URINARY TRACT INFECTION

A Clinical Case Analysis Committee of the

College of Nursing and School of Midwifery
City University of Pasay
Pasadeña St. F.B Harrison Pasay City

In partial fulfillment of the requirements in

NCM 109 Related Learning Experience 

By:
ESPINOSA, ANDY
EVORA, SICHEM D.
GUNDRAN, MARIA JAYZEN F.
HERNANDEZ, PRECIOUS R.
JUVIDA, CLARISSA
LEJANO, JAYSON KENNETH
LURENANA, HANNA

Submitted to: 

MR. RONALDO M. LOPEZ, RN, MAed

September 15, 2022

 TABLE OF CONTENTS
I. Introduction
II. Objectives
a. General Objective
b. Specific Objective
III. Limitations

I. Personal Data
II. Medical History
a. Past Medical History
b. Present Medical Illness
c. Social History
d. Environmental History
e. Immunization
f. OB Score
g. Developmental History
III. Patterns of Functioning
IV. Physical Examination / Review of System
V. Anatomy & Physiology
VI. Pathophysiology
VII. Laboratory and Diagnostic Examination
VIII. Medical and Surgical Interventions
IX. Drug Study
X. Nursing Care Management
a. List of Nursing Diagnosis / Problem
b. Nursing Care Plan
 I. Introduction

Urinary Tract Infection (UTI) is an infection in any part of the urinary systems,
including the bladder, urethra, ureters, and kidneys. It typically occurs when the bacteria
enter the urinary tract through the urethra and begin to spread in the bladder. In this
case, women are anatomically more vulnerable to infection than men because of the
shortness and width of the urethra than men, its proximity to the anus, and the frequent
irritation to the tissues – making it as one of the risk factors of UTI in women. Being
sexually active, using certain types of birth control such as diaphragms, menopause,
catheter use, suppressed immune system and enlarged prostate in men also
contributes as risk factor for UTI. 

      .  The common causative organism of urinary tract infection is Escherichia Coli,
which is one of the resident flora of the intestine (approximately 85%).  Bacterial
infection of UTI can happen in different parts of urinary tract, and each types vary on
locations; Cystitis (if it occurs in bladder), Pyelonephritis (in kidneys) and Urethritis (in
urethra). On the other hand, the symptoms includes pain or burn feeling when urinating,
bad-smelling or cloudy urine, blood or pus present in urine, and soreness or cramps in
lower belly/back/groin. If the infection reaches the kidney (pyelonephritis) pain in the
mid-back, fever, chills, nausea, vomiting and fatigue may occur. 

      The case of lower urinary tract infection rarely leads to severe complication,
however, if it is left untreated complications such as permanent kidney damage, sepsis,
multiple organ system dysfunctions and acute renal failure may happen. The primary
treatment for UTIs is antibiotics such as trimethoprim-sulfamethoxazole (Bactrim) or
nitrofurantoin (Furadantin). Therefore, it is essential to follow up on the course of
antibiotics with urinalysis 4 to 6 weeks after the course of drugs has been completed, to
ensure that the infection has been totally eradicated. 

     In the Philippines, Urinary Tract Infection (UTI) is the most common type of
community-acquired and hospital -acquired bacterial infection. In which according to
The 2019 Philippine Health Statistics of Epidemiology Bureau Department of Health,
Urinary Tract Infection (UTI) is one of ten leading causes of morbidity among males
(with the number of 81, 031 and a rate of 149.5) and females (with the number of 143,
828 and a rate of 270. 9), ranking it as 4th in the 10 leading causes of morbidity. Hence,
it ranked as the 3rd cause in NCR (National Capital Region) with a number of 41, 127
and a rate of 301.7. 
 II. Objectives

General Objective:
The objectives of this study are to obtain knowledge about
care of client with problems related to infectious, by presenting this
study with sufficient information to serve as a guide for student
nurses. This study also serves as a promotion to the healthcare of
the patient and to enhance the skills in the nursing process and
management.

