the body. The Urinary organs include the kidneys, ureters, bladder, and urethra.

The Urinary system works with the other systems of the body to help maintain homeostasis. The

kidneys are the main organs of homeostasis because they maintain the acid base balance and the

water salt balance of the blood.

Functions of the urinary system

One of the major functions of the Urinary system is the process of excretion. Excretion is the

process of eliminating, from an organism, waste products of metabolism and other materials that

are of no use. The urinary system maintains an appropriate fluid volume by regulating the
amount of water that is excreted in the urine. Other aspects of its function include regulating the

concentrations of various electrolytes in the body fluids and maintaining normal pH of the blood.

Several body organs carry out excretion, but the kidneys are the most important excretory organ.

The primary function of the kidneys is to maintain a stable internal environment (homeostasis)

for optimal cell and tissue metabolism. They do this by separating urea, mineral salts, toxins, and

other waste products from the blood. They also do the job of conserving water, salts, and

electrolytes. At least one kidney must function properly for life to be maintained. Six important

roles of the kidneys are:

Regulation of plasma ionic composition. Ions such as sodium, potassium, calcium, magnesium,

chloride, bicarbonate, and phosphates are regulated by the amount that the kidney excretes.

Regulation of plasma osmolarity. The kidneys regulate osmolarity because they have direct

control over how many ions and how much water a person excretes.

Regulation of plasma volume. Your kidneys are so important they even have an effect on your

blood pressure. The kidneys control plasma volume by controlling how much water a person

excretes. The plasma volume has a direct effect on the total blood volume, which has a direct

effect on your blood pressure. Salt(NaCl)will cause osmosis to happen; the diffusion of water

into the blood.

Regulation of plasma hydrogen ion concentration (pH). The kidneys partner up with the lungs

and they together control the pH. The kidneys have a major role because they control the amount

of bicarbonate excreted or held onto. The kidneys help maintain the blood Ph mainly by

excreting hydrogen ions and reabsorbing bicarbonate ions as needed.

Removal of metabolic waste products and foreign substances from the plasma. One of the most

important things the kidneys excrete is nitrogenous waste. As the liver breaks down amino acids
it also releases ammonia. The liver then quickly combines that ammonia with carbon dioxide,

creating urea which is the primary nitrogenous end product of metabolism in humans. The liver

turns the ammonia into urea because it is much less toxic. We can also excrete some ammonia,

creatinine and uric acid. The creatinine comes from the metabolic breakdown of creatine

phospate (a high-energy phosphate in muscles). Uric acid comes from the breakdown of

nucleotides. Uric acid is insoluble and too much uric acid in the blood will build up and form

crystals that can collect in the joints and cause gout.

Secretion of Hormones The endocrine system has assistance from the kidney's when releasing

hormones. Renin is released by the kidneys. Renin leads to the secretion of aldosterone which is

released from the adrenal cortex. Aldosterone promotes the kidneys to reabsorb the sodium

(Na+) ions. The kidneys also secrete erythropoietin when the blood doesn't have the capacity to

carry oxygen. Erythropoietin stimulates red blood cell production. The Vitamin D from the skin

is also activated with help from the kidneys. Calcium (Ca+) absorption from the digestive tract is

promoted by vitamin D.

Kidneys and ureters

The kidneys are large, bean-shaped organs towards the back of the abdomen (belly). They lie

behind a protective sheet of tissue within the abdomen. The kidneys perform many vital
functions which are important in everyday life. For example, they help us get rid of waste

products by making urine and excreting it from the body. A special system of tubes within the

kidneys allow substances such as sodium (salt) and chloride to be filtered.

The kidneys regulate the amount of water in the body. Humans produce about 1.5 litres of urine

a day. However, if we drink more water, we may produce more urine. On hot days, if we get

dehydrated and sweat more, we may produce less urine. This is why it's very important to drink

lots of water on hot summer days.

The kidneys also produce renin (a hormone important in regulating blood pressure) and

erythropoietin (helps produce red blood cells).

Located in the lower part of our bellies, the right kidney is slightly lower in position than the left,

allowing room for the liver. The kidneys are reddish brown in colour and measure about 10 cm

in length, 5 cm width and 2.5 cm thick. On the side of the kidney with the smaller curve is an

opening called the hilum, where blood vessels, nerves, and the ureters enter the kidney. On one

end of the ureters is a funnel-shaped expansion, called the renal pelvis, where urine collects. The

ureters carry urine to the bladder; they are 25–30 cm long tubes lined with smooth muscle. The

muscular tissue helps force urine downwards. The ureters enter the bladder at an angle, so urine

doesn't flow up the wrong way. The ureters are two tubes that drain urine from the kidneys to the

bladder. Each ureter is a muscular tube about 10 inches (25 cm) long. Muscles in the walls of the

ureters send the urine in small spurts into the bladder, (a collapsible sac found on the forward

part of the cavity of the bony pelvis that allows temporary storage of urine). After the urine

enters the bladder from the ureters, small folds in the bladder mucosa act like valves preventing

backward flow of the urine. The outlet of the bladder is controlled by a sphincter muscle. A full

bladder stimulates sensory nerves in the bladder wall that relax the sphincter and allow release of
the urine. However, relaxation of the sphincter is also in part a learned response under voluntary

control. The released urine enters the urethra.

Urinary Bladder

The bladder is a pyramid-shaped organ which sits in the pelvis (the bony structure which helps form the

hips). The main function of the bladder is to store urine and, under the appropriate signals, release it into a

tube which carries the urine out of the body. Normally, the bladder can hold up to 500 mL of urine. The

bladder has three openings: two for the ureters and one for the urethra (tube carrying urine out of the


The bladder consists of smooth muscles. The main muscle of the bladder is called the detrusor muscle.

