Republic of the Philippines

Isabela State University

Echague, Isabela

COLLEGE OF NURSING

In Partial Fulfillment of the Requirement in

NUR 422

(Intensive Nursing Practicum Hospital and Community Setting)

Case Study Of

Acute Pyelonephritis with Cystitis

To:
Clinical Instructor of NUR 422

College of Nursing –Isabela State University Echague,Isabela

By:

Baquiran, Icylie C.

Bilog, Abegail C.

Blanco, Clarence D.

Cachuela, Cheyeanne U.

Caday, Angelyn C.

Calangan, Westlee L.

Gumpal, Krista Marie T.

Hernal, Irish Mae R.

Sagadraca, Catherine N.

Turingan, Micah

BSN 4-1 (2nd Semester)

 Republic of the Philippines
Isabela State University
Echague, Isabela

COLLEGE OF NURSING
TITLE PAGE

TABLE OF CONTENTS

OBJECTIVES OF THE STUDY…………………………………….

OVERVIEW OF THE DISEASE …………………………………...

DEMOGRAPHIC PROFILE ………………………………...…….

NURSING HISTORY……………………………………………...

PHYSCAL ASSESSMENT ……………………………………….

ANATOMY AND PHYSIOLOGY …………………………….…

PATHOPHYSIOLOGY………………………………….…….….

LABORATORY OR DIAGNOSTIC RESULT AND

INTERPRETATION………………………………………….…..

COURSE IN THE WARD

NURSING CARE PLAN ………………………………………...

DRUG STUDY ………………………………………………....

DISCHARGE PLAN
OBJECTIVE

a. General
To gain sufficient knowledge about acute pyelonephritis with cystitis

b. Specific
• To define acute pyelonephritis with cystitis, its prognosis, etiology,
clinical manifestations, and complications
• To become familiar with the anatomy and physiology of the involved
system and understand the pathophysiology of the disease
• To assess the past and present health history of the patient that may have
contributed to the patient’s current health condition
• To analyze and interpret the patient’s diagnostic and laboratory results
• To understand the pharmacological treatments and the nursing
considerations for drug administration
• To obtain an effective nursing care plan for the patient
• To be able to formulate a successful discharge care plan

OVERVIEW OF THE DISEASE

Background of the Disease

UTIs are generally classified as infections involving the upper or lower urinary tract
and further classified as uncomplicated or complicated, depending on other patient-related
conditions. Lower UTIs include bacterial cystitis (inflammation of the urinary bladder). There
can be acute or chronic nonbacterial causes of inflammation in any of these areas that can be
mis-diagnosed as bacterial infections.

Pyelonephritis is a bacterial infection of the renal pelvis, tubules, and interstitial tissue
of one or both kidneys. Causes involve either the upward spread of bacteria from the bladder
or spread from systemic sources reaching the kidney via the bloodstream. Pathogenic bacteria
from a bladder infection can ascend into the kidney, resulting in pyelonephritis.

Acute pyelonephritis is usually manifested by enlarged kidneys with interstitial

infiltrations of inflammatory cells.

Epidemiological Report

International

Acute pyelonephritis in the United States is found at a rate of 15 to 17 cases per 10,000
females and 3 to 4 cases per 10,000 males annually. Young sexually active women are the
patients that are most often affected by acute pyelonephritis. Groups with extremes of age, such
as the elderly and infants, are also at risk due to abnormalities in anatomy and changes in
hormones. Pregnant women can also be at risk, and 20 to 30% will develop acute
pyelonephritis, usually during the second and early third trimester. Acute pyelonephritis has no
racial predisposition. (Belyayeva,M. & Jeong J., 2022).

Local
According to DOH report last October 2, 2023, the prevalence rate of UTI or Acute
pyelonephritis in Davao City. There's a total of 712 patients who have acute pyelonephritis
from the year 2019 to 2023. While in UTI there's a total 29,716 from the year 2019 to 2023.

Prognosis

Overall, the majority of cases of pyelonephritis are managed in an outpatient setting,

with most patients improving with oral antibiotics. Usually, young women are among those
most likely to be treated as outpatients. Despite pyelonephritis improving in most cases, there
is still significant morbidity and mortality that can be associated with severe cases of this
disease. The overall mortality has been reported at around 10 to 20% in some studies, with a
recent study from Hong Kong finding a mortality rate closer to 7.4%. More importantly, this
study found that old age (older than 65 years), male gender, impaired renal function, or
presence of disseminated intravascular coagulation were associated with increased mortality.
With the proper recognition of the underlying etiology and prompt intervention with adequate
treatment, even patients with severe pyelonephritis generally have a good outcome.

Etiology

K-lebsiella pneumoniae
E-scherichia coli
E-nterococcus species
P-seudomonas aeruginosa
S-taphylococus saprophyticus

Risk Factors
➢ Inability or failure to empty the bladder completely
➢ Obstructed urinary flow caused by:
- Congenital abnormalities
- Urethral strictures
- Contracture of the bladder neck
- Bladder tumors
- Calculi (stones) in the ureters or kidneys
- Compression of the ureters
➢ Decreased natural host defenses or immunosuppression
➢ Instrumentation of the urinary tract (eg, catheterization, cystoscopic procedures)
➢ Inflammation or abrasion of the urethral mucosa
➢ Contributing conditions such as:
- Diabetes mellitus (increased urinary glucose levels create an infection-prone
environment in the urinary tract)
- Pregnancy
- Neurologic disorders
Clinical Manifestations
• Bacteriuria - Most common bacteria is E. Coli specially in patient with cystitis which
invasion to the renal parenchyma. Specifically, the bacteria reach the kidney by
ascending from the lower urinary tract.
• Chills – When bacteria invade the kidneys, the immune system reacts by releasing
inflammatory substances such as cytokines and can trigger a systemic response.
• Fever - Inflammatory substances signal the body to raise its temperature, resulting in
fever. Fever is the body’s natural defense mechanism to fight off the infection by
creating an environment less conducive to bacterial growth.
• Flank pain - The pain is typically described as dull or aching and may be localized to
one or both sides of the back.
• Headache - Inflammatory substance may induce vasodilation and increased blood flow
to the brain.
• Hematuria- The inflammatory response triggered by the infection can damage blood
vessels within the kidney, leading to blood leakage into the urine.
• Malaise – Is a common symptom in patients with UTI which immune system already
have weakened due to the temperature has risen.
• Nausea & Vomiting – The inflammatory substance can affect the gastrointestinal tract
and may trigger irritation and discomfort to patient.
• Painful urination - Swelling and irritation from the infection can make urination
uncomfortable.
• Pyuria – The common condition can be found in laboratory findings in which the white
blood cells is elevated in normal range and presence of pus in the urine.
• Physical examination reveals pain and tenderness (in the area of the costovertebral
angle)
• Urgency - The inflammation and infection in the kidneys can irritate the bladder and
urinary tract, leading to increased urinary urgency.
• Frequency – The infection and inflammation in the kidneys can irritate the bladder and
urinary tract, leading to a heightened sensation of needing to urinate frequently.

Complications
• Sepsis: The infection can spread to the bloodstream, causing sepsis, a life-threatening
condition characterized by systemic inflammation and organ dysfunction.

• Renal abscess: Pus-filled pockets may develop within the kidney, requiring drainage
and aggressive antibiotic therapy.

• Chronic pyelonephritis: Recurrent or unresolved acute pyelonephritis can progress

to chronic pyelonephritis, leading to long-term kidney damage and impaired kidney
function.

• Septic shock: In severe cases, acute pyelonephritis can lead to septic shock, a medical
emergency characterized by low blood pressure and organ failure.
 • Renal papillary necrosis: This rare complication involves the death of renal papillae,
which are structures in the kidney, leading to kidney damage.

DIAGNOSTIC PROCEDURE
➢ Computer Tomography (CT) Scan- It is helpful in diagnosing pyelonephritis by showing
signs of inflammation or infection in the kidneys, such as swelling, fluid collections, or
abscesses. It can also help differentiate between uncomplicated and complicated cases.

• Instruct the client that there is no prior preparation, such as fasting, is

required.
• Encourage to drink water and can take prescribed medications prior to the
procedure as prescribed.
• Verify the client’s understanding of the procedure and be a witness in signing
informed consent.
• Instruct the client to change into the patient’s gown and remove all jewelry.

