XI.

Nursing Care Plan Age: 12 years old Sex: Male

Name of client: KM Chief Complaints: Headache and vomiting Attending Physician: Ludgero Magdaug M.D Assessment A. Actual Abnormal Findings Subjective: Amo gid niya basta may UTI sakit mangihi? the patient verbalized. Objective: -facial grimace -pain scale 7/10 -side lying position to avoid pain. v/s: T: 38.1 C P: 98 bpm R: 24 cpm BP:110/60 mmHg A. Wellness and Strength -strong family support -strong faith in God C. Weaknesses y Holding of urine y Poor financial support Nsg Diagnosis
Acute pain related to disease process as evidence by facial grimace, pain scale 7/10, side lying position to avoid pain and the patient verbalized amo gid niya basta may UTI sakit mangihi?. Definition: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow on set of any intensity from mild to severe with an anticipated of predictable end and a duration of less than 6 months. Source: Nurses Pocket Guide 8th ed.

Rationale
Holding the urge to urinate urinary retention causing bladder distension accumulation of uremic waste & electrolyte imbalances bacteria attach to & colonize the epithelium of urinary tract to avoid being washed out when voiding increase WBC to fight bacteria inflammatory process as an autoimmune response inflammation ofbladder hypothalamus signals the synthesis of prostaglandin pain receptors activated pain while urinating

Desired Outcomes After 2 days of nursing intervention the client will be able to: 1.Verbalize and demonstrate relief and control of pain and discomforts

Nursing Intervention Independent: -encourage right brain stimulation activities like playing board games

Justification

Evaluation After 2 days of nursing intervention the client was able to: 1.Goal met: Client was able to verbalize relief of pain.

-to release endorphins (it enhances sense of well being)

-monitor vital signs q4h

-it usually altered in acute pain

2.Demonstrate behavior/techniques to prevent pain discomforts like -monitor level of pain breathing exercise -provide comfort measures: such as proper positioning. 3. Verbalize understanding of disease process. -supervise and encourage deep breathing.

-to observe for signs of discomfort. -to provide non pharmacologic pain management. -focusing on breathing may help client feel in control and decrease pain .

2.Goal met: Client was able to demonstrate behavior that would help him in reducing the pain by doing breathing exercise and relaxing. 3.Goal met: Client was able to verbalize understanding about the condition and accept it.

Collaborative: -administer analgesic medication as ordered. -to relief pain discomfort

Name of client: KJM Chief Complaints: Headache and vomiting Attending Physician: Ludgero Magdaug M.D

Age: 12 years old Sex: Male

Assessment Actual abnormal cues: -dehydration -dry skin -itchiness Strength: -good family support Weakness: -financial support

Nsg Diagnosis

Rationale

Desired Outcomes After 3 days of nursing intervention, the client will be able to: -demonstrate behaviors and techniques to prevent skin breakdown -maintain optimal nutrition and physical well-being -participate in prevention measures and treatment program

Nursing Intervention -assess skin routinely, noting moisture, color and elasticity.

Justification That may indicate particular vulnerability and may impair skin integrity. Reduce likelihood of progression to skin breakdown.

Evaluation

Risk for impaired Inadequate fluid intake skin integrity related to impaired metabolic Imbalanced state (fluid status) concentration of fluids and electrolytes Definition: Impaired skin integrity- at risk for skin being adversely altered. Source: Nurses Pocket Guide, 12th editions Reduced circulating blood volume Reduced tissue perfusion Dry skin Impaired skin integrity

-observe for reddened or blanched areas, or skin rashes, and institute treatment immediately. -emphasize importance of adequate nutritional and fluid intake. Collaborative: -assess supply and sensitivity (nerve damage) of affected area.

To maintain general health and good skin turgor.

To evaluate actual or potential impairment of circulation to lower extremities To promote wellness.