Muscle fibres around the opening of the urethra forms a ring-like muscle that controls the passage of

urine. When we want to urinate, stretch receptors in the bladder are activated, which send signals to our

brain and tell us that the bladder is full. The ring-like muscle relaxes and the detrusor muscle contracts,

allowing urine to flow.

The blood supply of the bladder is from many blood vessels. Some of these blood vessels are named: the

vesical arteries, the obturator, uterine, gluteal and vaginal arteries. In females, a venous network drains

blood from the bladder arteries into the internal iliac vein. Nervous control of the bladder involves centres

located in the brain and spinal cord.


The urethra is a muscular tube that connects the bladder with the outside of the body. The

function of the urethra is to remove urine from the body. It measures about 1.5 inches (3.8 cm) in

a woman but up to 8 inches (20 cm) in a man. Because the urethra is so much shorter in a woman

it makes it much easier for a woman to get harmful bacteria in her bladder this is commonly

called a bladder infection or a UTI. The most common bacteria of a UTI is E-coli from the large

intestines that have been excreted in fecal matter.

The male urethra is 18–20 cm long, running from the bladder to the tip of the penis. The male

urethra is supplied by the inferior vesical and middle rectal arteries. The veins follow these blood

vessels. The nerve supply is via the pudendal nerve.

The female urethra is 4–6 cm long and 6 mm wide. It is a tube running from the bladder neck

and opening into an external hole located at the top of the vaginal opening. As the female urethra

is shorter than the male urethra, it is more likely to get infections from bacteria in the vagina. The

female urethra is supplied by the internal pudendal and vaginal arteries.


A nephron is the basic structural and functional unit of the kidney. The name nephron comes

from the Greek word (nephros) meaning kidney. Its chief function is to regulate water and

soluble substances by filtering the blood, reabsorbing what is needed and excreting the rest as

urine. Nephrons eliminate wastes from the body, regulate blood volume and pressure, control

levels of electrolytes and metabolites, and regulate blood pH. Its functions are vital to life and are

regulated by the endocrine system by hormones such as antidiuretic hormone, aldosterone, and

parathyroid hormone.

Each nephron has its own supply of blood from two capillary regions from the renal artery. Each

nephron is composed of an initial filtering component (the renal corpuscle) and a tubule

specialized for reabsorption and secretion (the renal tubule). The renal corpuscle filters out large

solutes from the blood, delivering water and small solutes to the renal tubule for modification.

The glomerulus is a capillary tuft that receives its blood supply from an afferent arteriole of the

renal circulation. The glomerular blood pressure provides the driving force for fluid and solutes

to be filtered out of the blood and into the space made by Bowman's capsule. The remainder of

the blood not filtered into the glomerulus passes into the narrower efferent arteriole. It then

moves into the vasa recta, which are collecting capillaries intertwined with the convoluted

tubules through the interstitial space, where the reabsorbed substances will also enter. This then

combines with efferent venules from other nephrons into the renal vein, and rejoins with the

main bloodstream.
Afferent/Efferent Arterioles

The afferent arteriole supplies blood to the glomerulus. A group of specialized cells known as

juxtaglomerular cells are located around the afferent arteriole where it enters the renal corpuscle.

The efferent arteriole drains the glomerulus. Between the two arterioles lies specialized cells

called the macula densa. The juxtaglomerular cells and the macula densa collectively form the

juxtaglomerular apparatus. It is in the juxtaglomerular apparatus cells that the enzyme renin is

formed and stored. Renin is released in response to decreased blood pressure in the afferent

arterioles, decreased sodium chloride in the distal convoluted tubule and sympathetic nerve

stimulation of receptors (beta-adrenic) on the juxtaglomerular cells. Renin is needed to form

Angiotensin I and Angiotensin II which stimulate the secretion of aldosterone by the adrenal

Glomerular Capsule or Bowman's Capsule

Bowman's capsule (also called the glomerular capsule) surrounds the glomerulus and is

composed of visceral (simple squamous epithelial cells) (inner) and parietal (simple squamous

epithelial cells) (outer) layers. The visceral layer lies just beneath the thickened glomerular

basement membrane and is made of podocytes which send foot processes over the length of the

glomerulus. Foot processes interdigitate with one another forming filtration slits that, in contrast

to those in the glomeruluar endothelium, are spanned by diaphragms. The size of the filtration

slits restricts the passage of large molecules (eg, albumin) and cells (eg, red blood cells and

platelets). In addition, foot processes have a negatively-charged coat (glycocalyx) that limits the

filtration of negatively-charged molecules, such as albumin. This action is called electrostatic


The parietal layer of Bowman's capsule is lined by a single layer of squamous epithelium.

Between the visceral and parietal layers is Bowman's space, into which the filtrate enters after
passing through the podocytes' filtration slits. It is here that smooth muscle cells and

macrophages lie between the capillaries and provide support for them. Unlike the visceral layer,

the parietal layer does not function in filtration. Rather, the filtration barrier is formed by three

components: the diaphragms of the filtration slits, the thick glomerular basement membrane, and

the glycocalyx secreted by podocytes. 99% of glomerular filtrate will ultimately be reabsorbed.

The process of filtration of the blood in the Bowman's capsule is ultrafiltration (or glomerular

filtration), and the normal rate of filtration is 125 ml/min, equivalent to ten times the blood

volume daily. Measuring the glomerular filtration rate (GFR) is a diagnostic test of kidney

function. A decreased GFR may be a sign of renal failure. Conditions that can effect GFR

include: arterial pressure, afferent arteriole constriction, efferent arteriole constriction, plasma

protein concentration and colloid osmotic pressure.

Any proteins that are roughly 30 kilodaltons or under can pass freely through the membrane.