➢ IV pyelogram- An IVP shows the kidneys, ureter, and bladder via x-ray imaging as the
dye moves through upper and lower urinary system.
Pre-procedure:
• Assess the patient's medical history, allergies, and renal function.
• Explain the procedure, including its purpose, risks, and benefits.
• Ensure that the patient is adequately hydrated before the procedure, as
hydration helps in flushing the contrast dye from the body.
• Verify consent forms are signed.
• Assist with any necessary pre-procedure preparations, such as fasting or
medication adjustments.
During the procedure:
• Provide emotional support and reassurance to the patient.
• Assist the radiology team as needed, such as positioning the patient and
preparing equipment.
• Monitor the patient's vital signs and comfort level throughout the
procedure.
Post-procedure:
• Monitor the patient for any adverse reactions to the contrast dye, such as
allergic reactions or kidney damage.
• Encourage increased fluid intake to help flush the contrast dye from the
body and prevent kidney damage.
• Assess the patient for signs of urinary retention, such as discomfort or
difficulty urinating.
• Provide pain management as needed.
• Educate the patient about post-procedure care and any restrictions on
activities or medications.
➢ Urinalysis & Urine Culture and Sensitivity test – Urinalysis provides important clinical
information about the kidney function and helps diagnose other diseases. The urine
culture determines whether bacteria are present in the urine as well as their strains and
 concentrations. It also identifies the antimicrobial therapy that is best suited for the strains
identified.
• Ensuring proper collection techniques and labeling.
• Providing instructions on how to collect samples and any necessary
preparations.
• Following protocols to prevent contamination and ensuring samples are
properly handled.
➢ Ultrasound – is a noninvasive diagnostic technique in which high-frequency sound
waves are passed into internal body structures, and the ultrasonic echoes are recorded on
an oscilloscope as they strike tissues of different densities.
• Instruct the patient for 8-12 hours NPO

➢ CBC - Complete blood count examines the different portions of the blood, including
platelets, red blood cells, and white blood cells. It can help diagnose a variety of health
problems such as anemia, blood clots, and infections.
• Educating the patient about the purpose of the CBC and any preparations
needed.
• Ensuring timely delivery of the specimen to the laboratory.

● Nursing Management
➢ When the patient requires hospitalization, fluid intake and output are carefully
measured and recorded. Unless contraindicated, 3 to 4 L of fluids per day is
encouraged to dilute the urine, decrease burning on urination, and prevent
dehydration.
➢ Assess the patient’s temperature every 4 hours and administer antipyretic and
antibiotic agents as prescribed.
➢ Promote comfort, symptomatic patients are often more comfortable on bed rest.
➢ Health teaching focuses on prevention of further infection by consuming
adequate fluids, emptying the bladder regularly, and performing recommended
perineal hygiene.
➢ Encourage the patient to comply with maintenance medications prescribed. The
importance of taking antimicrobial medications exactly as prescribed is
stressed, as is the need for keeping follow-up appointments.

● Medical Management

➢ Oral antibiotic agents may be prescribed once the patient is afebrile and showing
clinical improvement. A possible issue in acute pyelonephritis treatment is a
chronic or recurring symptomless infection persisting for months or years. After
the initial antibiotic regimen, the patient may need antibiotic therapy for up to
6 weeks if a relapse occurs.
➢ A follow-up urine culture is obtained 2 weeks after completion of antibiotic
therapy to document clearing of the infection.
➢ Hydration with oral or parenteral fluids is essential in all patients with UTIs
when there is adequate kidney function. Hydration helps facilitate “flushing” of
the urinary tract and reduces pain and discomfor
DEMOGRAPHIC DATA

Name: Patient C.

Age: 84 years old

Sex: Female

Birthday: December 15, 1939

Marital status: Widowed

Religion: Roman Catholic

Nationality: Filipino

Ethnicity: Ilocano

Dialect: Ilocano

Date of admission: April 14, 2024

Admitting diagnosis: To consider Acute Appendicitis

Final diagnosis: Acute Pyelonephritis with Cystitis

Admitted to WARD: April 14, 2024 At 12:10 AM

NURSING HISTORY

Present Health History

On April 14, 2024 12:10 AM, the patient was admitted with a complaint of RLQ pain
(pain scale of 10/10) radiating to her back and 3 episodes of vomiting. After the initial
assessment, her admitting diagnosis is to consider acute appendicitis. The patient started
experiencing abdominal pain at night after their dinner and vomited that made her family decide
to bring her to hospital. On the same day, she underwent NPO in the morning and abdominal
UTZ and found a right renal cortical cyst. Consequently, the doctor ordered Ketorolac for her
pain and Cefuroxime as her antibiotic. In the afternoon of her admission, she switched diet to
DAT and continuously taking her medication.

In terms of her diet, she verbalizes that prior to admission, she ate vegetables, took her
vitamins, and consumed 1 glass of milk. The patient claimed to have no vices.

Past Health History

According to the patient, she had a history of diabetes mellitus, she is also hypertensive
and continuously taking her maintenance drug. The patient does neither have any accidents in
the past years. In the year 2014, she underwent cataract surgery on her right eye and year 2015
on her left eye. Last December 2022, she had been diagnosed with Diabetes Mellitus due to an
infection on her right toe while she’s getting her toenails cleaned.

Since she was 75 years old up until now, she is still taking Amlodipine once a day for
her hypertension and taking Gajar and Alanerv as her vitamins. Furthermore, the only vaccine
or immunization she received was the Pfizer as her Covid 19 vaccine in the year 2021. She
does not have any known allergies. In terms of the diet, the patient is fond of eating vegetables,
monggo, fish and bread with milk as her snack.

Family Health History

Social Health History

According to the patient, she is widowed and has 3 children. She lives with their maid,
while her children have their own houses next to each other. Their family structure is extended,
and there are no problems with her family.

Before being admitted to the hospital, her usual social activities were very active. The
patient is fond of walking outside their compound in the afternoon and playing with her
grandchildren. The patient claims that her children also give her financial support. According
to the patient, she usually wakes up at 6 am, takes her bath at home, eats her breakfast, and
takes her vitamins, plays with her grandchildren at home, eats her lunch, goes outside to walk
in the afternoon, and goes to bed at 12 pm in the evening.

She has no trouble interacting with other members of their family or their
neighborhood. According to her, she belongs to a Christian social group and attends mass every
Sunday. She is grateful to her children, as they always help and take care of her.
 GORDON’S 11 FUNCTIONAL HEALTH PATTERN

Functional Health Before Hospitalization During Hospitalization

Pattern

General Description of The patient was eating The patient is at bed

Client nutritious foods such as experiencing pain when she
vegetable and takes a walk moves that causes the lack of
every afternoon. appetite to eat.

Health Perception-Health According to the patient, she The patient experiences pain
Management Pattern has existing diabetes mellitus from time to time when moving
and was hospitalized last and upon palpation and
December 2022. She also stated percussion of her flank by the
that she doesn't have any vices physician, she experienced pain
and she eats regularly. The and showed facial grimace. The
patient complies on taking her patient regularly complies with
maintenance medication and the medications that were
vitamins. She also walks in the prescribed.
afternoon as her exercise and
does not have any recent
accidents.

Nutritional-Metabolic The patient typically eats three The patient underwent NPO
Pattern meals a day, consisting of fish only in the morning on the first
and vegetables. The patient also day and in the afternoon, she
eats bread and drinks milk as her was instructed to have DAT as
snack in the afternoon. The prescribed and consumed 420
patient has no allergies to food mL of water. She's taking small
or any medication and is taking meals due to lack of appetite and
maintenance drugs and drinks 6 glasses of water. The
vitamins. Her typical fluid patient is taking vitamins and
intakes are milk and 6 glasses of medications that were
water a day. Her weight was 46 prescribed. She experienced
kg and her height was 4'10. weight loss during her
hospitalization.

Elimination Pattern The patient was not able to The patient was not able to
defecate and was experiencing defecate. She urinates twice in
constipation for 3 days, she the morning and twice in the
described her stool as hard and afternoon and frequently (more
formed. The patient urinates than 4 times) in the evening and
small amount of urine. experiencing pain. Her urine
output has decreased.

Activity-Exercise Pattern The patient walks every The patient was able to do her
afternoon which serves as her activities of daily living
exercise, she doesn't experience however, she experiences pain
any problems in breathing. radiating to her flank area
whenever she moves from time
to time.
 Sleep-Rest Pattern The patient usually goes to bed The patient cannot sleep well.
at 12 am and wakes up early 6 She usually sleeps around 12 am
am in the morning. but at times she wakes up at
night because of pain in her
flank area and frequently
urinating and wakes up at 6 am.
She takes a rest after receiving
her medication

Cognitive-Perceptual The patient has difficulty The patient still has altered
Pattern hearing on her right ear and she sensorium.
also wears glasses.

Self-Perception – Self- The patient feels grateful of her As she grows older, she thinks
Concept Pattern life and grateful for her children that her body becomes weaker
as they always help and take and feels the need to take
care of her. She feels her life has medications regularly. It
changed after she has been prompts her to take care of
diagnosed with diabetes herself more.
mellitus because she feels
conscious of her diet. Whenever
she feels sick, she would always
go to her daughter to be rushed
to the hospital.

Role-Relationship Pattern The patient lives with their The patients' daughter and
maid. Whenever she had an grandson took care of her during
illness, she always went to her her whole stay at the hospital.
daughter’s house. She is well
supported by her son and
daughters.

Sexuality-Reproductive She is widowed and not She is widowed and not

Pattern sexually active. sexually active.

Coping-Stress Tolerance The patient experienced a big Some of the patient's children
Pattern change in her life when she was cannot attend her needs during
diagnosed with DM last 2022 hospitalization due to busy
but she was fully supported by schedules and work. So, they
her sons and daughters. took turns and visited the patient
after their work.