Specific Objective:
At the end of the study, the group will be able to:

Cognitive:

1. Recognize the effect of the drugs administered on the patient,

2. Interpret the collected data from the patient and patient's medical
record, an
3. Formulate an effective nursing care plan

Psychomotor:

1. Gather reliable information about the patient’s condition through

a thorough interview,
2. Provide curative intervention through health teachings,
3. Conduct an assessment about Urinary Tract Infection, and
4. Properly perform nursing interventions.
Attitude:

1. Establish excellent communication skills to easily build rapport with the patient
and with the patient’s family members, and
2. Be respectful to people and rules such as keeping their confidentiality and
acknowledging their beliefs and culture.

III. Limitations

This case study mainly focuses on the health-related problem and risks associated with
Urinary Tract Infection prepared by Group 3 of BSN 3B as a requirement for the subject
Care of Clients with problems related to Infectious. The study would be done by
analyzing the data that is given by the patient and all the information given would be
confidential and obtained by the group.
I. Personal Data

Name: Ms. M
Address: Blk14 L7 Peach St. Casimiro TownHomes Pulang Lupa Uno
Las Pinas City
Age: 24 years old
Sex: Female
Civil Status: Single
Religion: Iglesia Ni Cristo
Birthplace: Gasan, Marinduque
Educational Attainment: College Graduate
Attending Physician: MELODY CELINE D. DE LEON, RMT
Chief Complaint / Reason for Seeking Healthcare:Difficulty in urination
Medical Diagnosis: Urinary Tract Infection

II. Medical History

a. History of Present Illness

2 days prior to consultation (July 10) - M.A experienced difficulty urinating
and intermittent cramps in right lower back with a pain scale of 6/10 which
started around 9 am in the morning. To alleviate the pain, she drank 1-2 cups
of buko juice, and no medication was taken 

Day of consultation (July 12), M.A proceeded to undergo laboratory

examination – such as Urinalysis, Hematology, Fecalysis and X-ray for her
medical requirement at work. It was seen in her urinalysis report an increased
number of bacteria, amorphous substance, and epithelial cells as well as
increased differential count of her lymphocytes in hematology report.
Medication (Cefuroxime) was prescribed by the physician.

b. Past Medical History

M.A was diagnosed with Dengue Stage3, the year 2004 when she was 6
years old. M.E cannot recall the medication that she took. In
In addition, she was not allowed to drink milk and eat junk food because of
her condition. M.E experienced allergies to body lotion given
by her sister last month but she did not take any medication. M.E mention that
she completed all her childhood immunizations

c. Family Medical History:

 d. Social History

Ms. M.A has her own support system and the type of family she
belongs to the nuclear family. Her religion is INC her former work is Cashier
at Super market. Her family source of income is her mother and sister. The
usual activity of Ms. M is doing house hold chores and online activity with her
phone. She has a good bond and relationship in her family and friends.
Usually she drinking alcohol occasionally.

e. Environmental History
The patient lives in a rented apartment with 2nd floor, it is well ventilated
place with 3 windows (1 in the living room and 2 on each bedroom) and has 1
door and a gate. The rented apartment is made in concrete and has their own
2 bathroom (1 in the first floor near in the chicken and 1 in their master
bedroom). Nawasa is their source of water and Mineral water as for their
drinking. Meralco is their source of electricity. They have a motorcycle as their
mode of transportation. Their house is near at the hospital, school, pharmacy,
wet market and convenient stores. They have a scheduled garbage collector

f. Immunization

Name of 1st Dose 2nd Dose 3rd Dose 4th Dose 5th Dose Booster
Vaccine
Dengue __/__/2004 incomplet
Vaccine e
Covid Vaccine 08/20/21 09/10/2021 Complete
(pizer) but No
booster
 g. Gynecology History

She attained her menarche at the age of 14 years old with 28 to 30days
regular cycle with a 4days duration of menses (3 days heavy period and 1day
light period). She usually experiencing menstrual cramps during her 1st day
of period.

G. Developmental History

Jean Piaget’s Cognitive Development

STAGE AGE GROUP NORMAL FINDINGS ACTUAL FINDINGS
Formal Adolescent-young Adolescence begin to think Ms. M.A is capable of
operational stage adult more about moral, seeing multiple potential
(12 and up) philosophical, ethical, solution to problems that
social, and political issues arise and think more
that require theoretical and logically about things
abstract reasoning. They around her.
also begin to use deductive
logic, or reasoning from a
general principle to specific
information.
 Erick Erickson Theory
Stage Age Group Normal findings Actual Findings
Intimacy Young Adulthood At this stage, intimacy and Ms. M.A 1st relationship
versus 19-40 isolation are the focus of was at the ag
isolation development. This stage e of 17, them
begins at age of 19 to 40.
Relationship lasted for
You are establishing and
about a year during
building upon relationships
high school Ms. M is
during this time in your life.
now single and happy
You have meaningful
relationships with her
relationship with friends
family and friends.
and family, you experience
intimacy with others. If you
struggle with relationship,
you may feel isolated and
lonely.