Although, there is some extra hindrance for negatively charged molecules due to the negative

charge of the basement membrane and the podocytes. Any small molecules such as water,

glucose, salt (NaCl), amino acids, and urea pass freely into Bowman's space, but cells, platelets

and large proteins do not. As a result, the filtrate leaving the Bowman's capsule is very similar to

blood plasma in composition as it passes into the proximal convoluted tubule. Together, the

glomerulus and Bowman's capsule are called the renal corpuscle.

Proximal Convoluted Tubule (PCT)

The proximal tubule can be anatomically divided into two segments: the proximal convoluted

tubule and the proximal straight tubule. The proximal convoluted tubule can be divided further

into S1 and S2 segments based on the histological appearance of it's cells. Following this naming

convention, the proximal straight tubule is commonly called the S3 segment. The proximal

convoluted tubule has one layer of cuboidal cells in the lumen. This is the only place in the

nephron that contains cuboidal cells. These cells are covered with millions of microvilli. The

microvilli serve to increase surface area for reabsorption.

Fluid in the filtrate entering the proximal convoluted tubule is reabsorbed into the peritubular

capillaries, including approximately two-thirds of the filtered salt and water and all filtered

organic solutes (primarily glucose and amino acids). This is driven by sodium transport from the

lumen into the blood by the Na+/K+ ATPase in the basolateral membrane of the epithelial cells.
Much of the mass movement of water and solutes occurs in between the cells through the tight

junctions, which in this case are not selective.

The solutes are absorbed isotonically, in that the osmotic potential of the fluid leaving the

proximal tubule is the same as that of the initial glomerular filtrate. However, glucose, amino

acids, inorganic phosphate, and some other solutes are reabsorbed via secondary active transport

through cotransport channels driven by the sodium gradient out of the nephron.

Loop of the Nephron or Loop of Henle

The loop of Henle (sometimes known as the nephron loop) is a U-shaped tube that consists of a

descending limb and ascending limb. It begins in the cortex, receiving filtrate from the proximal

convoluted tubule, extends into the medulla, and then returns to the cortex to empty into the

distal convoluted tubule. Its primary role is to concentrate the salt in the interstitium, the tissue

surrounding the loop.

Descending limb
Its descending limb is permeable to water but completely impermeable to salt, and thus

only indirectly contributes to the concentration of the interstitium. As the filtrate

descends deeper into the hypertonic interstitium of the renal medulla, water flows freely

out of the descending limb by osmosis until the tonicity of the filtrate and interstitium

equilibrate. Longer descending limbs allow more time for water to flow out of the filtrate,

so longer limbs make the filtrate more hypertonic than shorter limbs.

Ascending limb

Unlike the descending limb, the ascending limb of Henle's loop is impermeable to water,

a critical feature of the countercurrent exchange mechanism employed by the loop. The

ascending limb actively pumps sodium out of the filtrate, generating the hypertonic

interstitium that drives countercurrent exchange. In passing through the ascending limb,

the filtrate grows hypotonic since it has lost much of its sodium content. This hypotonic

filtrate is passed to the distal convoluted tubule in the renal cortex.

Distal Convoluted Tubule (DCT)

The distal convoluted tubule is similar to the proximal convoluted tubule in structure and

function. Cells lining the tubule have numerous mitochondria, enabling active transport to take

place by the energy supplied by ATP. Much of the ion transport taking place in the distal

convoluted tubule is regulated by the endocrine system. In the presence of parathyroid hormone,

the distal convoluted tubule reabsorbs more calcium and excretes more phosphate. When

aldosterone is present, more sodium is reabsorbed and more potassium excreted. Atrial

natriuretic peptide causes the distal convoluted tubule to excrete more sodium. In addition, the

tubule also secretes hydrogen and ammonium to regulate pH. After traveling the length of the
distal convoluted tubule, only 3% of water remains, and the remaining salt content is negligible.

97.9% of the water in the glomerular filtrate enters the convoluted tubules and collecting ducts

by osmosis.

The Urinary system is a very important component inside our body. It plays a very

important role in our everyday life. The urinary system, with groups of organs like the kidneys,

which filters excess fluid and other substances in the bloodstream, And this fluids and other

substance result to be our urine.

The urinary is composed of different organs which work together to accomplish different

important tasks. The Urinary organs include the kidneys, ureters, bladder, and urethra. The

kidneys are the main organs of homeostasis because they maintain the acid base balance and the

water salt balance of the blood. A nephron is the basic structural and functional unit of the

kidney. The name nephron comes from the Greek word (nephros) meaning kidney. Its chief

function is to regulate water and soluble substances by filtering the blood, reabsorbing what is

needed and excreting the rest as urine. Nephrons eliminate wastes from the body, regulate blood

volume and pressure, control levels of electrolytes and metabolites, and regulate blood pH.

Excretion is the process of eliminating, from an organism, waste products of metabolism

and other materials that are of no use; this is one of the major functions of the system. The

urinary system maintains an appropriate fluid volume by regulating the amount of water that is

excreted in the urine. Several body organs carry out excretion, but the kidneys are the most

important excretory organ. There are also the six important functions of this system; the

regulation of plasma ionic composition, Regulation of plasma osmolarity, regulation of plasma

volume, regulation of plasma hydrogen ion concentration (pH), removal of metabolic waste

products and foreign substances from the plasma.

The human body is composed of different body systems which help keep the balance and

fights harmful substances in and out of our body, but even so, we still have to do our share of

work to take care of ourselves and not abuse our body.

Client Centered Pathophysiology
For infection to occur, bacteria must gain access to the bladder, attach to and colonize the

epithelium of the urinary tract to avoid being washed out with voiding, evade host defense

mechanisms, and initiate inflammation. Most UTIs result from fecal organisms that ascend from

the perineum to the urethra and the bladder and then adhere to the mucosal surfaces.