Value-Belief Pattern The patient's religion is Roman The patient prays daily as she
Catholic, and she attends mass seeks guidance from Almighty
every Sunday afternoon. Father for her fast healing and
recovery.
 Intake and Output

Date And Time Parenteral Fluid Amount Consumed Urine Output

04-13-24 PLR X 12 400 300

NOC Total : 400 300

4-14-24 PLR X 12 600 300

AM 50
ORAL NPO
NOC Total : 650 300
PM PLR X 12 450 600
200
Water 210
210

NOC Total : 1070 600

4-15-24 PLR X 12 450 500
AM water 210
NOC: 660 500

PM PLR X 12 350
water 210 500
150

PLR X 12 450
NOC: 1160 500

PHYSICAL ASSESSMENT

I. PHYSICAL ASSESSMENT
Date of Assessment: April 15, 2024
General appearance: Patient is conscious but appears slightly lethargic. Attends to questions
but shows difficulty in responding due to hearing difficulty.

AREA ASSESSED METHOD ACTUAL FINDINGS ANALYSIS

USED

SKIN Inspection Skin appears tan in color but NORMAL

Color darker in more exposed areas.

Texture Palpation Skin is slightly dry and saggy NORMAL

Temperature Palpation Skin is warm to touch NORMAL

Turgor Palpation Skin is pinched; returned to NORMAL

its original state in 3 seconds

Lesions Inspection Dark scar on the right foot NORMAL

 Uniformity Inspection Skin is generally uniform ABNORMAL
except for sun exposed areas
of the body and scars seen on
the right foot of the patient

Moisture Inspection Slight dryness in the skin NORMAL

folds

Thickness Palpation and Epidermis is thin NORMAL

Inspection

HEAD Inspection Proportionate to body size NORMAL

Size and and age
Circumference

Shape Inspection Symmetrical round hard and NORMAL

smooth without lesions and
bulging

HAIR Inspection Black hair with white strands NORMAL

Color due to aging

Distribution Inspection Evenly distributed NORMAL

Texture Palpation Dry and thin NORMAL

Presence of Inspection There are no presence of lice NORMAL

parasite and other parasite

NAILS Inspection With nail polish NORMAL

Color (nail bed)

Shape Inspection Convex curve NORMAL

Texture Inspection Generally smooth NORMAL

Tissue Palpation Epidermis is intact NORMAL

surrounding nail

Capillary refill Palpation Returns 1-2 seconds NORMAL

test

FACE Inspection Symmetrical features, NORMAL

Symmetry, symmetrical at rest. Face
movement squinting when in pain
(excessive movement)

EYES Inspection White sclera, iris is light in NORMAL

Color color

Pupils Inspection Pupils are equal in size NORMAL

Reaction to Light Inspection Pupils constrict in response to NORMAL

light
 Accommodation Inspection Pupils constrict when NORMAL
focusing on a near object and
dilate when focusing on a
distant object

EARS Inspection Same color as the fascial skin NORMAL

Color

Position Inspection Along the outer canthus of the NORMAL

eye and lateral to the brows
and auricles

Discharge Inspection No discharge NORMAL

NOSE Palpation No tenderness NORMAL

Tenderness

Discharge and Inspection No nasal flaring and NORMAL

flaring discharge

Position Inspection At midline of the face, nares NORMAL

are symmetrical

MOUTH Inspection Lips appears dry ABNORMAL

Lips

Presence of lesions Inspection No presence of lesion NORMAL

Buccal mucosa Inspection Moist and pinkish in color NORMAL

Teeth Inspection Teeth are yellowish, multiple NORMAL

teeth are missing, and
dentures are present

Gums Inspection Dark pink in color, moist NORMAL

Tongue Inspection It is placed at the midline, NORMAL

pink in color, freely moving,
without lesions, and
appropriate in size

NECK Inspection No discomfort upon moving NORMAL

Mobility and can flex and extend
without difficulty

Position Inspection Located centrally between the NORMAL

shoulders

THORAX AND Inspection Symmetrical expansion NORMAL

LUNGS during respiration
Symmetry

Chest wall Inspection and No tenderness, no masses NORMAL

palpation
 Breath sounds Auscultation Vesicular or bronchovesicular NORMAL

Chest expansion Palpation Symmetric chest expansion NORMAL

HEART Auscultation During auscultation of the NORMAL

Rate and Rhythm heart, findings include the
presence of regular heart
sounds (S1 and S2) with a
rhythmic pattern, and no extra
heart sounds or murmurs
present.

ABDOMEN Skin color is brown, no signs NORMAL

Skin condition of lesions

Abdominal Inspection Bloated and round ABNORMAL

contour

Bowel sounds Auscultation Decreased bowel sound ABNORMAL

Tenderness Palpation No tenderness upon palpation NORMAL

UMBILICAL Inspection No signs of redness and NORMAL

Color and inflammation
integrity

Tenderness Palpation No tenderness and pain NORMAL

experienced upon palpation

UPPER BACK Intact skin, brown in color NORMAL

Skin Integrity with presence of moles
Inspection
Symmetry Both sides are seen as NORMAL
symmetrical

Tenderness Palpation No tenderness or pain upon NORMAL

palpation upon vertebrae, ribs
or muscles

LOWER BACK Inspection Intact skin, brown skin in NORMAL

Color and color and no presence of
integrity lesions

Tenderness Percussion Intense pain felt at ABNORMAL

costovertebral angle when
percussed

Palpation Tenderness and localized ABNORMAL

pain at right flank area
when palpated

UPPER Inspection No deformities or swelling NORMAL

EXTREMITIES seen and brown in color
Color and
 integrity

ROM Inspection Performed without pain NORMAL

Muscle Strength Inspection Decreased muscle tone and NORMAL

and tone strength due to aging

LOWER No visible deformities seen NORMAL

EXTREMITIES Inspection and any discoloration
Skin

ROM Inspection Slow and coordinated NORMAL

movement

ANATOMY AND PHYSIOLOGY

Introduction
The kidneys play an important role in maintaining homeostasis. They remove waste
products through the production and excretion of urine and regulate fluid balance in the body.
As part of their function, the kidneys filter essential substances from the blood, such as sodium
and potassium, and selectively reabsorb substances essential to maintain homeostasis. Any
substances not essential are excreted in the urine. The formation of urine is achieved through
the processes of filtration, selective reabsorption, and excretion. The kidneys also have an
endocrine function, secreting hormones such as renin and erythropoietin. The organs of the
renal system ensure that a stable internal environment is maintained for the survival of cells
and tissues in the body – homeostasis. This chapter will discuss the structure and functions of
the renal system.
Renal system
The renal system, also known as the urinary system, consists of:

➢ Kidneys, which filter the blood to produce urine;

➢ Ureters, which convey urine to the bladder;
➢ Urinary bladder, a storage organ for urine until it is eliminated;
➢ Urethra, which conveys urine to the exterior.
➢
Functions of The Kidney
1. A- maintaining ACID-base balance
2. W- maintaining WATER balance
3. E- ELLECTROCYTE balance
4. T- Toxin Removal
5. B- BLOOD pressure control
6. E- making ERYTHROPOETIN
7. D – vitamin D metabolism

Figure 1: Organs of the urinary system.

Kidneys: EXTERNAL STRUCTURES
The kidneys are bean-shaped organs. They are retroperitoneal which means they lie
behind the peritoneum and are located on each side of the vertebral column near the psoas
major muscles. They are each about the size of a tightly clenched fist. The kidneys extend from
the lower portion of the rib cage at the level of the last thoracic (T12) vertebra to the third
lumbar (L3) vertebra (see figure 7.23). The liver is superior to the right kidney, causing the
right kidney to be slightly lower than the left. Each kidney measures about 11 cm long, 5 cm
wide, and 3 cm thick, and each weigh about 130 g, which is approximately the weight of 1 cup
of flour.
Covering and supporting the kidneys are three layers:

➢ Renal fascia- outer layer and consists of a thin layer of connective tissue.
➢ Adipose tissue-middle layer that surrounds the capsule where it cushions the kidneys from
trauma.
➢ Renal capsule- protects the kidneys from trauma and maintains their shape.

Figure 2: External Layers of The Kidney

Kidneys: INTERNAL STRUCTURES

There are three distinct regions inside the kidney:

➢ Renal cortex- lightly reddish outer colored region and has a granular appearance
➢ Renal medulla- a darker, reddish-brown, inner region and has an abundance of blood
vessels and tubules of the nephrons. Consists of approximately 8–12 renal pyramids.
➢ Renal pelvis- a flat, funnel-shaped cavity that collects the urine into the ureters it is the
region where two or three calyces converge.
 Figure 3: Internal Layers of The Kidney

Nephrons
These are small structures and they form the functional units of the kidney. The nephron
consists of a glomerulus and a renal tubule. There are approximately 1.3 million nephrons
distributed throughout the cortex and medulla of each kidney. Nephrons usually measure about
50–55 mm in length and it is in these structures where urine is formed. The nephrons:

✓ filter blood;
✓ perform selective reabsorption;
✓ excrete unwanted waste products from
filtered blood.
The nephron is divided into several sections:

1. Bowman’s capsule or glomerular

capsule
2. Proximal convoluted tubule
3. Loop of Henle
4. Distal convoluted tubule (DCT)
5. Collecting ducts
Types of Nephrons
1. Juxtamedullary nephrons have renal
corpuscles that are found deep in the cortex near
the medulla. They have long loops of Henle, which
extend deep into the medulla. Longer loops of
Henle are well adapted for water conservation.
Only about 15% of nephrons are juxtamedullary
nephrons.
2. Cortical nephrons have renal corpuscles that are distributed throughout the cortex. Their
loops of Henle are shorter than those of juxtamedullary nephrons and
are closer to the outer edge of the cortex.
Pathway of Renal Blood Vessels

Ureters
ss the ureters are tubes through which
urine flows from the kidneys to the
urinary bladder. The ureters extend
inferiorly and medially from the renal
pelvis and exit the kidney at the renal
hilum. The ureters descend through the
abdominal cavity and enter the urinary
bladder.