Sigmund Freud’s Psychosexual stages of development

Stage Age Normal findings Actual Findings
Genital Adolescent to During this stage, a person Ms. M didn’t complete
Adulthood begins their puberty and attained the resolution of
will last throughout for the these stages which is
rest of their life. The goal of settling down in one-to-
this stage is to establish a one relationship with
balance between the another person. The
various life areas patient is still exploring
this psychosexual stage
of development and at
the fixations when in
trying to figure out where
to invest her libido in this
stage.

III. Patterns of Functioning

Patterns of Before Hospitalization During Hospitalization Analysis/
Functioning Interpretation
Health Perception Lack of knowledge about Understand medical Due to her condit
and Health UTI diagnosis she experienced a
Management The patient said she According to Ms. M.A, she of changes when
Pattern doesn't check-up when constantly followed her comes to her he
she feels something. Even health management during perception.
though it hurts so much her checkups.
when she urinates, she The patient said that he
ignore the symtoms and continues to drink the
she just let it go. prescribed medicine.
She always stays at home
and drinks sterilized milk and
buko juice to fasten her
recovery from illness.

Nutrition and Ms. M.A was not allowed The patient eat meals 3 Due to her condit
Metabolic Pattern to drink milk and eat junk times a day. The patient Lim
food. The patient said, she Limits herself by followin
The patient said, she drink herself by following a good good diet and to av
2-3 glasses of water in a diet drink 8-10 glasses of salty foods and ot
day and eat meals 3 times water in a day. food that can trig
a day. her condition.
.

Elimination Pattern According to Ms. M.A, -as verbalized by the There has a chan
urinates 2-3 times a day, patient , she still Defecates in Elimination Patt
a pale yellow colored every after 3 days also her due to her illness
urine. she feels pain when stool is still medium to dark
holding urine. brown she urinates per day
She defecates every after 6-7, and the urine is pale
3 days As said, medium to Yellow in color and no
dark brown colored stools discomfort is felt
and no discomfort is felt

Activity-exercise Ms. M.A daily activities The patient she still doing There is no chan
Pattern that she does, such as her daily routine such as in Activity-exerc
walking, and cleaning and walking, and cleaning and Pattern
doing household chores doing household chores and
and doing her doing her schoolworks.
schoolworks. Enjoys watching Netflix and
When it comes to leisure spending using cellphone
hobbies, the patient said According to the patient,
 she enjoys watching having a uti didn't affect her
Netflix and spending using because she still able to do
cellphone. her work.
The patient said, she has
no any supplements
intake.
Before, as stated by the The patient stated that she There are no chan
Sleep Rest Pattern patient, she said that it still sleeps at 1am in sleep/rest pattern
takes her 1 am sometimes sometimes 3am and wakes
3 am to go to bed up at 11am.
because she is still She said, no sleeping aids
watching kdrama and intake.
wakes up at 11am.
She said, no sleeping aids
intake.
Cognitive- Ms. M.A said her hearing, Ms. M.A said her hearing, There are no chan
Perceptual sight, taste and memories sight, taste and memories in Cognit
Pattern are okay. are okay. Perceptual
The patient is aware of The patient is aware of her Pattern.
her surroundings and surroundings and oriented in
oriented in terms of date, terms of date, time, and
time, and location. She location. She remembers
remembers important important events in her life
events in her life
Self-Perception and Ms. M.A is productive and The patient is productive and There is no chan
self-concept pattern physically active. She is physically active. She still in Self-Perception a
not too worried about her not too worried about her self-concept pattern
self appearance, she is self appearance and she is
satisfied with herself. satisfied with herself.
The patient said her The patient said her
personal characteristics personal characteristics are
are that she is quick to that he is quick to trust,
trust, loving, hardworking loving, hardworking and
and sometimes sometimes reprimanding.
reprimanding. She said, she just let it go even if she
there was no changes in already feels the symptoms
her body. of her illness.
She did make up once so
that the appearance is still
okay
Role relationship Ms. M.A said she is still The patient said she is still The patient has
Pattern studying and has no work studying and has no work good relations
and lives with her family, lives with her family, when it comes
including her 2 siblings including her 2 siblings and family and friends.
and her mother. her mother.
 She is a socialize person The patient stated that she is
and has friends to a part of the individuals she
communicate with. interacts with family and
friends.
Sexuality- Has 1 partner and have Has 1 partner and have The patient has a o
Reproductive close relationship with her close relationship with her partner and
Pattern boyfriend. boyfriend. sexually active.
The patient said, she had The patient said, she had
her 1st period when she is her 1st period when she is
13yrs. Old. 13yrs. Old.
Coping-Stress Mrs. M.A. said, the reason Mrs. N.A. said, the reason There is no change
Tolerance Pattern experienced to be experienced to be stressed Values-Beliefs
stressed depends on the is depend on the problem Pattern.
problem how will she how will she handle it but
handle it but sometimes sometimes ignore it. Her
ignore it. Her stress stress coping tactics staying
coping tactics staying calm and taking care of
calm and taking care of herself and family.
herself and family.