Bacterial Invasion of the Urinary Tract

By increasing the normal slow shedding of bladder epithelial cells (resulting in bacteria

removal), the bladder can clear itself of even large numbers of bacteria. Glycosaminoglycan

(GAG), a hydrophilic protein, normally exerts a nonadherent protective effect against various

bacteria. The GAG molecule attracts water molecules, forming water barrier that serves as

defensive layer between the bladder and the urine. GAG may be impaired by certain agents

(cyclamate, saccharin, aspartame, and trytophan metabolites). The normal bacterial flora of the

vagina and urethral area also interfere with adherence of Escherichia coli (the most common

microorganisms causing UTI). Urinary immunoglobulin A (IgA) in the urethra may also provide

a barrier to bacteria.


An obstruction to free-flowing urine is a problem known as urethrovesical reflux, which is the

reflux (backward flow) of urine from the urethra into the bladder. With coughing, sneezing, or

straining, the bladder pressure rises, which may force urine from the bladder into the urethra.

When the pressure returns to normal, the urine flows back into the bladder, bringing into the

bladder bacteria from the anterior portions of the urethra. urethrovesical reflux is also caused by
dysfunction of the bladder neck or urethra. The urethrovesical angle and urethral closure pressure

may be altered with menopause, increasing the incidence of infection in postmenopausal women.

Reflux is most often noted, however, in young children. Treatment is based on its severity.

Ureterovesical or vesicoureteral reflux refers to the backflow of urine from the bladder

into one or both ureters. Normally, the ureteroveical junction prevents urine from traveling back

into the urether. The ureters tunnel into the bladder wall so that the bladder musculature

compresses a small portion of the ureter during normal voiding. When the ureterovesical valve is

impaired by congenital causes or ureteral abnormalities, the bacteria may reach and eventually

destroy the kidney

Loss of integrity of the mucosal lining (caused by in indwelling catheter, tumor, parasites, or

Decreased resistance to invading organisms

Inflammatory changes occur in the affected portion of the Urinary tract.

Clumps of bacteria may be present.

Inflammatory changes in the renal pelvis and throughout the kidney.

Scarring of the kidney parenchyma (occurs in chronic infection), which interferes kidney
Nursing Management
Problem Prioritization

Problem Identified Score Justification

Acute Pain related to

inflammation of bladder
I’ve arranged my problems
mucosa as evidenced by 3
according to airway, breathing
verbal reports, facial grimace
and circulation since
and guarding
Increased temperature related Maslow’s hierarchy of needs

to infectious process possibly wouldn’t be applicable

evidenced by elevated body 1 because these are all under the

temperature, skin flushed/ physiological needs.

warm to touch.
Risk for fluid volume excess 2
Nursing Care Plan

Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Acute Pain Shorter length of After 8 hours Independent: After 8 hours
>”Masakit pag related to urethra, of nursing  Establish rapport.  To build nurse- of nursing
umiihi ako” as inflammation anatomical intervention patient intervention
verbalized by of bladder proximity to the patient will  Perform a relationship. the patient
the patient. mucosa as vagina report pain is comprehensive  To assess etiology/ report pain is
evidenced by  relieved/ assessment of pain precipitating relieved/
Objective: verbal reports, Ascending controlled. to include location, contributory controlled.
>facial facial grimace infection after characteristic, onset/ factors.
grimace and guarding. entry by way of duration, frequency,
>guarding the urinary quality, severity,
>expressive meatus and precipitating/
behavior  aggravating factors.
(restlessness, Infection  Note client’s locus
crying,  of control
irritability) Pain (internal/external)
>self focusing
 Individuals with
external locus of
control may take
little or no
 Provide comfort responsibility for
measure (e.g., back pain management.
rub, change of  To provide non-
position, use of pharmacologic pain
heat/cold). management.
 Work with client to
prevent pain. Use
flow sheet to  Timely
document pain, intervention is
therapeutic more likely to be
interventions, successful in
response, and length alleviating pain.
of time before pain
 Encourage patient to
drink plenty of

 To promote urinary
output and to flush
 Instruct patient to out bacteria from
void frequently urinary tract.
(every 2-3 hours)  To enhance
and to empty bacterial clearance,
bladder completely. reduces urine statis,
 Review drug and prevent
regimen (note use of reinfection.
drug which are  Some drugs may
nephrotoxic). result in urinary
 Monitor medication retention.
regimen and
antimicrobials.  To identify
patient’s response
Dependent: in treatment
 Instruct patient to
maintain acidic
environment of the  To discourage
bladder by use of bacterial growth
agents such as when appropriate.
vitamin C.
 Encourage patient to
take prescribed
analgesics and
antispasmodics as  To relive pain.
 Assist in thorough
diagnosis including
neurologic and
psychologic factors
as appropriate when  To know where the
pain persists. pain starts.
Assessment Diagnosis Planning Intervention Rationale Evaluation
S: Increased Infectious agents After 2 hours Independent: After 2 hours
>“Mainit ang temperature (Pyrogens) of  Monitor heart rate  Dysrhythmias and of compre-
pakiramdam related to stimulate comprehensive and rhythm. changes arecommon hensive
ko” as infectious  nursing dueto electrolyte nursing
verbalized by process Monocytes intervention, imbalance and intervention,
the patient. possibly Release the patient dehydration and the patient
evidenced by  temperature direct effect of temperature
O: elevated body Pyrogenic will lower hyperthermia on lowers down
>Flushed skin, temperature, cytokines down to blood and cardiac to normal
warm to skin flushed/ Stimulate normal levels: tissues. levels: T:
touch. warm to  T: 36.5°C –  To monitor or 36.5°C – 37.
>Restlessness touch. Anterior 37.5°C potentiates fluid and
>V/S taken as hypothalamus electrolyte loses.
follows: results in  Record all sources
T: 38.1  of fluid loss such as
P: 70 Elevated urine, vomiting and  To decrease
R: 19 thermoregulator diarrhea. temperature by
BP: 110/90 y set point  Promote surface means through
leads to cooling by means evaporation and
 of tepid sponge conduction.
Increased Heat bath.  To minimize
conservation shivering.
(Vasoconstriction  Wrap extremities
/behaviour with cotton
changes) blankets.  To offset increased
  Provide oxygen demands
Increased Heat supplemental and consumption.
production oxygen.  To support
(involuntary circulating volume
muscular and tissue perfusion.
contractions)  Administer  To reduce metabolic
result in replacement fluids demands and
 and electrolytes. oxygen
FEVER consumption
 Maintain bed rest.  To increased
metabolic demands.

