ANGELA CORINE U.

DELA CRUZ
BSN III-C

PATIENT’S NAME: YUAN CRISOSTOMO MARCOS

AGE: 10 y/o
SEX: MALE
ADRESS: BARABGAY 6, TONOTON PIDDIG, ILOCOS NORTE

ATTENDING PHYSICIAN: HEMAEZ, LORNA MADAMBA

DATE ADMITTED: MAY 17, 2022 @ 10:00 AM
DATE DISCHARGED: MAY 21, 2022 @ 10:00 AM

WARD: PEDIATIC WARD

ROOM: 1
BED: 5

FINAL DIAGNOSIS: URINARY TRACT INFECTION

PATIENT’S NAME: YUAN CRISOSTOMO MARCOS
AGE: 10 y/o
SEX: MALE
WARD: PEDIATIC WARD
ROOM: 1
BED: 5

F-
ACTIVITY INTOLERANCE
D-
body weakness, guarding behavior and facial grimace
“agkakapsut nak ken haan nak unay makagaraw garaw” verbalized by the patient
A-
Vital signs taken and recorded
Encouraged to increase fluid intake
Encouraged to perform an activity more slowly (sitting and walking)
Advised the patient to move with assistance by the guardian
Placed in comfortable position

R-
Health teaching imparted and willing to comply.
Generic Name: Nursing Responsibilities
Ampicillin Sulbactam Action Rationale
Brand Name: 1. Follow 14 Rs of To avoid medication administration error
Unasyn Medication Administration
Dose/ Route/Frequency: 2. Assess for hypersensitivity To prevent allergic reactions which may aggravate
500 mg IV x 8 hours with the drug the condition
3. Prepare the drug aseptically To maintain the sterility of the drug
Mechanism of Action: It
works by stopping the growth 5. Administer the drug as To avoid over dosage to the drug
of bacteria. Also, by preventing prescribed
bacteria from destroying
ampicillin.
Physiologic classification: 6. Advised to increase fluid To promote hydration and excretion of the drug
Antibiotic intake
Pharmacologic
Classification: 8. Encourage to have adequate To conserve energy
Beta-lactamase inhibitors rest and sleep
Desired Effect: Prevent 9. Educate about the different To give information and gain cooperation
infection side and adverse effects of the
drug
10. Advised to report any side For further treatment and avoid other complications
Indication/s: Treatment of or adverse effect felt
infections 12.
Contraindication/s: 13.
Hypersensitivity to Antibiotic

Side Effects: Hoarseness, nausea, vomiting

Adverse Effects: Abdominal pain DRUG-DRUG: It cause the aminoglycoside to be less effective in
treating your infection.

DRUG STUDIES

AMPICILLIN SULBACTAM
 RANITIDINE

Generic Name: Ranitidine

Brand Name: Zantac
Date Ordered: May 17, 2022
Dosage/Route/Frequency: 50 mg IV q 8 °
Pharmacologic Classification: Histamine-2 Antagonist
Physiologic Classification: H2 blockers
Mechanism of Action: The hormone gastrin, produced by cells in the lining of the stomach,
stimulates the release of histamine, which then binds to histamine H2 receptors, leading to the
secretion of gastric acid.
Indication: Treatment of duodenal ulcer, benign gastric ulcer
Desired Effect: It decreases the amount of acid that the stomach makes and relieves symptoms
of stomach pain and heartburn.
Side Effect: Headache, abdominal pain, agitation, constipation, diarrhea, dizziness

Nursing Responsibilities Rationale

1. Follow the 14 R’s of drug administration. To ensure safety and helps avoid any
medication errors.

2. Assess for possible contraindications or To prevent potential allergic reactions

cautions: History of allergy to any H2
antagonists

3. Arrange for decrease dose in cases of To prevent serious toxicity

hepatic or renal dysfunction

4. Monitor the patient continually if giving IV To allow early detection of potentially serious
doses adverse effects, including cardiac arrhythmias

5. Assess the patient carefully for any Because of the drug effects on liver enzyme
potential drug-drug interactions if given in systems
combination with other drugs

6. Provide comfort, including analgesics, To minimize possible adverse effects

 ready access to bathroom facilities, and
assistance with ambulation

7. Periodically reorient the patient and To ensure patient safety and improve patient
institute safety measures if CNS effects occur tolerance of the drug and drug effects

8. Monitor patient response to the drug (relief To provide well-being

of GI symptoms, ulcer healing, prevention of
progression of ulcer)