Urinary Bladder
The urinary bladder is a hollow muscular organ, it is a smooth, collapsible, muscular
sac that stores urine and is located in the pelvic cavity posterior to the symphysis pubis. The
rugae and transitional epithelium allow the bladder to expand as it fills. The second layer in the
walls is the submucosa, which supports the mucous membrane. It is composed of connective
tissue with elastic fibers that allows urine to accumulate in the bladder that expands without a
significant rise in the internal pressure of the bladder.
Interior of the bladder reveals three openings-the two ureter openings, and the single
opening of the urethra which drains the bladder. The inner floor of the bladder includes a
smooth triangular section called the trigone. Trigone is important clinically because infections
tend to persist in this region.
 The urethral sphincter is a complex of muscles that encircle the urethra and control the
flow of urine. In simple terms we can divide this complex into two urethral sphincters; an
internal urethral sphincter and an external urethral sphincter. The internal urethral sphincter. It
is made of smooth muscle, and is under autonomic or involuntary control. While the external
urethral sphincter It is formed from skeletal muscle and therefore is under voluntary control.
In the male the bladder lies anterior to the rectum, and in the female, it lies anterior to
the vagina and inferior to the uterus. The bladder normally distends and holds approximately
350–750 mL of urine. In females the bladder is slightly smaller
Urethra
The urethra is a thin-walled tube that carries urine by peristalsis from the bladder to the
outside of the body. At the bladder-urethra junction, a thickening of the smooth muscle forms
the internal urethral sphincter, an involuntary sphincter that keeps the urethra closed when urine
is not being passed. A second sphincter, the external urethral sphincter, is formed by skeletal
muscle as the urethra passes through the pelvic floor. This sphincter is voluntarily controlled.

Male urethra
The male urethra passes through four
different regions:

➢Prostatic region
➢Membranous portion
➢Bulbar urethra
➢Penile region

Female urethra
The female urethra is bound to the
anterior vaginal wall. In the female, the
urethra is approximately 4 cm long and leads
out of the body via the urethral orifice. In the
female body the urethra’s only function is to
transport urine out of the body.
Urine Formation
Three major processes that are involved in the formation of the urine:

1. Glomerular filtration - Urine formation begins with the process of filtration, which
goes on continually in the renal corpuscles. As blood passes through the glomeruli,
much of its fluid, containing both useful chemicals and dissolved waste materials, soaks
out of the blood through the membranes where it is filtered and then flows into
Bowman’s capsule.
2. Tubular reabsorption – reabsorption occurs via three processes: osmosis, diffusion
and active transport. Selective reabsorption processes ensure that any substances in the
filtrate that are essential for body function are reabsorbed into the plasma
3. Tubular secretion - Substances secreted into the tubular fluid include: potassium ions
(K+), hydrogen ions (H+), ammonium ions (NH4+), creatinine, urea, some hormones
and drugs are removed and secreted by the tubule cells into the filtrate.
Composition of Urine
Urine is 96% water and approximately 4% solutes derived from cellular metabolism.
Other constituents include urea, chloride, sodium, potassium, creatinine and other dissolved
ions, and inorganic and organic compounds. Urine is a sterile and clear fluid of nitrogenous
wastes and salts. It is translucent with an amber or light-yellow color. Its color is due to the
pigments from the breakdown of hemoglobin. Concentrated urine tends to be darker in color
than normal urine. It is slightly acidic, and the pH may range from 4.5 to 8.
Micturition
Micturition or voiding, is the act of emptying the bladder. As noted, two sphincters, or
valves-the internal urethral sphincter (more superiorly located) and the external urethral
sphincter (more inferiorly located)-control the flow of urine from the bladder. Ordinarily, the
bladder continues to collect urine until about 200 ml have accumulated. At this point, stretching
of the bladder wall activates stretch receptors. Impulses transmitted to the sacral region of the
spinal cord and then back to the bladder via the pelvic splanchnic nerves cause the bladder to
go into reflex contractions. As the contractions become stronger, stored urine is forced past the
internal urethral sphincter (the smooth muscle, involuntary sphincter) into the upper part of the
urethra. The person will then feel the urge to void. Because the lower external sphincter is
skeletal muscle and is controlled voluntarily, we can choose to keep it closed and postpone
bladder emptying
Nitrogenous Wastes
Common nitrogenous wastes:

1. Urea - formed by the liver as an end product of protein breakdown when amino acids
are used to produce energy.
2. Uric Acid- released when nucleic acids are metabolized.
3. Creatinine - associated with creatinine metabolism in muscle tissue.
PATHOPHYSIOLOGY
 LABORATORY RESULTS AND INTERPRETATION

ULTRASOUND (Whole Abdomen)

Name: Patient C.
Age: 84 years old
Date: 04-14-2024

A cortical cyst measuring 1.8 cm is seen in the upper pole.

Urinary bladder wall is thickened.

IMPRESSION:

● Right renal cortical cyst

● Suggestive cystitis
● Atrophic uterus and ovaries
● Chronic medical renal disease, left normal sonogram of liver, gallbladder,
pancreas and spleen, non-dilated ducts

URINALYSIS (UA)
Name: Patient C.
Age: 84 years old
Date: 04-14-2024, 9:34 AM

MACROSCOPIC Results Interpretation

Color Straw Normal

Transparency Clear Normal

Volume (mL) 7

CHEMICAL Results Normal Interpretation

Specific Gravity 1.010 1.010-1.025 Normal

pH 7.0 4.5-8 Normal

Protein Negative Negative Normal

Glucose Negative Negative Normal

Ketone Negative Negative Normal

Erythrocytes TRACE Negative Presence of erythrocytes

indicates bladder infection
and inflammation.

Nitrite Negative Negative Normal

Urobilinogen Normal Negative Normal

 Bilirubin Negative Negative Normal

Leukocytes Negative Negative Normal

MICROSCOPIC Results Normal Interpretation

WBC/hpf 0.2 0-3 Normal

RBC/hpf 0.2 0-5 Normal

Epithelial cells - Occasional Few Normal

squamous

Epithelial cells - round None None Normal

Amorphous sediments None None Normal

Crystals None None Normal

Mucus None None Normal

Bacteria Occasional Few Presence of bacteria in the

urine indicates urinary
tract infection.

HEMATOLOGY
Name: Patient C.
Age: 84 years old
Date: 04-14-2024, 1:10 AM

PARAMETER Results/Unit Reference Range Interpretation

RBC 4.1 (x10^12/L) 4.0-6.0 Normal

Hematocrit 0.37 35.0-50.0 Normal

Hemoglobin 121 (g/L) 110-160 Normal

WBC 6.0 (x10^9/L) 5.0-10.0 Normal

Differential Count:
Lymphocytes 0.32 0.25-0.35 Normal

Monocytes 0.08 0.03-0.14 Normal

Eosinophils 0.02 0.01-0.06 Normal

Basophils 0.00 0.00-0.01 Normal

Segmenters 0.58 0.50-0.65 Normal

PARAMETER Results/Unit Reference Range Interpretation

Blood Indices: MCV 91 fL 86-110 Normal

MCH 30 pg 26-38 Normal

MCHC 33 g/dL 31-37 Normal

RDW-CV 13.1 % 11.0-16.0 Normal

Platelet Count 172 (x109/L) 150-450 Normal

*Platelet count manually
checked

MPV 9.5 fL 6.5-12.0 Normal

SEROLOGY/IMMUNOLOGY
Name: Patient C.
Age: 84 years old
Date: 04-14-2024, 1:43 AM

TEST RESULT

ABO Group B

Rh Type Positive
COURSE IN THE WARD

Date/Time Physician’s Nursing Responsibilities Rationale

Order

4-13-24 Please admit to ROC Ask the patient’s room of choice For patient comfort
12:10 AM under the service.of Coordinate in the general ward To prepare the room
Dr. A
BP: 130/70 Assist and accompany the patient and S.O To ensure safety and comfort
HR: 92 to the room
RR: 24
Temp:
36.1°C
SpO2: 95%
Ht. 4’10

Wt. 44kg

Secure consent for Verify the understanding of the patient To ensure that the client and significant others understand
admission and securing consent the importance of securing the consent
management For verification that the patient signed the consent and
Be a witness as the patient signs the fully understand what is in the consent form
consent
To serve as a record for legal purposes
Attached the consent to patient chart

NPO for now Instruct the patient not to eat or drink For patient to understand his condition and cooperate to
anything treatment
 Inform also significant others about the To raise awareness on patient condition
NPO status of the patient

Dx: CBC, ABO Pre-procedure

typing, UA Inform the patient about the procedure For patient awareness and to facilitate cooperation
Carry out order and coordinate with For them to conduct diagnostic procedure to patient. In
medical technologist order to determine any abnormalities
Prepare and educate the patient before the For the patient readiness and gain better understanding
procedure about the procedure

Post-procedure For them to be updated and order an intervention if there

are any alterations of patient laboratory results
Document to patient chart and relay the
result to the physician once available

Tx: None for now Conduct a comprehensive assessment of Regular assessments help monitor the patient's status,
the patient's condition, including vital detect any deterioration or improvement
signs, symptoms, and any changes since the
last assessment.