Value – Belief The patient is a INC. The patient is a INC. The most import
Pattern The patient said, she pray The patient said, she goes to things in life to h
before she eat and sleep, church twice a week every she said her family.
wakes up in the morning, Thursday and Sunday
she goes to church twice The patient is praying for her
a week every Thursday family to be whole and
and Sunday healthy during the pandemic.
Mrs. N.A. belief in life is
that her family is the top
priority for everything
 III. Physical Examination / Review of System

BODY PARTS NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS/

INTERPRETATION
GENERAL The patient is well groomed Normal Findings
APPEARANCE Patient is well groomed and behave according to her
AND Patient behaves age.
BEHAVIOR according to her age

Generally, uniform in The skin of the patient is Normal Findings

color except in the areas generally uniform in color
exposed to the sun. Skin except in areas exposed to
is intact the sun. No mass, area of
When pinched it springs tenderness, Warm to touch,
SKIN
back to its previous state and when pinched it springs
immediately. back to its previous state
Warm to touch
No Edema

HAIR -black color, evenly The hair of the patient is Normal Findings
distributed, thin, silky brown and blonde (due to
smooth hair dye). Evenly distributed
No infestation or infection and shiny. There are no
No flaking, lice, or nits areas of tenderness
No presence of
flakes/dandruff, lice, or nits.
FACE Rounded, free from The patient face is rounded, Normal Findings
wrinkles, pimples, or free from wrinkles, and no
scars area of tenderness or
 Proportionate and masses
symmetric
Movements are equal
bilaterally
EYES -Black or brown in color, The patient eyes are black Normal Findings
symmetrical in shape and in color, symmetrical in
size, non-protruding, no shape and movements, non-
redness protruding, and no redness

EYEBROWS -Black, symmetrical, thin, The patient eyebrows is Normal Findings

can raise and lower Black, symmetrical, thin, can
eyebrows without raise and lower eyebrows
difficulty, Parallel and without difficulty, Parallel
evenly distributed to each and evenly distributed
other
EYELASHES -Black, evenly distributed The eyelashes of the patient Normal Findings
and parallel to each other are Black, evenly
-Curled outward distributed, and parallel to
each other. And it is also
curled outward.

EYELIDS -No swelling or The eyelids of the patient

discharge, or lesion have no swelling or lesion.

Lid Margin Clear, without scaling and The patient’s Lid margin has
lesions. clear, with no lesions.

EARS -Parallel, symmetrical, The patient ears are Normal Findings

proportional to the size of parallel, symmetrical and
the head proportional to the size of
-Firm cartilage the head.

NOSE Mid-line, symmetrical, The patient nose is mid-line, Normal Findings

and patent symmetrical, and patent

LIPS -appears pink and moist. The patient lips are pink in Normal Findings
-no lesions were noted. color and moist. There are
no lesions.
TEETH -whitish teeth and smooth The teeth of the patient are Abnormal Findings
surfaces & edges. whitish but there is a
-no missing areas or presence of missing areas There is the
caries. and dental caries. presence of
missing areas and
 dental caries.