-review medical regimen. Stress importance of follow-up care

Name of client: KJM Chief Complaints: Headache and vomiting Attending Physician: Ludgero Magdaug M.D Assessment Actual Abnormal Findings Subjective: sakit ulo niya kuno, kainit pa siya ho. Mother verbalized. Objective: - Warm to touch skin - Flushed skin v/s : T- 38.1 P- 98 bpm R- 32 cpm BP- 110/60 mmHg B. Strength > Good family support > strong faith in GOD C. Weaknesses > poor financial support Nsg Diagnosis

Age: 12 years old Sex: Male

Rationale

Desired Outcomes After 8 hours of nursing intervention, the client will be able to:

Nursing Intervention 1.Monitor V/S q3h.

Justification 1.Evaporation is decreased by environmental factors of high humidity and high ambient temperature. 2.To decrease the body temperature without using pharmacologic agents.

Evaluation After 8 hours of nursing intervention, the client was able to: Goal met: Client was able to maintain his temperature within normal range. His temperature went down to 37.2rC. Goal partially met: Client was not able to identify the contributing factors but was able to identify sign and symptoms and intervention. Goal met: Patient was able to demonstrate normal body temperature at 37.5rC.

Alteration in body temperature, hyperthermia Holding the urge to related to disease process urinate as evidence by increase body temperature of 38.1 urinary retention C, warm and flushed causing bladder skin, and the mother distension verbalized sakit ulo niya kuno kag ka init pa sa iya accumulation of uremic ho." waste & electrolyte imbalances Definition: Body temperature bacteria attach to & elevated above normal colonize the epithelium range. of urinary tract to avoid being washed out when th Nurses Pocket Guide 8 voiding ed., (2002) increase WBC to fight bacteria indicates infection increase BMR hyperthermia

-maintain core temperature within normal range

2.increase fluid intake

-identify underlying cause/contributing factors and importance of treatment, as well as signs and symptoms requiring further evaluation or intervention -demonstrate behaviors to monitor and promote normothermia

3.Monitor laboratory studies such as ABGs, electrolytes, cardiac and liver enzymes, glucose, urinalysis and coagulation profile 4. Administer antipyretics/analgesics (e.g., aspirin, acetaminophen,) as ordered.

3.May reveal tissue degeneration, myoglobinuria, proteinuria, and hemoglobinuria can occur. 4. To reduce body temperature/ restore normal body.

XII. Drug study Name: KJM Chief complaint: Headache and vomiting Attending physician: Ludgero Magdaug M.D. Age: 12 years old Diagnosis: Lower Urinary Tract infection

Name of Drug

Action and Mechanics of action Frequency: Q4 Chemical effect: May produce analgesic effect by blocking pain impulses, by inhibiting prostaglandin or pain receptor synthesizer. May relieve fever by acting in hypothalamic heat- regulating center.

Indication

Contraindication

Adverse effect

Nursing consideration

Generic name: paracetamol

Mild pain or fever

Contraindicated in patients who are hypersensitive to drug. Use cautiously in patients with history of chronic alcohol abuse hepatotoxicity may occur after therapeutic doses

Hematologic: haemolytic anemia, neutropenia, leukopenia, pancytopenia, thrombocytopenia. Hepatic: liver damage (with toxic doses), jaundice Metabolic: hypoglycaemia

-Give liquid form to children who have trouble swallowing. -warm patient that high doses or unsupervised long-term use can cause liver damage. Excessive alcohol use may increase risk for hepatotoxicity. -tell patient to keep tract of daily acetaminophen intake, including OTC and prescription medications. Warn patients not to exceed total recommended dose of acetaminophen per day because of risk of hepatotoxicity.

Brand name: Calpol

Dosage: 1TAB/325mg

Classification: Analgesic/ antipyretic

Route: Oral Therapeutic effect: relieves pain and reduces fever.

Skin: rash and urticuria

Name: KJM Chief complaint: Headache and vomiting Attending physician: Ludgero Magdaug M.D.

Age: 12 years old Diagnosis: Lower Urinary Tract infection

Name of Drug

Action and Mechanics of action

Indication

Contraindication

Adverse effect

Nursing consideration

Generic name: mebendazole

Frequency: BID

Brand name: Vermox

Dosage: 100mg

Chemical Effect: selective and irreversibly inhibits uptake of glucose and other nutrients in susceptible helminths.