Implement measures to manage the Symptom management improves the patient's quality of
patient's symptoms, such as pain relief, life, promotes comfort, and enhances their overall well-
positioning for comfort being while waiting for further treatment decisions.

Monitor VS q4 and Monitoring the patient’s physiological To detect any changes that may indicate complications
record status such as, blood pressure, heart rate,
respiratory rate, and oxygen saturation
 Monitor I&O every Measure and record anything the patient To monitor the patient’s intake and output that would
shift and record drinks, including water and beverages, and help to assess whether the patient is dehydrated or
all foods that are liquid as wells as the overhydrated
fluids provided through intravenous therapy

Refer accordingly Coordinate to the attending physician and To provide information needed to give patient necessary
refer the general status of the patient care and treatment

4-13-24 IVF #1 PLR 1L ×12 Verify doctor’s order For action to be legal
hrs Select an appropriate venous access site Reduces the risk of complication associated with IV
and assess it for signs of infection, therapy, ensuring a secure well-functioning access site
infiltration or other complications
Early detection of fluid overload allows for timely
Monitor for signs of fluid overload such interventions to prevent complications such as pulmonary
as, edema, increased blood pressure or edema
respiratory distress

4-14-24 For UTZ (Whole Pre-procedure

9:12 AM Abdomen) Inform the patient about the procedure, Preparation and explanation reduce anxiety and ensure
provide instructions for fasting if required cooperation, leading to a smoother procedure
and address any concerns to ensure
Mild direct (- cooperation and comfort For patient awareness and prevent getting anxious
) rebound (-) Carry out order and coordinate with
rovsings radiologist. Notify the patient that the
procedure does not typically cause any To help prevent complications or any alterations during
pain the procedure
4. to ensure that the patient has understood the procedure
Ensuring safety and comfort of the patient clearly
during the procedure
 Verify the patient’s understanding
regarding the procedure
For them to be updated and order an intervention if there
Post-procedure are any alterations of patient laboratory results

Document and relay result to the physician

once available

Ketorolac Amp IVF Assess the patient’s pain level and To evaluate the patient’s response and adjust pain
now document baseline vital signs before management strategies if necessary
administering
To ensure accurate dosage and concentration are given
Verify the prescription order and check the
medication label

Cefuroxime 750mg Monitor patient for signs and symptoms of Prompt reporting to the prescriber facilitates timely
IVTT q8 ANST superinfection and diarrhea and treat assessment and adjustment of the treatment plan,
appropriately potentially preventing complications associated with
untreated superinfections.

Early detection and intervention can help prevent the

progression of adverse reactions to more severe
Instruct patient to notify prescriber about complications and ensure the safety and well-being of the
rash, loose stools, diarrhea, or evidence of patient
superinfection
To prevent further complications and ensure patient
comfort and safety.

Advice patient receiving drug IV to report

discomfort at IV insertion site
4-14-24 IVF TF #2 PLR 1L × Verify doctor’s order For action to be legal
12° Select an appropriate venous access site Reduces the risk of complication associated with IV
(-) fever and assess it for signs of infection, therapy, ensuring a secure well-functioning access site
infiltration or other complications
(-) Early detection of fluid overload allows for timely
SOB/DOB Monitor for signs of fluid overload such interventions to prevent complications such as pulmonary
as, edema, increased blood pressure or edema
respiratory distress

4-14-24 4:18 May have DAT Assess their current health status, To ensure that the patient is medically stable and able to
PM including any underlying medical safely consume food and fluids without exacerbating
conditions, recent surgical procedures, their condition or causing complications.
decrease pain gastrointestinal function, dietary
restrictions, allergies, and tolerance to oral
(-) rebound (- intake.
) rovsings)

Continue Cefuroxime Monitor patient for signs and symptoms of Prompt reporting to the prescriber facilitates timely
IV superinfection and diarrhea and treat assessment and adjustment of the treatment plan,
appropriately potentially preventing complications associated with
untreated superinfections.

Early detection and intervention can help prevent the

progression of adverse reactions to more severe
Instruct patient to notify prescriber about complications and ensure the safety and well-being of the
rash, loose stools, diarrhea, or evidence of patient
superinfection
To prevent further complications and ensure patient
comfort and safety.
 Advice patient receiving drug IV to report
discomfort at IV insertion site

Continuous previous Verify the doctor’s order To ensure that medication is given safely and accurately
medication and serves action are legal

Providing education to the patient about

each medication they are taking, including to recognize and report any adverse reactions or changes
its purpose, dosage, potential side effects, in their condition.
and administration instructions.

allows nurses to detect early signs of medication

regularly assessing the patient's response effectiveness or adverse reactions, enabling timely
to medications, including therapeutic intervention and adjustment of the treatment plan as
effects and any adverse reactions. needed to optimize patient outcomes.

4-14-24 5:40 Continue patients Verify the doctor’s order To ensure that medication is given safely and accurately
PM medications: and serves action are legal

decrease pain
(-) fever Providing education to the patient about
each medication they are taking, including to recognize and report any adverse reactions or changes
(-) tenderness its purpose, dosage, potential side effects, in their condition.
and administration instructions.
 regularly assessing the patient's response allows nurses to detect early signs of medication
to medications, including therapeutic effectiveness or adverse reactions, enabling timely
effects and any adverse reactions. intervention and adjustment of the treatment plan as
needed to optimize patient outcomes.

Linagliptin (Trajenta) Verify the doctor’s order To ensure that medication is given safely and accurately
5 mg 1 tab OD and serves action are legal

Monitor for signs and symptoms of Early detection and intervention can help prevent the
hypoglycemia progression of adverse reactions

Ketoanalogue 1 tab Verify the doctor’s order To ensure that medication is given safely and accurately
OD and serves action are legal
Assess patient renal function and
nutritional status To determine the appropriateness of ketoanalogues
supplementation and ensure proper dosing

Monitoring for any changes in renal To identify any adverse reaction or complications related
function to the use of ketoanalogues

Clopidogrel 75 mg 1 Verify the doctor’s order To ensure that medication is given safely and accurately
tab OD and serves action are legal
 Instruct patient to notify prescriber if Early detection and management of abnormal bleeding
unusual bleeding or bruising occurs promote patient safety and minimize the risk of serious
adverse events associated with medication use.

Inform patient that drug may be taken

without regard to meals
To enhance its absorption or minimize gastrointestinal
side effects.

Alanerv 1 tab OD Verify the doctor’s order To ensure that medication is given safely and accurately
and serves action are legal

2. monitoring for signs of improvement in to assess the effectiveness of the supplement

symptoms related to vitamin or mineral
deficiencies.

3. providing education on the importance 3. to promote patient understanding and adherence to the
of proper nutrition and supplementation treatment plan

Amlodipine 10 mg 1 Verify the doctor’s order To ensure that medication is given safely and accurately
tab OD and serves action are legal
 Regularly assess the patient’s blood Monitoring blood pressure and cardiovascular status
pressure and cardiovascular status before helps evaluate the effectiveness of medication and
and after therapy ensures appropriate adjustments to the medication
regimen.

04-15-24 IVF TT #3 PLR 1L × Verify doctor’s order For action to be legal

12° Select an appropriate venous access site Reduces the risk of complication associated with IV
and assess it for signs of infection, therapy, ensuring a secure well-functioning access site
(-) fever(-) infiltration or other complications
SOB/DOB Early detection of fluid overload allows for timely
Monitor for signs of fluid overload such interventions to prevent complications such as pulmonary
as, edema, increased blood pressure or edema
respiratory distress

4-15-24 Continue Verify the doctor’s order To ensure that medication is given safely and accurately
11:25 AM medications: and serves action are legal

decrease pain • Norgesic Forte BID

RLQ Assess patient pain level To determine appropriate dosage and effectiveness of the
medication
(+)
costovertebra Providing information on potential side To recognize and report any adverse reactions
l tenderness effects

4-15-24 5:20 IVF TF #3,4 PLR 1L Verify doctor’s order For action to be legal
pm × 12° Select an appropriate venous access site Reduces the risk of complication associated with IV
and assess it for signs of infection, therapy, ensuring a secure well-functioning access site
infiltration or other complications
 Monitor for signs of fluid overload such Early detection of fluid overload allows for timely
as, edema, increased blood pressure or interventions to prevent complications such as pulmonary
respiratory distress edema

4-16-24 > May go home Initiate the discharge planning process by To ensures a smooth transition from the healthcare
11:24 AM coordinating with the healthcare team to facility to the patient's home or next level of care,
ensure all necessary tasks are completed promoting continuity of care and patient safety.
before the patient leaves the facility
help ensure that patients and their caregivers understand
how to safely continue their care at home, reducing the
Provide the patient and their family likelihood of complications or setbacks after discharge.
members with comprehensive discharge
instructions, including information about
medications, follow-up care, activity
restrictions, and signs and symptoms to Accurate documentation is essential for maintaining a
monitor at home. legal and professional record of the discharge process and
ensuring continuity of care.