 Provide high
calorie diet, tube
feedings, or To facilitate fast
parenteral nutrition. recovery.
 Administer
antipyretics orally
or rectally as
prescribed by the

Collaborative: Indicates presence

 Monitor of infection &
hematologic test & dehydration.
other pertinent lab
records. Ensures continuous
 Discuss condition intervention.
of the patient with
other members of
the health care
Assessment Diagnosis Planning Intervention Rationale Evaluation
S: Risk for fluid Low hematocrit After 8 hours Independent: After 8 hours
volume excess  of nursing  Note client’s age,  Provides of nursing
O: Increase plasma intervention current level of information intervention
>hct= 0.237 volume the patient will hydration, and regarding ability to the patient
 demonstrate mentation. tolerate demonstrates
Hypovolemia adequate fluid fluctuations in fluid adequate
 balance as level risk for fluid balance
edema, weight evidenced by creating or failing as evidenced
gain, pulmonary stable vital to respond to by stable
congestion and sign, palpable problem. vital sign,
oliguria / anuria. pulses/good  To prevent palpable
quality, normal  Measure I/O. fluctuations/ pulses/good
skin turgor, monitor urine output imbalances in fluid quality,
moist mucous (hourly as needed), levels. normal skin
membranes; noting amount, turgor, moist
individual color, time of day, mucous
appropriate dieresis. membranes;
urinary output;  Note presence of  To include losses individual
lack of vomiting, liquid in output appropriate
excessive stool; inspect. calculations. urinary
weight  Auscultate BP,  PP widens before output; lack
fluctuation calculate pulse systolic BP drops of excessive
(loss/gain), and pressure. in response to fluid weight
no edema loss. fluctuation
present.  This relate to fluid (loss/gain),
 Weigh daily or as status. and no edema
indicated and present.
evaluate changes.
 Review laboratory  To determine
data, chest x-ray. changes indicate of
electrolyte and/ or
fluid imbalance.

Dependent:  To promote fluid

 Administer IV fluids management.
as prescribed using
infusion pumps.
Medical Management
a. IVF

Client’s response to
Date given Type of IVF Indication/ Purpose
04/26/10 Isotonic Restore sodium and Same osmolarity as
chloride losses. the cells (270 – 300
PNSS 1L x 20 A solution that has the mmol/L). Equal solute
gtts/min same salt concentration Dilute or dissolve and water—exact
as the normal cells of drugs for IV, IM, or same number of
the body and the blood. SC use. particles in both
As opposed to a
solutions—no net
hypertonic solution or a
Flushing for IV movement of water.
hypotonic solution. An
catheters. Does not change cell
isotonic beverage may
be drunk to replace the volume.
Extracellular fluid
fluid and minerals
which the body uses replacement. Priming
during physical activity. solution for

Initiate and terminate

blood transfusion so
RBCs will not

Metabolic alkalosis
where there is fluid
loss and mild sodium

04/27/10 Isotonic Lactated Ringer's and

5% Dextrose
04/28/10 A solution that has the Injection, USP is
same salt concentration
indicated as a source
as the normal cells of
D5LR 1L of water, electrolytes
the body and the blood.
As opposed to a and calories or as an
hypertonic solution or a alkalinizing agent.
hypotonic solution. An
isotonic beverage may
be drunk to replace the
fluid and minerals
which the body uses
during physical activity.
04/29/10 Hypertonic D5NM is indicated The cell will shrink
for parenteral (crenation) by loss of
04/30/10 A hypertonic solution maintenance of its fluid to the
contains a greater routine daily fluid and surrounding
D5NM IL x 8° @ 30- concentration of electrolyte hypertonic
31 gtts/min impermeable solutes requirements with environment. High
than the solution on minimal carbohydrate osmotic pressure of
the other side of the calories from surrounding fluid
membrane.When a dextrose. Magnesium pulls fluid out of the
cell’s cytoplasm is in the formula may cell.
bathed in a help to prevent
hypertonic solution iatrogenic magnesium
the water will be deficiency in patients
drawn into the receiving prolonged
solution and out of parenteral therapy.
the cell by osmosis. If
water molecules
continue to diffuse out
of the cell, it will
cause the cell to