-pinworm, -hypersensitive to the poundworm, drug or any of its whipworm, hookworm components. -trichinosis -capillariasis -toxocariasis -dracunculiasis

GI: transient abdominal pain, diarrhea

-tablets may be chewed, swallowed whole or crushed, mixed with foods. -give drug to all family members to decrease risk of spreading infections. -teach patient about personal hygiene, especially good hangwashing techniques. -advise patient not to prepare food for others.

Classification: Pharmacologic

Route: PO

Therapeutic effect: Kills helminth infestation

Class: benzimidazole

Therapeutic class: Anthelmintic

Name: KJM Chief complaint: Headache and vomiting Attending physician: Ludgero Magdaug M.D.

Age: 12 years old Diagnosis: Lower Urinary Tract infection

Name of Drug

Action and Mechanics of action

Indication

Contraindication

Adverse effect

Nursing consideration

Generic name: penicillin

Frequency: Q6

Chemical Effect: Inhibits cell wall synthesis during microorganism multiplication Therapeutic effect: Kills susceptible bacteria

-moderate to severe systemic infection. -bacterial endocarditis -anthrax

-hypersensitive to the drug or penicillin. -use cautiously in patients with other drug allergies, especially to cephalosporins and cephamycin

-CNS neuropathy, seizures -CV: thrombophlebitis -hematologic: hemolytic anemia, leucopenia, thrombocytopenia -Musculoskeletal: arthralgia -other: hypersensitivity reaction overgrowth of nonsusceptible, vein irritation, pain at injection site.

-give drug deep IM in midlateral thigh in young child. -dont massage the injection site, avoid injection near major nerves to prevent severe neurovascular damage. -periodiacally monitor renal and hematopoietic function in patient receiving long-term therapy. -instruct client to apply ice compress in injection site to ease discomfort.

Brand name: Crystapen

Dosage: 750,000 units

-neurosyphilis -necrotizing ulcerative gingivitis

Classification: Anti-bacterial

Route: IVTT

Therapeutic class: Rapid-acting antibiotic

XIII. Health Teaching Plan

Medication

Exercise

Treatment

Hygiene

Outpatient

Diet

A. paracetamol -analgesic/antipyretic -prostaglandin or pain receptor sensitizers. May relieve fever by acting in hypothalamic heatregulating center. -1tab/325mg every 4hours -taken orally and follow with a full glass of water.

-encourage regular pelvic floor strengthening exercise. -demonstrate and instruct patient in use of Credes maneuver to facilitate emptying of bladder. -encourage client to use Valsalva maneuver if appropriate to increase intra-abdominal pressure

Treatment of UTI may include the following: -PE and history; an exam of body to check general signs of health, including checking for signs of disease such as hyperthermia. Patients health habits and past illnesses and treatments will also be taken.

-patient should maintain proper hygiene -emphasize importance of perineal care after each voiding to reduce risk of ascending infection.

-after completion of treatment, patient is advised to have a follow up check-ups -continue medication as prescribed -discuss concerns and details about the treatment to the physician -go for a counselling if possible

-limit the intake of coffee, tea, softdrinks (they irritates the bladder) -encourage cranberry juice (to acidify urine) -encourage adequate fluid intake, specially vit. C enriched (they discourage bacterial growth and stone formation)

B. mebendazole -anthelmintic -selective and irreversibly inhibits uptake of glucose and other nutrients in susceptible helminths -kill helminth infestation -100mg BID -urinalysis: is the physical, chemical, and microscopic examination of urine. It involves the number of test to evaluate the urine specimen for appearance, color, clarity, pH, specific gravity and presence of

-tablets may be chewed swallow whole, mixed with foods, crushed.

bacteria, blood, cast, glucose, ketones, leukocytes, proteins, RBC & WBC.

C.penicillin -rapid acting antibiotic -inhibits cell wall synthesis during microorganism multiplication -kills suxceptible bacteria -750,000 units thru IVTT q6h. -dont massage the injection site. -avoid injection near major nerves to prevent severe neurovascular damage