GUMS -Appears pinkish and The patient’s gums are Normal Findings
moist no swelling or pinkish and moist no
lesions swelling or lesions
-colors and consistency
along gums are even
-no lesions were noted

TONGUE -pink, moist moderate The tongue of the patient is Normal Findings
size with papillae in mid line, pink in color, and
-tongue is mid line, no no lesions.
deviations noted
VOICE -No hoarseness and well The patient voice has no Normal Findings
– modulated hoarseness and well-
modulated
NECK Inspection: proportional The patient is proportional to Normal Findings
to the size of the body the size of the body and
and straight. straight. Has no palpable
Palpation: no palpable lumps, masses, or areas of
lumps, masses, or areas tenderness
of tenderness
CHEST: GENERAL The skin is brown, with The patient skin is brown, Normal Findings
APPEARANCE moles, no scars and with moles, no scars, and
lesions. lesions

POSTURE AND -good posture The patient is able to Normal Findings

SHAPE OF THE -thorax is dome shaped maintain position, symmetric
THORAX and symmetric. and no lumps, mass or area
of tenderness.
TEMPERATURE -uniform temperature, The patient skin is intact and Normal Findings
skin is intact. Slightly warm to touch
Warm to touch.
AREAS OF There is no presence of The patient has no presence Normal Findings
MASSES, mass, lumps and areas of of mass, lumps and areas of
TENDERNESS AND tenderness. tenderness.
LUMPS
BREATH SOUND No presence of any The patient breath sound Normal Findings
crackles, wheezing, or has no presence of any
abnormal sounds. crackles, wheezing, or
abnormal sounds.
BREAST The breast is white, Normal Findings
with/without moles. The patient breast is intact
and uniform in color, with
Rounded shape, slightly moles, unequal size, nipple
 unequal in size. is ever ted and dark in color
and No scars or lesions.
Skin or nipple change

No scars or lesions.

No mass, lesions, lumps

and area of tenderness
HEART Auscultation: No The patient heart has no Normal Findings
presence of any presence of any
adventitious sound. adventitious sound and no
Palpation & Percussion: murmur
No enlargement of heart.
Stay in 5th left intercostal
to 7th intercostal space.

ARM Warm and smooth, no The patient arm is Normal Findings

presence of mass, symmetrical, no redness
lesions and area of Warm to touch, no bruise or
tenderness. Warm to lesion, no area of
touch tenderness and masses.
ABDOMEN -free from lesion, flat, or The patient abdomen is flat, Normal findings
raised brown moles may and free from lesion
be visible;rounded or
scaphoid

UMBILICAL Inverted or everted The patient umbilicus is Normal Findings

Inverted, located
Protruding, flat or midline/midway,color is
hallowed same as the surrounding
Located midline/midway area and has no redness

Color is same as the

surrounding area
No redness

ABDOMINAL -Soft abdomen, no -Soft Abnormal Findings

PALPATION tenderness, no muscle -direct tenderness Because there is
guarding, no lumps or -No masses and lumps direct tenderness in
masses -No patient lower
organomegaly abdomen
-Lower abdominal Pain
KIDNEY symmetrical, with smooth Back pain or side Abnormal Findings
Inspection and surfaces. Normal kidneys Because the
Palpation should be non‐painful on patient feels pain
palpation. on her lower back
and ssid when
palpated.
BLADDER -Not palpable(on empty Palpable Abnormal
PALPATION above bladder) Because the
the smphysis pubis -Regular, smooth, firm & Abnormal accumulation of patient's bladder is
oval shaped arising in the air or fluid palpable, and has
middle (on full bladder) an abnormal
accumulation of air
and fluid on her
absence of masses and bladder.
renal calculi, and no
abnormal accumulation of
air or fluid.
URETHRA No redness, but feel pain, Abnormal Findings
Inspection and strong smell when
urinating stated by the
patient.

V. Anatomy & Physiology

Organs function of
urinary system

kidney- kidneys
remove waste from
the blood
through tiny filtering
units called
nephrons.
Each nephron is
made up of a ball
of small blood
capillaries,
called a glomerulus. There is also a small tube called a renal tubule, which drains the
urine and joins other tubules carrying the urine out of the kidney to the ureter.