b. Diet : DAT/ General diet

Client’s response to
Date ordered Indication/ Purpose Type of foods taken
April 26-30, 2010 (Please refer to the The client is well
course in the ward.) nourished and strong.
Generic Name: Ranitidine hydrochloride Trade Name: Zantac
Route of Administration: Intravenous Dosage: 50 mg q 8°
Mode of Indications/ Adverse Nursing Health
Drug Class Drug Interaction
Action Contraindications Reactions Considerations Teachings
Histamine competetively Indication: • Constipation, • Antacids may  Do not confuse  Take as
H-2 inhibits gastric • Short-term(4-8 nausea and decrease Zantac with directed with or
receptor secretion by weeks) and vomiting, ranitidine Xanax or with immediately
blocking blocking the maintenance diarrhea, absorption Zyrtex following
drug effects of treatment of abdominal pain, • Decrease  Give antacids meals, wait 1
duodenal ulcer pancreatitis Cyanocobalami concomitantly hr. before
histamine on (rare) n absorption r/t for gastric pain taking an
• Pathologic
histamine H-2 hypersecretory • Headache, increased although they antacid
receptors; both conditions such dizziness, gastric pH may interfere  Do not drive or
daytime and as Zollinger- malaise, • Decrease with ranitidine operate
nocturnal basal Ellison insomnia, diazepam absorption machinery until
gastric acid are syndrome and vertigo, effects r/t  About one-half drug effects are
systemic confusion, decreased GI of the clients realized;
inhibited, weak
mastocytosis anxiety, tract absorption may heal dizziness or
inhibitor of agitation, drowsiness may
• Short-term • May increase completely
cytochrome P- depression, warfarin within 2 weeks; occur.
treatment of
450; drug active benign fatigue, hypoprothrombi thus,
interactions ulcers somnolence, nemic effects endoscopy may
involving Contraindication: hallucinations • Increase show no need
inhibition of • Cirrhosis of the • Bradycardia, Glipzide effects for further
hepatic liver, impaired tachycardia, treatment
renal or hepatic premature  No dilution is
metabolism are ventricular beats
function required for IM
not expected to following rapid use
occur IV use,  For IV
vasculitis, injection, dilute
cardiac arrest 50 mg in 0.9%
• Thrombocytope NaCl injection
nia, to a total
pancytopenia, volume of 20
leucopenia, mL
aplastic anemia
Generic Name: Potassium Chloride Trade Name: Kalium durule
Route of Administration: P.O Dosage: 750 mg Twice a day
Mode of Indications/ Adverse Nursing Health
Drug Class Drug Interaction
Action Contraindications Reactions Considerations Teachings
Electrolyte Potassium is Indication: • Paresthesias of • None  Give PO doses  Dilute or
readily and • Treat the extremities, significant 2-4 times per dissolve PO
rapidly hypokalemia due listlessness, day. Correct liquids,
absorbed from to digitalis mental hypokalemia effervescent
intoxification, confusion, slowly over a tablets, or
the GI tract.
diabetic acidosis, weakness or period of 3-7 soluble powders
Through a heaviness of days to in 3-8 oz of
diarrhea and
number of salts vomiting, limbs, flaccid minimize risk cold water, fruit
can be used to familial periodic paralysis of or vegetable
supply the paralysis, certain • Peripheral hyperkalemia juice, or other
potassium cases of uremia, vascular  If with suitable liquid
cation, hyperadrenalism, collapse with esophageal and drink
starvation and fall in blood compression, slowly.
debilitation, and pressure, administer  If GI upset
chloride is the cardiac dilute liquid occurs, products
corticosteroid or
agent of choice diuretic therapy arrhythmias, solutions of can be taken
since • Hypokalemia heart block, potassium after meals or
hypochloremia with or without possible cardiac rather than with food with
frequently metabolic arrest tablets a full glass of
accompanies acidosis and • Nausea,  Do not water.
potassium following vomiting, administer  Swallow
surgical abdominal pain, potassium IV enteric-coated
deficiency. diarrhea, GI undiluted. tablets and
accompanied by ulcerations Usual methods extended-
nitrogen loss, • Oliguria is to administer release capsules
vomiting and • Cold skin, gray by slow IV do not chew or
diarrhea, suction pallor infusion in dissolve in the
drainage and dextrose mouth.
increased urinary solution at a ;  Report any
excretion of concentration adverse side
potassium of 40-80 effects and keep
Contraindication: mEq/L at a rate all visits for lab
• Severe renal not to exceed and exams.
function 10-20 meEq/hr.
impairment with
azotemia or
before urine flow
has been
Generic Name: Ascorbic acid Trade Name:Vitamin C
Route of Administration: P.O Dosage: 500 mg; once a day
Mode of Indications/ Adverse Nursing Health
Drug Class Drug Interaction
Action Contraindications Reactions Considerations Teachings
. Indication: • Faintness or • None  Use cautiously  Advised to take
• dizziness with significant in G-6PD before
Contraindication: fast IV deficiency to breakfast;
administration avoid preferably to

• Diarrhea, possibility of take with
epigastric hemolytic orange juice for
burning anemia better
• Acidic urine,  Avoid rapid IV absorption
oxaluria, renal administration
calculi  Protect solution
from light
 Discourage
for colds;
harmful side
effects are
 IV form used
y in some
cancer centers
as adjunct to
treat some
forms of cancer
Generic Name: Cefuroxime Trade Name: Ceftin
Route of Administration: IV Dosage: 750 mg IV Q8°
Mode of Indications/ Adverse Drug Nursing Health
Drug Class
Action Contraindications Reaction Interaction Considerations Teachings
Cephalos- Second Indications: CV: phlebitis, Drug-drug. • Before • Tell patient to
porin, second generation • Pharyngitis, thrombo- Aminoglycoside giving drug take drug as
generation cephalosporin tosilitis, phlebitis. s: May cause ask patient if prescribed,
that inhibits infection of the GI: pseudo- synergistic he is allergic even after he
cell-wall urinary or lower membranous activity against to penicillins feels better.
synthesis, respiratory colitis, nausea, some or • Instruct patient
promoting tracts, and skin anorexia, organisms; may cephalosporins to take oral
osmotic or skin-structure vomiting, increase . form with
instability, infection caused diarrhea. nephrotoxicity. • Obtain food.
usually by Streptococcus Hematologic: Loop diuretics: specimen for • Instruct patient
bactericidal pneumoniae and transient May increase culture and to notify
S. pyogenes, neutropenia, risk of adverse sensitivity prescriber
Haemophilus eosinophilia, renal reactions. tests before about rash or
influenza, hemolytic, Probenecid: giving first evidence of
Staphylococcus thrombo- May inhibit dose. Therapy superinfections
aureus, E.coli, cytopenia. excretion and may begin .
Moraxella Skin: increase while awaiting • Advice patient
catarrhalis, maculopapular cefuroxime results. receiving drug
Neisseria and erythematous level. • Absorptio IV to report
gonorrhea, and rashes, urticaria, Drug-food. Any n of oral drug discomfort at
Klebsiella and pain, induration, food: may is enhanced by IV insertion
Enterobacter sterile abscesses, increase food. site.
species. temperature absorption. • Tablets • Tell patient to
• Serious lower elevation, tissue may be notify
respiratory tract sloughing at IM crushed, if prescriber
infection, UTI, injection site. absolutely about loose
bone or joint Other: necessary, for stools or
infection, hypersensitivity patients who diarrhea.
septicemia, reactions, serum can’t swallow
meningitis, and sickness, tablets.
gonorrhea. anaphylaxis. • If large
doses are
Contraindications: given, therapy
• Contraindicated is prolonged,
in patients or patient at
hypersensitive to risk, monitor
drug or other patient for
cephalosporins. signs and
• Use cautiously in symptoms of
patients super-
hypersensitive to infection.
because of
possibility of
with other beta-
• Use cautiously in
women and in
patients with
history of colitis
or renal

