NIGHTINGALE INSTITUTE OF

NURSING

SUBJECT :
TOPIC :

SUBMITTED TO:- SUBMITTED BY:-

SUBMITTED ON:-
 IDENTIFICATION DATA
DEMOGRAPHIC DATA
NAME OF THE PATIENT :- Shyam shankar
AGE :- 40 years
GENDER :- male
MARITAL STATUS :- married
RELIGION :- hindu
EDUCATION :- B.A
OCCUPATION :- pvt. job
ADDRESS :- 705 , mehrauli, n-delhi
WARD :- ward 2
NAME OF THE HOSPITAL :- bhagwati hospital
DATE OF ADMISSION :- 10th june, 2021
PROVISIONAL DIAGNOSIS :- fever
FINAL DIAGNOSIS :- URINARY TRACT INFECTION (UT I)
CHIEF COMPLAINTS:-
The client was admitted to the hospital due to fever since 2 days.

SOCIO ECONOMIC STATUS:-

Middle class
Nuclear family
Monthly income of the family- Rs-25000-/-
FACILITIES:-
Proper ventilation
Water - tap water
Drainage- closed drainage
Toilet- attached to house
Social relationship with neighbours-good
 FAMILY HISTORY:-
S. Name of Age/sex Relationship Marital status Education Occupation Health status
No the family with patient
member
1 Shyam 40/m Self Married B.a Pvt.job unhealthy
Shankar
2 Renu 38/f Wife Married 12th Housewife Healthy
shankar
3 Suraj 18/m Son Unmarried 12th Student Healthy

4 Pinki 15/f Daughter Unmarried 10th Student healthy

 FAMILY TREE:-

female
Shyam renu shanker
shankar 40/m 38/f
male

patient

suraj 18/m pinki 15/f

FAMILY MEDICAL HISTORY:-

The client shyam shankar of 40 years old belongs to a nuclear family.he
doesn’t have any history of hereditary diseases.
PERSONAL HISTORY:-
Diet - vegetarion
Bath - daily
Sleeping pattern - regular at night for 7 to 8 hrs
Urinary elimination pattern - 2 to 3 times a day
Bowal elimination pattern - 1 time in a day
Hobbies - reading,net surfing,eating
Bad habbits - no bad habbits

PAST MEDICAL HISTORY:-

The client have past medical history of fever since 2 days.
PAST SURGICAL HISTORY:-
The client doesn’t have any past surgical history.
PRESENT MEDICAL HISTORY:-
The client was admitted in the hospital with
complaints of fever since 2 days after the investigations.he was
diagnosed with UTI.

PRESENT SURGICAL HISTORY:-

The client doesn’t have any present surgical history.

PHYSICAL EXAMINATION
IDENTIFICATION DATA
NAME OF THE PATIENT :- Shyam shankar
AGE :- 40 years
GENDER :- male
DIAGNOSIS :- URINARY TRACT INFECTION (UT I)
VITAL SIGN
TEMP. :-101.1’f
PULSE :-84b/min
RESPIRATION :-24 b/min
BLOOD PRESSURE :-130/80 mmhg
ANTHROPOMETRIC MEASUREMENTS
HEIGHT :- 170CM
WEIGHT :- 60 KG
GENERAL APPEARANCE AND MENTAL STATUS
CONSCIOUS :- Conscious
ATTITUDE :-Calm
BODY BUILT :-average
POSTURE :-erect
GAIT :-co-ordinated
HEAD AND FACE
HEAD :-no lesions,scar,wound
FACE :-patient was anxious
HAIR AND SCALP
COLOUR :-Black
DISTRIBUTION :- disturbed
DANDRUFF :-not present
INFECTION :-no infection present
SKIN
COLOUR :-Black
TEXTURE :- smooth
TEMPRATURE :-warmth
EYE
EYE BROW :-present
EYE LIDS :-present
EYE LASHES :-present
PUPIL :-reactive to light
VISUAL ACTIVITY :-normal 6/6
CONJUNCTIVA :-no infection
EAR
LOCATION :-on either side of the cranium ot approximately eye level
DISCHARGE :-no discharge
HEARING ACTIVITY :-normal
NOSE
NOSTRILS :-clear
NASAL SEPTUM :-normal, no deviation
NASAL POLYPS :-not present
DISCHARGE :-not discharge
MOUTH AND PHARYNX
LIPS :-pink colour
TEETH :-yellowish
TONGUE :-red in colour
PHARYNX :-exudate
NECK
THYROID GLAND :- not enlarged
LYMPH NODES :-Non-palpable, non tender
CHEST
INSPECTION :-normal symmetry
PALPATION :-no abnormal masses found
AUSCULTATION :-deep shallow breathing S1 and S2, heart sound heard
PERCUSSION :-abnormal sounds present
ABDOMEN
INSPECTION :-no scars,leasions
PALPATION :-bowal sound heard
AUSCULTATION :- no presence of fluid distension
PERCUSSION :- not tenderness