Ureters- It carries urine from the kidney to the bladder. Muscles in the ureter walls
tighten and relax forcing urine down this tube, away from the kidneys. If urine backs up,
or stands still, a kidney infection can develop. About every 10 to 15 seconds, urine is
emptied into the bladder from the ureters.

Bladder- It is a triangle-shaped, hollow organ located in the lower abdomen. It is held in

place by ligaments attached to the pelvic bones. The bladder's walls relax and expand
to store urine, and contract and flatten to empty urine through the urethra.

Sphincter Muscles- Circular muscles that help keep urine from leaking by closing tightly
like a rubber band around the opening of the bladder.

Urethra- the tube that allows urine to pass outside the body. The brain signals the
bladder muscles to tighten, which squeezes urine out of the bladder. At the same time,
the brain signals the sphincter muscles to relax to let urine exit the bladder through the
urethra. When all the signals occur in the correct order, normal urination occurs.
VI. Pathophysiology 
 VII. Laboratory and Diagnostic Examination

JULY 12, 2021

URINALYSIS

Actual Findings Normal Findings ANALYSIS/ INTERPRETATION

Color: Yellow Clear/light/pale Indicate Urinary Tract Infection (UTI)

Transparency: Turbid Clear or cloudy Indicate with infections, inflammations and

other diseases that affect the functioning of
the urinary tract

Reaction: Acidic 4.5 to 8.0 Indicate a medical condition, such as:

diabetic ketoacidosis, which is a
complication of diabetes, dehydration, and
diarrhea.

Specific 1.015 1.005 to 1.025 Normal Specific Gravity

Gravity:

Sugar: Negative Negative Normal Blood Glucose Level

Albumin: Negative Negative Normal Protein Level

Epithelial Few Range 5 to 7 Normal Epithelial Cells Level

Cells: (None)

Pus Cells: TNTC / hpf 2 to 3 pus Indicate toward underlying Urinary Tract
cells/hpf Infection (UTI)

RBC: 15-18 / hpf ≤2 RBCs/hpf (red Abnormal Red Blood Cell (indicate of
blood cells per high infection in urine)
power field)

Amorphous Many None Indicate Dehydration form not drinking

Substances: enough fluids

Bacteria: Many None Indicate an infection somewhere in the

urinary tract.
 JULY 12, 2021
HEMATOLOGY

NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS/

INTERPRETATION
Hemoglobin 120 – 160 gms/dL 10.4 Low Hemoglobin
Level
Hematocrit .37 - .42 30 Low Hematocrit Level
WBC (Leukocyte) 5.7 – 10.0 7.1 Normal WBC
Differential Count
Segmenters 0.55 – 0.65 0.55 Normal Segmenters
Lymphocytes 0.15 – 0.35 0.38 High Lymphocytes
Level
Monocytes 0.03 – 0.05 0.07 High Monocytes Level

JULY 12, 2021

FECALYSIS
Color: Yellow Brown
Consistency: Semi-Formed
Others: ` No intestinal parasite seen

JULY 12, 2021

X-RAY REPORT
 FINDINGS:
Both lung fields are clear.
Heart is not enlarged.
Diaphragm and sinuses are intact.

IMPRESSION:
ESSENTIALLY NORMAL CHEST

VIII. Medical and Surgical Interventions

Cefuroxime - 1-tab 2x a day for 7 days. used to treat bacterial infections

in many different parts of the body. It belongs to the class of medicines known as
cephalosporin antibiotics. It works by killing bacteria or preventing their growth.

IX. Drug Study

Name of Classificati Mechanism Indication Contraindication Adverse Nursing

Drug on of Action s of Drug Effects Responsibilitie
of Drug s
Generic Cephalospor Interferes For Contraindicate Severe Monitor
Name: in antibiotics. with treatment d in patients diarrhea patient for
Cefuroxim bacterial cell of many hypersensitive to  signs and
e wall synthesis different the drug or other Bleeding symptoms of
by inhibiting types of cephalosporins  infection.
Brand the final step- bacterial  Use cautiously Lethargy  Give drug
Name: in cross- infections in patients with a  with
Zinacef linking such as history of colitis Decreas food intake to
Actual peptidoglycan bronchitis and in those with e decrease GI
dosage, s strands. It , sinusitis, renal sufficiency. d upset and
route, makes the tonsillitis,  According to platelets enhance
frequency: cell ear CDC, oral Hct absorption.
500mg/tab membrane infection, cephalosporins   Explain to the
, PO, BID rigid and skin are not Anorexia patient about
protective infection, recommended to the importance
without it gonorrhea treat gonococcal and purpose of
bacterial cells and infections. the drug You
rupture and urinary can check with
die. tract  Discontinue if
infection. hypersensitivity
reaction
occurs.
 Take note of
the side effects
in the stomach
upset or
diarrhea