Document the discharge process, including

the patient's condition at the time of
discharge, discharge instructions provided,
medications prescribed, and any follow-up
appointments scheduled.
> Home meds: Educate the patient about cefuroxime, . Patient education promotes medication adherence
including its purpose, dosage, potential
• Cefuroxime 50 mg side effects, and important safety
BID × 1 week precautions. 2Early detection of adverse effects allow for timely
intervention
Instruct the patient to monitor for common
adverse effects of cefuroxime, such as
gastrointestinal upset, rah or any allergic
reactions, and to report any unusual
symptoms promptly

> Continue all other

Review the patient's current medication to ensure accuracy and continuity of care.
maintenance
list and compare it with the doctor's order
medication

Assess the patient's understanding of their By assessing the patient's understanding, nurses can
medications, including their names, identify gaps in knowledge and provide education to
dosages, frequencies, and purposes. promote correct medication use, thereby improving
adherence and enhancing therapeutic outcomes.

> OPD 4-23-24 Schedule the patient's follow-up Ensures that the patient receives timely medical care and
Tuesday 10:00 AM appointment in the outpatient department continues to be monitored for their condition
according to the physician's instructions
To promotes understanding and compliance with the
Provide the patient with clear instructions follow-up plan, ensuring that the patient recognizes the
regarding the date, time, and location of significance of continued medical care
their follow-up appointment.
 Document the doctor's order for the Document the doctor's order for the follow-up
follow-up appointment, including the date, appointment, including the date, time, and purpose of the
time, and purpose of the visit, in the visit, in the patient's medical record.
patient's medical record.

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Data: Acute pain related Within 1-2 minutes INDEPENDENT: INDEPENDENT: After 1-2 minutes of
to inflammation of of rendering rendering nursing
“Bigla agsakit toy tiyan renal tissues as nursing • Assess pain, noting • This is to help interventions, the
ko hanngang toy likod evidenced by interventions, the location, characteristics, evaluate degree of patient can now:
ko(referring to lower guarding behavior, patient will: quality and intensity by discomfort and may
abdomen radiating to RLQ pain the use of pain scale reveal developing
flank area) lalo nu radiating to flank complications
agkuti nak. Sobra ti - verbalize relief or
area and a pain - verbalize relief or control of pain
sakit na”as verbalized scale of 10/10
by the client control of pain
• Enlargement,
• Assess the flank area asymmetry, redness,
and costovertebral angle and edema of the flank - decreases pain scale
C- “kinukurot-kurot” - decrease pain where pain is present area can indicate from 10/10 to 2/10
scale from 10/10 to inflammation.
O- usually occurs at 2/10 Tenderness and
night discomfort upon
L- RLQ radiating to percussion on these
flank area areas can also indicate
infection or
D- on and off pain inflammation.
S- PS: 10/10
P- when in pain, she
rubs over the area of
pain • Assess and note urine • Decreased urine flow
flow and characteristics may reflect urinary
A- often worsens with retention with increased
certain movements pressure in upper
urinary tract

Objective Data: • Encourage fluid intake • Adequate fluid intake

at 2 liters per day will
• facial grimace help with urine dilution,
• RLQ pain radiating to promote renal blood
flank area flow, reduce bladder
irritation, and flush
• pain scale 10/10 bacteria from the
urinary tract.
• guarding behavior
• V/S taken as follows:
• Frequent voiding will
BP: 130/90
• Encourage the patient help to empty the
HR: 74 bpm to void frequently bladder, avoiding
RR: 19 cpm bladder distention and
Temp: 36.3 preventing reinfection.
SpO2: 95% Patient may be hesitant
 to void due to pain but
should be educated on
these reasons

• Provide adequate • Bed rest can help

periods of rest relieve moderate pain
and promote healing

• Encourage patient to • To provide support,

verbalize concerns like reduction of anxiety or
pain, muscle rigidity and fear that can promote
any unusual feeling relaxation and comfort

• Promote non • To manage the client’s

pharmacological pain pain more effectively.
management like use of This method of pain
relaxation exercises management has great
(focus breathing, potential to relieve
diversional or someone’s pain in
distractional activities) addition to
pharmacologic
management, and it is
simple and inexpensive
compared with
pharmacological
methods
 • Reduces muscle or
joint stiffness.
• Assist with range of Ambulation returns
motion exercises and organs to normal
encourage ambulation position and promotes
healing

DEPENDENT: DEPENDENT:

• Administer • To help relieves pain

medications as enhances comfort and
prescribed such as promote rest
analgesics
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Data: Urinary retention Within 3 hours of INDEPENDENT INDEPENDENT After 3 hours of
related to nursing nursing interventions,
“Nu umisbu nak, bassit infection as interventions, the • Assess the voiding • To determine if there the patient
lang maiyisbok” as evidenced by patient will pattern (frequency and is an indication of demonstrated proper
verbalized by the bladder distention, demonstrate proper amount) urinary retention bladder emptying
patient. dysuria and bladder emptying techniques, including
decrease urine techniques, double voiding and
output including double • Ascertain whether • Sensation and complete emptying of
Objective Data: voiding and client has sensation of discomfort can vary, the bladder, to prevent
complete emptying bladder fullness and depending on urinary retention
• frequency urinating at determine level of underlying cause of
night of the bladder, to
prevent urinary discomfort retention
• bladder distention retention
• dullness upon • Assess and monitor • These parameters help
percussion of the urinary elimination determine adequacy of
hypogastric area including consistency, urinary tract function
• dysuria odor, volume and color

• nocturia • Palpating the bladder

• decrease urine output • Palpate for bladder may assist in
distension and observe determining if there is
for overflow abdominal tenderness or
if there is bladder
distention

• Monitor the client’s • Adequate fluid intake

daily fluid intake and is necessary for
output production of healthy
output. If client is not
voiding despite
adequate fluid intake,
fluid may be restricted
temporarily to prevent
bladder overdistention
until adequate urine
flow is established

• Provide the patient • These measures can

with routine voiding assist with the
measures including relaxation of the
privacy, normal voiding perineal muscles, which
positions or the sound of can further help
running water promote appropriate,
effective voiding

• To provide functional
• Assist client to sit
position of voiding
upright on bedpan or
commode or stand
• Encourage the patient • This may minimize
to urinate when the urge urinary retention and
is felt or void every 2 to overdistention of the
4 hours bladder

• Limit ingestion of • These foods have a

 bladder irritants such as natural diuretic effect
colas, coffee, tea, and a bladder irritant
alcohol and chocolate
• Emphasize importance
of having good perineal • To reduce the risk of
hygiene infection, which can
further contribute to
urinary retention
DEPENDENT DEPENDENT
• Catheterize with • To resolve and help
intermittent or relief of retention
indwelling catheter as
ordered
• Administer medication • To treat underlying
such as antibiotics as cause
prescribed

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Data: Impaired bowel Within 6 hours of INDEPENDENT INDEPENDENT After 6 hours of
elimination related nursing nursing intervention
“Tallo nga aldaw nga to decreased in intervention and • Assess and note color, • To provide a baseline and treatment, the
haan nak metten gastrointestinal treatment, the odor, consistency, for comparison and patient verbalizes
makatakke” as motility as patient will amount, and frequency promote recognition of relief from the
verbalized by the evidenced by verbalize relief of stool changes. discomfort of
patient bloated abdomen, from the constipation and
has not defecated discomfort of return to normal
 for 3 days straight constipation and • Assess and identify • Assessing causative patterns of bowel
and abdominal return to normal factors like medications, factors is an essential functioning
Objective Data: cramps patterns of bowel diet that may cause or first step in teaching
• patient has not functioning contribute to and planning for
defecated for 3 days constipation improved bowel
straight elimination
• bloated abdomen
• abdominal cramps • To provide additional
• Auscultate bowel information about the
• difficulty/straining to sounds noting locations
pass stool status of bowel motility
and characteristics and potential underlying
causes of constipation

• Encourage the patient • Adequate fluid intake

to increase fluid intake makes the stool softer
of 1.5 to 2L/day as and easier to pass
tolerated throughout the large
intestine.

• Increased fiber will

• Instruct the client to improve the consistency
increase fiber and bulk of stool and facilitate
in diet like fruits and passage through the
vegetables (ASH DASH colon
diet)

• Encourage taking a
• Promote pain relief sitz bath before stool
during defecation defecation to relax the
sphincter. Relaxation of
the rectal muscles
relieves the pain. It
makes the passage of
stool easy without
forceful strain

• Encourage activity and • To stimulate

exercise according to the contractions of the
client’s tolerance level intestines

• Provide health teaching

to the patient indicating • To promote wellness
the importance of having and may help reduce
a regular bowel concerns and anxiety
elimination about situations.
DEPENDENT DEPENDENT
• Administer laxatives or • To encourage waste
stool softeners and/or flow and assist with
enema (suppository) as initiating bowel
prescribed movement
COLLABORATIVE COLLABORATIVE
• Refer to dietician • To plan specific diet
regarding her food for the patient
intake
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Imbalanced Within 2 days of INDEPENDENT: INDEPENDENT: Goal partially met.