NAILS
SHAPE :-elongated
NAIL BED ANGLE :-160’ angle
CAPILLARY REFILLS :- immediate
BACK
CURVATURE :-patient was having normal body curvature.
EXTERMITIES
UPPER EXTERMITIES :-normal range of motion
LOWER EXTERMITIES :-normal range of motion
EXTERNAL GENITALIA
HEMORRHOIDS :-not present
FISSURE :-not present
FISTULA :-not present
IMPRESSION:- The patient Mr. Shyam Shanker,40 years male was admitted in
BHAGWATI HOSPITAL with complaints of fever since 2 days.

INVESTIGATION

 BLOOD TEST :- CBC, KFT ,LFT

 URINE ROUTINE NAD MICROSCOPY
 CHEST X-RAY
 CT KUB
 ECG
 MEDICATION
S.no Drug Dose Route Frequency Action Indication Contraindication Side effect Nurse resposibility
name

1 Inj. monocef 1gm IV BD Antibiotic Treatment of Risk for hypersensivity Nausea,vomiting,rash,loose Administered sensevity
infection stool test and ask for any
allerges.

2 Inj.pantocid 40gm IV BD Proton pump Treatment of Risk for hypersensivity Headache,joint pain,dizziness Administered
inhibitor gastritis medication as per
doctor’s order

3 Tab 325mg IV BD painkiller pain Risk for hypersensivity Nausea ,vomiting Administered
combiflam medication as per
doctor’s order

NURSING CARE PLAN

 ASSESSMENT DIAGNOSIS GOAL PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Acute pain •Reduce the pain in • After 7 days Independent: • Provides • After 7 days
“burning sensation in related to urinary tract of nursing information to aid in of nursing interventions,
urinary tract as urinary tract infection (UTI) intervention • Assess pain, noting determining choice or the patient pain will be
verbalized by the infection. s, the location, intensity (scale effectiveness of relieved or controlled.
patient. patient pain of 0 – 10), duration. interventions.
will be
relieved or •Encourage increased • Increased hydration
Objective: controlled. fluid intake. flushes bacteria and
•Facial grimace. toxins.
• Restlessness. • Investigate report
of bladder fullness. • Urinary retention may
• V/S taken as develop, causing tissue
follows: •Observe for changes in distention and
T: 37.3 mental status, behavior potentiates risk for
P: 82 or level of further infection.
R: 19 consciousness.
BP: 120/90 •Accumulation of
•Provide comfort uremic waste and
measure like back rub, electrolyte imbalances
helping patient assume may be toxic to the
position of comfort. CNS.
Suggest use of
relaxation technique •Promotes relaxation,
and deep breathing refocuses attention, and
exercises. may enhance coping
abilities.
• Encourage use of sitz
baths, warm soaks to • Promotes muscle
the perineum. relaxation.
• Reduces bacteria
present in urinary tract
Collaborative: and those introduced by
•Administer drainage system
antibacterial as
prescribed.
HEALTH EDUCATION
 Drink plenty of water to flush out bacteria.
 Don’t hold your urine.
 Urinate when you feel like you need to.
 Wipe from front to back after bowel movements.
 Urinate before and after sex emptying the bladder
completely each time to help wash away bacteria.
 If you get urinary infections often, you may want to avoid
using a diaphragm and or spermicides.
 Ask your health provider about other birth control
options.
 Regular cheak-up.
 Change life style.
 CONCLUSION

The patient mr. Shyam Shankar of 40

years old male was very co-operative. I got all
informations regarding this disease and I also taught the
patient about its diagnosis treatment and all
medications.
His condition is now improving.
 BIBLIOGRAPHY
 Bookname……………………………………………
…page no………….to………….
 https://pubmed.ncbi.nlm.nih.gov/11930
851/
 https://www.mayoclinic.org/diseases-

conditions/urinary-tract-
infection/symptoms-causes