X. Nursing Care Management

b. Nursing Care Plan

HYPERTHERMIA
ASSESMENT DIAGNOSIS PLANNING INTERVENTI RATIONALE EVALUATI
ON
Subjective: ● Hypert ● After 7 ● After 7 da
hemiar days of ● Provide a ● A tepid sponge bath is nursing
“nilagnat po elated nursing tepid done to reduce fever. interventio
ako nung to interventio sponge patient wa
may uti ako” infecio n, patient bath. to maintai
as stated by us will temperatu
the patient. proces maintain within nor
s core ● To prevent the range..
● Flushe temperatu ● encourag occurrence of
d skin re within e dehydration
● warm normal adequate precipitated by an
to range. fluid increase in
touch. intake. temperature.

Objective:

● Dysuri
a ● It helps prevent
● Urinar shivering.
y
retenti ● Encourag
on. e the use
● Restle of blanket
ssness and wrap
extremitie
T: 38.2 s with ● To reduce
RR: 17 bath metabolic
PR: 82 towels. demands/oxygen
BP: 120/90 consumption.
● Advice
patient to
Maintain
bed rest.

● To reduce body
Dependent: temperature.

● Admini
ster
antipyr
etic
drugs
as
 indicat
ed.

DEFICIENT KNOWLEDGE

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: ● Deficient ●After 8 hours ● Teach patient ● This ● After 8 hours
knowledge of nursing Perineal prevents of nursing
“Hindi ko daw muna related to intervention hygiene after a infection, intervention
makukuha yung unfamiliarity the patient will bowel odors, and the patient
medical ko kase of the nature verbalize movement. irritation. was able to
may UTI daw ako.” and knowledge of verbalize
as verbalized by the treatment of causes and knowledge of
patient. UTI treatment of causes and
UTI, controls ● Teach patient treatment of
Objective: risk factors, to use ● because they UTI, controls
and complete tampons keep the risk factors,
● Dysuria medical during periods bladder and
● Urinary treatment of rather than opening area completes
retention. UTI. sanitary drier, hence medical
● Restlessnes napkins limiting the treatment of
s growth of UTI.
bacteria.
T: 38.2
RR: 19
PR: 82 ● Teach patient
BP: 120/90 to Avoid
wearing tight- ● Such fabrics
fitting or can
constricting accumulate
undergarments moisture
 made of non- and can
breathing provide an
materials. environment
for bacterial
growth.

● teach patient
to wear Cotton
fabric and
loose fitting
clotting

ACUTE PAIN

ASSESMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: ● ACUTE ● After 7 days ● Encourages ● To provide ● After 7
PAIN of nursing verbalization of necessary days of
“masakit kapag related to intervention pain and intervention to nursing
umiihi, lalo na Urinary , patient discomforts lessen pain if it intervention,
kapag nagpipigil tract pain will be occurs. patient pain is
ako.” as verbalized infection relieved relieved and
by the patient. and controlled.
controlled. ● To prevent
Objective: ● Advice to avoid irritation of the
drinking urinary tract.
● Facial coffee,teas,
grimace colas and
● Restlessnes alchohol.
s
● To flush out
T: 38.2 ● Advise to bacteria in
RR: 19 drink more urinary tract.
PR: 82 fluids.
BP: 120/90 ● To prevent
further
 ● Advise to infections.
perform daily
perenial care.

References:
Welcome to Department of Health website | Department of Health Website. (n.d.).
Retrieved September 11, 2022, from
https://doh.gov.ph/sites/default/files/publications/2019PHS_Final_092121.pdf
https://www.medicalnewstoday.com/articles/what-does-a-uti-look-like
https://www.webmd.com/women/guide/your-guide-urinary-tract-infections
Gould, B. E., & Dyer, R. M. (2011). Pathophysiology for the Health Professions.
Saunders Elsevier.