Generic Name: Paracetamol Trade Name:

Route of Administration: PO Dosage:
Mode of Indications/ Adverse Drug Nursing Health
Drug Class
Action Contraindications Reaction Interaction Considerations Teachings
Non-narcotic Decreases Indications: Hematologic: Drug-drug. • Alert: many • Tell parents to
analgesic fever by a • Control of pain hemolytic Barbiturates, OTC and consult
hypothalamic due to headache, anemia, carbamazepine, prescription prescriber
effect leading earache, neutropenia, hydantoins, products before giving
to sweating dysmenorrheal, leucopenia, rifampin, contain drug to
and arthralgia, pancytopenia. sulfinpyrazone: acetaminophen children
vasodilation. myalgia, Hepatic: jaundice. high doses of ; be aware of younger than
Also inhibits musculoskeletal Metabolic: long term use of this when age 2.
the effect of pain, arthritis, hypoglycemia. these drugs may calculating • Advice
pyrogens on immunizations, Skin: rash, reduce daily dose. patients or
the teething, urticaria. therapeutic • Use liquid parents that
hypothalamic tonsillectomy. effects and form for drug is only
heat-regulating • To reduce fever enhance children and for short-term
centers. May in bacterial or hepatotoxic patients who use; urge them
cause analgesia viral infections. effects of have difficulty to consult
by inhibiting • As a substitute acetaminophen. swallowing. prescriber if
CNS for aspirin in Avoid using • In children, giving to
prostaglandin upper GI disease, together. don’t exceed children for
synthesis, aspirin allergy, Lamotrigine: five doses in longer than 5
acetaminophen bleeding may decrease 24 hours. days or adults
has no anti- disorders, clients lamothrigine for longer than
inflammatory on anticoagulant level. Monitor 10 days.
or uricosuric therapy, and patient for • Tell patients
effect. gouty arthritis. therapeutic not to use for
effects. marked fever
Contraindications: Warfarin: may (temperature
• Contraindicated increase higher than
in patients hypoprothrombi 103.1°F
hypersensitive to nemic effects [39.5°C]),
drug. with long-term fever
• Use cautiously in use with high persisting
patients with doses of longer than 3
long term acetaminophen. days, or
alcohol use recurrent fever
because unless directed
therapeutic dose by prescriber.
hepatoxicity in
these patients.

Generic Name: ferrous sulfate Trade Name:

Route of Administration: PO Dosage: 100 to 200 mg (2 to 3 mg/kg)
Indications/ Adverse Drug Nursing Health
Drug Class Mode of Action
Contraindications Reactions Interaction Considerations Teachings
Hematinics Provides GI: nausea, Antacids,  GI upset may  Tell patient to
elemental iron, epigastric pain, cholestyramine be related to take tablets
an essential vomiting, resin, dose. with juice
component in the constipation, cimetidine: may  Between-meal (preferably
doses are orange juice)
formation of black stools, decrease iron
preferable. or water, but
hemoglobin. diarrhea, absorption. Drug can be not milk or
anorexia. Separate doses given with antacids.
Other: if possible. some foods,  Instruct patient
temporarily Chloramphenic although not to crush or
stained teeth from ol: May delay absorption may chew
liquid forms. response to iron be decreased. extended-
 Enteric-coated release forms.
products  Advice patient
Monitor patient.
reduce GI to report
Fluroquinolones upset but also constipation
penicillamine, reduce amount and change in
tetracyclines: of iron stool color or
may decrease absorbed. consistency.
GI absorption  Alert: oral iron
of these drugs, may turn stools
possibly black.
Although this
resulting in
decreased levels iron is
of efficacy. harmless, it
Separate doses could mask
by 2 to 4 hours. melena.
 Monitor
hematocrit, and
count during
 Look alike-
sound alike:
Don’t confuse
different iron
salts; elemental
content may
Discharge Planning

• Paracetamol

• Cefuroxime

• Ascorbic acid

• Potassium Chloride

• Ranitidine hydrochloride

• Ferrous sulfate


Participation in aerobic exercise, including jogging, walking, swimming and bicycling, can

enhance circulation and aid in the elimination of blood congestion in the pelvic area. Inverted-

position exercises, such as yoga headstands and shoulderstands, and rotating the legs in a

bicycle-like motion, are also beneficial for improving circulatory functioning. If you suffer from

back or neck pain and are unable to perform these exercises, you can use an old door couch and

the other on the floor. The slanted position of the body facilitates the transport of blood away

from the pelvic region and toward the head. It is advisable to limit such exercises to 3 to 5

minutes at a time because remaining in a slanted position for extended periods can cause



• The first step in treating urinary tract infections is prevention. Prevention measures

include drinking plenty of fluids, urinating as soon as possible when the urge is felt, and

drinking cranberry juice, which may have infection-fighting qualities.