Nutrition related nursing After 2 days of
"Awan ganak mangan" to loss of appetite 1. Assess nutritional 1. Identify deficiencies,
intervention the nursing intervention
as verbalized by the as evidenced by history, including suspect the possibility
client will maintain the client maintain an
patient. weight loss, preferred food. of intervention.
an adequate adequate nutritional
weakness and nutritional status as
drowsiness status as evidenced by:
evidenced by:
OBJECTIVE: 2. Observe and record 2. Observing caloric
the patient food intake intake/lack of quality a) Increased Body
food consumption. weight
a) Increase Body
- weak appearance weight 3. To increase appetite
3. Encourage and help b) Increased in
- drowsiness and oral input.
oral hygiene. appetite.
- weight loss (from b) Increase in
46kg to 44kg) appetite. 4. Lowering distention
4. Avoid foods that
- patient has not eat and gastric irritation.
stimulate gas production
much food
such as beans and dairy
- nausea and vomiting products

5. Evaluate
5. Weight as indicated effectiveness or need
for changes in
nutritional therapy
6. Provide feeding 6. Reduces risk of
safety, such as elevating regurgitation and
head of bed while aspiration.
eating.

7. Enhances digestion
7. Encourage to eat and client's tolerance of
small frequent feeding nutrients and can
improve client
cooperation in eating.

8. Use flavoring (e.g.

8. To enhance food
lemon and herbs) if salt
satisfaction and
is restricted.
stimulate appetite.

9. Encourage family
9. To stimulate appetite
member bring food that
seem appealing

10. Avoid food that 10. Minimize

stimulate intolerances or discomfort
gastric motility (e.G.
foods that are gas
forming,hot/cold, spicy
caffeinated beverages)
11. Promote pleasant, 11. To enhance intake
relaxing environment,
including socialization
when possible
12. Prevent or minimize 12. May have a
unpleasant odor or negative effect on
sights. appetite and eating.

13. Promote adequate 13. To reduce the

and timely fluid intake. possibility of early
limit fluid 1 hr prior to satiety.
meal.
DEPENDENT:
DEPENDENT:
1. This particular diet is
1. Resume diet as only given when the
tolerated client can now tolerate
any food she desires
that is nutritious and
appropriate to her
condition.

2. To treat the
2. Administer underlying cause.
pharmaceutical agents,
as indicated. (vitamins)
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Disturbed sleep Within 1 day of INDEPENDENT: INDEPENDENT: Goal Met:

pattern related to nursing After 1 day of nursing
"Kurang ti turog ko ti interventions, the 1. Assess patient 1. Knowing the specific
rabii, mamin uppat nak frequency of perception of cause of etiologic factor will interventions, the
client must be able
gamin nga makariing ti urinating at night sleep difficulty and guide appropriate client can able to
achieve optimal
rabii tatnu umisbo" as evidenced by possible relief measures therapy. achieve optimal
amounts of sleep as
weak appearance evidenced by to facilitate treatment. amounts of sleep as
as verbalized by the and presence of evidenced by
appearance rested,
patient. dark circles under verbalization of appearance rested,
the client's eyes. feeling rested and verbalization of
2. Manage the
improvement sleep 2.Appropriate lighting feeling rested and
environment for clients
OBJECTIVE: pattern. helps clients to relax. improvement sleep
by adjusting ambient
pattern.
- weak appearance lighting to maintain
daytime light and
- presence of dark nighttime dark.
circles under the
patient’s eyes
-nocturia 3. Provide bedtime care 3.Promote physical
such as straightening comfort
bed sheets, changing
damp linens, or gown, or
provide back massage
making sure to avoid the
painful areas.
4.Turn on soft music, 4. Enhances relaxation
calm TV programs, or a
quiet environment as the
client prefers.

5. Determine the 5. To alleviate pain

position where the
patient is most
comfortable.
6. Review non 6. Promotes relaxation
pharmacological ways to and may enhance a
lessen pain, including patient's coping abilities
techniques such as by refocusing attention.
Therapeutic Touch (TT)
and relaxation skills.
7. Minimize sleep- 7. Promote readiness
disrupting factors (e.g., for sleep and improve
shut room door, adjust sleep duration and
room temperature as quality.
needed, reduce talking
and other disturbing
noises such as phones,
beepers, alarms)
8. Encouraged patient to 8. To reduce the amount
void before going to of urine in the bladder
sleep therefore decreasing the
number of voiding at
night

9. Advised patient to
9. Afternoon naps will
take afternoon naps
help reduce fatigue due
to lack of sleep.

10. Recommend quiet 10. To reduce

activities, such as stimulation so clients
reading or listening to can relax.
soothing music in the
evening

11. To decrease tension,

11. Instruct in relaxation
prepare for rest or sleep.
techniques, music
therapy and meditation

12. Perform monitoring 12. Allows for longer

and care activities periods of uninterrupted
without waking clients sleep, especially during
whenever possible. night.
13. Advised patient to 13. Drinking fluid
limit fluid intake during the night
especially during night increases the chance to
avoid it since the
bladder will be full.

DEPENDENT:
DEPENDENT:
1. For specific
1. Refer to a physician interventions and/or
as indicated. therapies including
medications and
biofeedback
 DRUG STUDY

Drug name Mechanism of Indications Contraindications Adverse Effect Nursing Responsibilities

Action
Generic Name Inhibits platelet Indicated for Use cautiously in Verify doctor’s order
Clopidogrel aggregation by hypertensive patient at risk for CNS: confusion,
Bisulfate blocking ADP patient to increased bleeding hallucinations, Instruct patient to notify prescriber if
receptor on reduce rate of and with those headache. CV: unusual bleeding or bruising occurs.
Brand Name platelets, stroke. renal or hepatic hypotension,
Plavix preventing impairment. hemorrhage at any Encourage the patient to inform all health
clumping of site. EENT: care providers, including dentists, before
platelets. epistaxis, rhinitis, undergoing procedures or starting new
Classification taste disorder. drug therapy, about taking drug.
TC: Gi: hemorrhage,
Antiplatelet abdominal pain, Inform patient that drug may be taken
drugs constipation, without regard to meals.
diarrhea, dys-pepsia,
PC: Platelet gastritis, ulcers.
aggregation GU: UTI, hematuria.
inhibitors Hematologic:
thrombotic
thrombocy-
topenicpurpura.
Musculoskeletal:
arthral-gia, myalgia,
arthritis. Respiratory:
bron-chospasm,
interstitial
pneumonitis,
respiratory tract
bleeding. Skin: rash,
 pruritus, bruising,
eczema, urticaria,
toxic epidermal
necrolysis. Other:
flulike syndrome,
angioedema,
anaphylaxis, serum
sickness.
Side Effects

Dosage, Route CNS: Headache,

& Frequency: dizziness, weakness,
syncope, flushing

75mg PO, OD CV: Hypotension,

edema

Dermatologic: Rash,
pruritus

GI: Nausea, GI
distress, constipation,
diarrhea, GI bleed

Other: increased
bleeding risk
 Drug name Mechanism of Indications Contraindications Adverse Effect Nursing Responsibilities
Action
Generic Name Inhibits calcium Management Use cautiously in CNS: headache, Verify doctor’s order
Amlodipine ion influx across of patients receiving somnolence, fatigue,
Besylate cardiac and Hypertension other peripheral dizziness. CV: edema,
smooth-muscle vasodilators, flushing, palpitations. Monitor BP frequently during initiation
Brand Name cells, dilates especially those Gl:nausea, abdominal of therapy.
Norvasc coronary arteries with severe aortic pain. Respiratory:
and arterioles, stenosis or pulmonary edema, Notify prescriber if signs of HF occur,
and decrease BP hypertrophic dyspnea. Skins such as swelling of hands and feet or
Classification and myocardial cardiomyopathy pruritus, rash. shortness of breath.
TC:Antihypert oxygen demand with outflow tract
ensives obstruction, and in
patients with HF Alert: Abrupt withdrawal of drug may
PC: Calcium with reduced increase frequency and duration of chest
channel LVEF. pain. Taper dose gradually under medical
Side Effect
blockers supervision.
Dosage, Route • Swelling of
& Frequency: your legs or
ankles
5 mg PO • Tiredness or
OD extreme
sleepiness
• Stomach pain.
• Nausea
• Dizziness
• Hot or warm
feeling in your
face (flushing)
• irregular heart
rate
(arrhythmia)
• Very fast heart
rate
(palpitations)
• Abnormal
muscle
movements
• Tremors
 Drug name Mechanism of Indications Contraindications Adverse Effect Nursing Responsibilities
Action
Generic Name Inhibits cell- Urinary Tract Use cautiously in CV: phlebitis, Verify doctor’s order
Cefuroxime wall synthesis, Infection patients with thrombophlebitis.
Sodium promoting history of colitis Gl: diarrhea, Assess the patient’s medical history,
osmotic and in those with pseudomembranous allergies and current medications.
Brand Name instability; renal insufficiency colitis, nausea,
Zinacef usually anorexia, vomiting. Obtain skin test before giving the drug
bactericidal. Hematologic: hemolytic
anemia, Instruct patient to notify prescriber
Classification thrombocytopenia, about rash, loose stools, diarrhea, or
TC: transient neutropenia, evidence of superinfection.
Antibiotics eosinophilia.
Skin: maculopapular
PC: Second- and erythematous
generation rashes, urticaria, pain,
cephalosporins induration, sterile
abscesses, temperature
elevation, tissue
sloughing at IM
injection site.
Other: anaphylaxis,
hypersensitivity reac-
tions, serum sickness.