9. Offer support and encouragement To help the patient cope with the disease and
the drug regimen

10. Arrange for regular follow-up To evaluate drug effects and underlying
problem

PARACETAMOL

Generic Name: Paracetamol

Brand Name: Tylenol
Date ordered: May 17, 2022
Mechanism of Action: Paracetamol exhibits analgesic action by peripheral blockage of pain
impulse generation. It produces antipyresis by inhibiting the hypothalamic heat-regulating center.
Its weak anti-inflammatory activity is related to inhibition of prostaglandin synthesis in the CNS.
Pharmacological Classification: Antipyretic/ Analgesic Physiological Classification: Non-
opioid
Indication: Indicated for mild-to-moderate pain and moderate-to-severe pain with adjunctive
opioid analgesics; also indicated for reduction of fever Desired Effects: To lower the body
temperature of the patient.
Adverse Effects: Hepatotoxicity, acute renal tubular necrosis.

Nursing Responsibilities Rationale

Follow the 14 R’s in administering the drug To ensure safety and helps avoid any
medication errors.

Check that the patient is not taking any other Patients should be cautioned not to take any
medication containing paracetamol. other products containing paracetamol and
they should read the label of all other
medication carefully to ensure that it does not
contain paracetamol.

Monitor for S&S of: hepatotoxicity, poisoning, usually from accidental ingestion
or suicide attempts; potential abuse from
psychological dependence (withdrawal has
been associated with restless and excited
responses).

Inspect skin daily and instruct patient to do The appearance of a rash should be carefully
the same. evaluated to differentiate a nonallergenic
ampicillin rash from a hypersensitivity
reaction. Report rash promptly to physician.

Take medication around the clock continue taking medication until it is all gone

Adhere to policy for site change and site care. Assess for Redness, swelling, pain at site

Assess for Swelling, Pallor, Coolness, Notify Supervisor/Physician as per individual

Discomfort, Sluggish flow hospital policy and Document findings and
actions
 NURSING CARE PLAN

ASSESSMENT:
Objective cues: guarding behavior, facial grimace, temperature of 38. 3
Subjective cues: “nasakit tay puson ko nu umisisbo nak”

NURSING DIAGNOSIS: Infection related to Urinary Retention as fanifested by guarding

behavior, facial grimace, temperature of 38. 3 and a verbalization of “nasakit tay puson ko nu
umisisbo nak”

INFERENCE: UTI is a medical condition that results from invasion and multiplication of
pathogens in the urinary tract. The urinary tract involves the kidneys, bladder, and urethra.
Usually, bacteria that enter the urinary tract system are removed by the body before they can
cause symptoms. But, in some cases, bacteria overcome the natural defenses of the body,
therefore causes infection. UTIs are usually classified as infections involving the upper or lower
urinary tract. 

OUTCOME IDENTIFICATION: After 1-2 hours of nursing intervention, patient will be

able to:
 Readily demonstrate lifestyle changes related to UTI prevention
 Absence of guarding behavior and facial grimace
 Decrease of temperature from 38.3 to 37.2 degree Celsius
 A verbalization of “haan unay nasakit toy puson ko nu umisisbo nak’

NURSING INTERVENTIONS RATIONALE

Asses vital signs and monitor the signs of For baseline data
infection
 Assess for signs and symptoms of urinary To treat underlying infection
tract infection.
Teach the patient some lifestyle changes To promote good hygiene and to avoid
related to UTI prevention, including proper infection
perineal hygiene and avoidance of
undergarments that have non- breathing
materials that are tight fitting.
 Encourage the patient to void every 2-3 hours To facilitate flushing of bacteria from the
bladder and avoid urine accumulation
Encourage the patient to increased oral fluid Increasing fluid intake to 2 to 3 liters per day
intake unless contraindicated. helps facilitate urine production, dilutes urine,
reduces irritation of the inflamed bladder,
promotes renal blood flow, and flushes
bacteria from the urinary tract.
Instruct to avoid coffee, tea, spices, alcohol, These foods are considered urinary tract
and sodas. irritants and may irritate the urinary system
Teach the patient the use of non- Alternative therapies such as relaxation,
pharmacological techniques for pain massage, guided imagery, or distraction may
management as appropriate. decrease pain and provide comfort.
Administer drugs agents as prescribed To treat and reduce the pain

EVALUATION: After 2 hours of nursing intervention, patient was be able to demonstrate

lifestyle changes related to UTI prevention, absence of guarding behavior and facial grimace,
decrease of temperature from 38.3 to 37.2 degree Celsius and a verbalization of “haan unay
nasakit toy puson ko nu umisisbo nak’