• For women, prevention measures include urinating promptly after having sexual

intercourse, wiping the genital area from front to back after urinating or defecating, and

not using douches or deodorant feminine products. These can be irritating to the genitals.

• Other treatments:

o Treating Urinary Tract Function by use of Baking Soda

 A mixture of 1/2 tsp baking soda in eight ounce glass of water can be very

helpful on the first signs of urinary tract infection. The presence of baking

soda in your system raises the acid-base balance of the acidic urine.

o Treating Urinary Tract Infection by drinking water or fluids

 It is very important for your system to have a good flow of urine. This can

be done by consuming plenty of water. It cleanses your body by diluting

and flushing out the unwanted substance.

o Treating Urinary Tract Infection by Cranberry Juice

 Cranberry juice disallows bacteria to cling to the cell, which line the

urinary tract. It is a great remedy to fight this infection. If you cannot have

the cranberry juice directly you can mix it with apple juice to add some


o Treating Urinary Tract Infection by Aromatherapy

 You can make an essential oil by using equal parts of sandalwood,

bergamot, tea tree, frankincense and juniper. Mix all these ingredients to

make an oil to be rubbed over your bladder area. Continue this massaging

technique for three to four days once the symptoms subside.

o Treating Urinary Tract Infection by Echinacea

 You can consume at least two capsules three times a day of Echinacea and

Oregon grape root or goldenseal to fight the infection.

Health teachings

• For women with recurrent UTIs, give the following instructions:

a. Reduce vaginal introital concentration of pathogens by hygienic measures.

b. Wash genitalia in shower or while standing in bath-tub – bacteria in bath water

may gain entrance into urethra.

c. Cleanse around the perineum and urethral meatus after each bowel movement,

with front-to-back cleansing to minimize fecal contamination of periurethral area.

• Drink liberal amounts of water to lower bacterial concentrations in the urine.

• Avoid bladder irritants – coffee, tea, alcohol, cold drinks, and aspartame.

• Avoid external irritants such as bubble baths, talcum powders, perfumed vaginal

cleansers or deodorants.

• Patients with persistent bacteria may require long-term antimicrobial therapy to prevent

colonization of periurethral area and recurrence of UTI.

a. Take antibiotic at bedtime after emptying bladder to ensure adequate

concentration of drug overnight because low rates of urine flow and infrequent

bladder emptying predispose to multiplication of bacteria.

b. Use self-monitoring tests (dipsticks) at home to monitor UTI.

Out-patient/ Follow up

• Advise women with simple, uncomplicated cystitis that they do not require follow-up as

long as symptoms are completely resolved with antibiotic therapy.


• Since bacteria that cause infections in your urinary tract cannot live in very acidic

conditions, one of the suggestions you should heed if you are prone to urinary tract

infections is to increase your intake of vitamin-C-rich foods and to drink citrus juices that

have a lot of vitamin C. Not only will this increase the acidity of your urine, it will also

make you more resistant to infection.

• Some foods may have to be avoided when you have UTI, and these include processed

foods, cheeses, and other dairy products. You may also need to avoid chocolates, coffee,

and tea that have high caffeine content.

• Other things you may need to avoid when you have urinary tract infections include spicy

food, fizzy drinks or soda pop, beer, and other alcoholic beverages.

• Try to increase your intake of healthy substances like vegetables and fruits. You can also

have these in fresh juice form by juicing them or pureeing them. You can also mix fruit

and vegetables in one healthy juice that you can drink every day for your health.


Decrease the entry of microorganisms into the bladder during intercourse.

a. Void immediately after sexual intercourse.

b. A single dose of an oral antimicrobial agent may be prescribed after sexual


As a conclusion of this study, it is very important to maintain the basic ways to attain

wellness. Proper care is the key in achieving health. Since women are more susceptible in having

Urinary Tract Infections they should have enough knowledge in providing self care and proper

hygiene to prevent these diseases.

This study awakened me in such a way that as an infection occurs, from an infection

alone, it can lead to other complications and might as well have an irreversible condition of not

prevented ad treated. So it is important to learn how to prevent it before its too late for it to be


Also, the health care providers, being the ones who interact with the patients and being

one of the sources of information should have broad knowledge or understanding for such

diseases. In promoting continuing care, health care providers should explain within the level of

understanding of their patients the things they need to know.


This study provides a brief background of causes and manifestations of the disease; it

recommends a good example in relating it with other cases as well as in looking for appropriate

treatment for this condition.

It also recommends as a new case for doctors, that this study will serve as an

encouragement for further research about other onset of manifestations that can occur and the

newest treatment. For nurses, further nursing management can be added regarding patients with

this case will be done if further reading and research is done. As time goes by, many things have

been changed and improved. This study recommends and hopefully serve as encouragement to

further widen our knowledge in preventing and treating the disease.


Tortora, Gerard J.,Principles of Anatomy and Physiology .Tenth edition. Biological Sciences
Textbooks, Inc. 2003. p 1028-1048.

Lippincott: Manual of Nursing Practice. Eight edition.

Lippincott William & Wilkins. 2006. p 1233-1240.

Doenges, Marilynn E., Moorhouse, Mary Frances, Murr, Alice C. Nurse’s Pocket Guide:
Diadnoses, Interventions, and Rationales. Ninth edition. F.A. Davis Company, Philadelphia,

Marieb, Elaine N., Essentials of Human Anatomy & Physiology. Eight edition. Pearson
Education, Inc,. 2006. p 535-557

Nursing 2007: Drug Handbook. 27th edition. Lippincott Williams & Wilkins. 2007