Side Effect
Dosage, Route • Discomfort with
& Frequency: IM adminis
tration
750mg IV q8 • oral candidiasis
ANST (thrush)
• Mild diarrhea
• Mild abdominal
cramping
• Vaginal
candidiasis
• Nausea
• Allergic reaction
(rash, pruritus,
urticaria)
• thrombophlebitis
(pain, redness,
swelling at
injection site).
 Drug name Mechanism of Indications Contraindications Adverse Effect Nursing Responsibilities
Action
Generic Name May inhibit To treat Advanced renal CNS: dizziness, Verify doctor’s order
Ketorolac prostaglandin moderate to impairment or risk drowsiness, headache
Tromethamine synthesis to severe pain of renal impairment CV: Edema, hypertension
produce anti- due to volume EENT: stomatitis Give I.V. injection over at least 15
Brand Name inflammatory, depletion ENDO: Hyperglycemia seconds
Toradol analgesic, and GI: abdominal pain,
antipyretic bloating; constipation Assess pain (note, type, location and
effects. . GU: urine retention intensity) prior to and 1-2 hr following
Classification HEME: anemia, aplastic administration.
PC: NSAID’s or hemolytic anemia
TC: Analgesic SKIN: Diaphoresis, Monitor patient—especially if elderly—
pruritus, rash, urticaria for less common but serious adverse GI
Other: anaphylaxis, reactions, including constipation, and
injection site pain vomiting.
Side effects
Notify prescriber if pain relief is
Dosage, • Headache inadequate or if breakthrough pain
Route & • abdominal occurs between doses because
Frequency: cramps/pain, supplemental doses of an opioid
dyspepsia analgesic may be required.
30mg q6 PRN • Nasal discomfort
• Constipation Use ketorolac cautiously in patients with
• Ocular irritation hypertension, and monitor blood
• Allergic reactions
pressure closely throughout therapy
(manifested by
pruritus, stinging) because drug can lead to onset of
hypertension or worsen existing
hypertension
PATIENT TEACHING
Tell patient that ketorolac also may
increase risk of serious adverse GI
reactions; stress importance of seeking
immediate medical attention if signs or
symptoms occur, such as abdominal or
epigastric pain, black tarry stools,
indigestion, and vomiting blood or
coffee ground material.

Alert patient to the possibility of serious

skin reactions, although rare, occurring
with ketorolac therapy. Urge patient to
seek immediate medical attention if
signs or symptoms occur, such as
blisters, fever, a rash, or other signs of
hypersensitivity, such as itching.

Encourage patient to have dental

procedures performed before starting
drug therapy because of increased risk of
bleeding.

Teach patient proper oral hygiene

measures, and encourage him to use a
soft-bristled toothbrush while taking
ketorolac.
 Drug name Mechanism of Indications Contraindications Adverse Effect Nursing Responsibilities
Action
Generic Name Ketoanalogues To improve Hypercalcemia, Hypercalcemia may Verify doctor’s order
Ketoanalogue+amino prevents kidney health in disturbed amino develop.
acid unnecessary patients acid metabolism
increase in urea diagnosed with Assess electrolyte levels.
Brand Name levels in urea
CKD.
Ketolog levels in the Assess allergy to the drug
blood due to the
intake of non- Give medication with food to
Classification essential amino prevent GI upset
TC: Nutritional acids in patients
Supplement with kidney Monitor vital signs
failure.
Instruct patient to report
immediately if symptoms of
hypercalcemia like muscle
weakness, constipation
Side Effects

Dosage, Route & • Increased Monitor calcium levels and other

Frequency: calcium levels electrolyte levels
• Nausea
Adult: not less than • Vomiting
70kg 4-8 tab, PO, • Diarrhea
BID • Abdominal
pain
 Drug name Mechanism of Indications Contraindications Adverse Effects Nursing Responsibilities
Action
Generic Name Slow Adjunctive Patients with a CNS: Headache Verify doctor’s order
Linagliptin inactivation of treatment to diet history of CV: Hyperlipidemia,
incretin and exercise to hypersensitivity hypertriglyceridemia • Monitor patient for sign and
Brand Name hormones by improve to the drug EENT: Mouth ulceration, symptoms of hypoglycemia
Tradjenta inhibiting DDP- glycemic control nasopharyngitis, stomatitis
4 enzyme. in patient with ENDO: Hypoglycemia • Monitor glucose level periodically
Classification type 2 diabetes. GI: Acute pancreatitis,
PC: Dipeptidyl constipation, diarrhea, • Inform patient of potential risks and
peptidase-4 elevated lipase level benefits of linagpitin and alternative
(DDP-4) GU: UTI modes of therapy.
enzyme MS: Arthralgia (may be
inhibitor disabling and severe); • Instruct patient to take drug only
back, extremity, or joint and prescribed
TC:Antidiabetic pain; myalgia;
agent rhabdomyolysis • Teach patient to recognize and
RESP: Bronchial manage hypoglycemia and
hyperreactivity, cough hyperglycemia
SKIN: Bullous
pemphigoid, localized skin
exfoliation, rash, urticaria • Advice patient to notify health care
Other: Anaphylaxis, provided promptly during period of
angioedema, elevated uric stress
acid, weight gain
Side Effects
Dosage, Route • Headache
& Frequency: • Nasopharyngitis Instruct pt to report evidence of
• Cough hypoglycaemia
5 mg 1 tab, PO,
OD Instruct patient abut diet, exercise,
footcare hygiene, signs of
hyper/hypoglycaemia, and methods to
avoid infx.

Drug name Mechanism of Indications Contraindications Adverse Effects Nursing Responsibilities

Action
Generic The mechanism of Food supplement Hypersensitivity to • Bleeding Verify doctor’s order
Name action of lipoic with antioxidant Alanerv Capsule
Lipoic Acid acid involves its effect on free • Assess patient for
role as an radicals, with Hypersensitivity
Brand Name antioxidant, its
action on cell
Alanerv ability to Instruct patient to take alanervv on a
regenerate other trophism and full stomach
Classification antioxidants, its helps protect the
participation in nervous cells. • Tell patient to inform
Food energy the healthcare provider if she is
supplements metabolism, its having any of the mentioned side
influence on effects of the drug
insulin sensitivity, Side Effects
 Dosage, its neuroprotective • Headache
Route & effects, its anti- • Fever
Frequency: inflammatory • Diarrhea
properties. • Nausea
300mg, PO, • Vomiting
OD • Blurred vision
• Eye or skin
irritation
• Abdominal pain

Drug name Mechanism of Indications Contraindications Adverse Effects Nursing Responsibilities

Action
Generic Name Inhibits both For the relief of Hypersensitivity to Drowsiness, dizziness, Assess the patient's pain intensity
histamine H1 mild to moderate orphenadrine, dry mouth, blurred and location before administration
Norgesic Forte receptors and pain. acetaminophen, or vision, urinary and at regular intervals afterward.
NMDA receptors. any component of retention, constipation,
Brand Name and nausea. Monitor for signs of central
the formulation.
Orphenadrine nervous system depression (e.g.,
Citrate and drowsiness, dizziness) and advise
Glaucoma. patients to avoid driving or
Acetaminophen
operating machinery if affected.
Classification Obstructive
uropathy. Monitor liver function tests
Analgesic periodically in patients taking
Side Effects Norgesic Forte for an extended
(pain reliever)
 duration to detect potential
Obstructive hepatotoxicity associated with
Dosage, Route gastrointestinal Dry mouth, dizziness, acetaminophen.
& Frequency: conditions. drowsiness,
lightheadedness,
PO, BID Myasthenia gravis. blurred vision, upset Advise patients to avoid activities
stomach, heartburn, requiring mental alertness or
nausea, vomiting, coordination until they know how
Patients receiving
constipation, or trouble the medication affects them.
monoamine
sleeping may occur
oxidase (MAO) Encourage patients to report any
inhibitors adverse effects or unusual
symptoms experienced while
taking the medication.
 DISCHARGE PLAN

MEDICATION Teach the importance of regularly taking prescribed medications and the potential
unpleasant effect of non-compliance.
● Linagliptin (Trajenta) 50 mg #30 1 tab once a day
● Clopidogrel 75 mg #30 1 tab once a day
● Alanerv #30 1 tab once a day
● Amlodipine 10 mg #30 1 tab once a day
● Cefuroxime 500 mg #21 1 tab twice a day x7 days

EXERCISE Encourage patient to have light physical activities as tolerated such as morning
and afternoon walks and to move around the house for a few minutes.

TREATMENT ● Continue all other maintenance medications

● Follow up OPD on April 23,2024 at 10 am
● Encourage patient to take multivitamins as prescribed by the doctor

HEALTH ● Maintain a healthy weight.

TEACHING ● Instruct the patient to avoid bladder irritants such alcohol, caffeine, acidic
foods.
● Encourage the patient to empty her bladder every time she feels full or feels
urinating to prevent bladder detention.
● Educate patient on proper wiping (from front to the back)

OUTPATIENT • Advised patient to come back for a follow up check up

• Instruct the patient and guardian to notify the physician if there is
recurrence or severity of symptoms, any side effect or the development of
complication.

DIET ● Instruct client to eat nutritious food and a well balanced diet. Decreasing
sodium and protein intake such canned goods, dried and fast food
● Instruct the patient and SO to increase fluid intake to promote hydration
● instruct client to avoid processed and meat food

SPIRITUAL Encourage patient to engage in prayer and meditation as part of their healing
process.