PROBLEM LIST

Name: D, C. Chief Complaint: Abdominal pain

Age: 48 years old Diagnosis: Complicated UTI, AKI 2° t/c Endometriosis

CUES PROBLEM RANK PHYSIOLOGIC BEHAVIORAL

ACTUAL POTENTIAL ACTUAL POTENTIAL

SUBJECTIVE: Hypertension 1 Excess fluid volume Risk for decreased Anxiety related to Risk for infective
related to excessive cardiac output change in health status coping as evidence
"Sauna bago ko na dala hospital sodium intake as related to increase as evidence by by maturational crisis
pala kaon ko baboy og tambok evidenced by altered preload awareness of
namian pod ko mag kaon mga blood pressure physiological symptoms
parat na pagkaon"
"Panalagsa gasakit akung tahi, Pain 2 Acute pain related to Risk of infection Disturbed sleep pattern Risk for
medyo kalihok nku pero mawad- operative procedure injury related to disruption related to acute pain as powerlessness
an ko gyapon pwersa kung mag as evidence by pain scale of skin, tissue and evidence by discomfort related to lack of
tindog2 og lakat2" as verbalized of 6 out of 10 muscle integrity when sleeping sleep
by the patient.
Body 3 Impaired physical mobility Risk for activity Impaired comfort related Risk for sleep
OBJECTIVE: weakness related to decrease intolerance related to to lack of situational as deprivation related to
muscle strength as immobility evidence by discomfort
-Pain scale: 6 out of 10 evidence by the restlessness
verbalization of the patient
Vital Signs:
Temp: 36.8°C
BP: 150/2100 mmHg
RR: 25 cpm
PR: 106 bpm

NURSING CARE PLAN

Name: D, C. Diagnosis: Complicated UTI, AKI 2° t/c
Endometriosis

Age: 48 years old Ward: Private Room 2

Chief Complaint: Abdominal pain

General Objective: To facilitate the maintenance of fluid and electrolyte balance.

ASSESSMENT NURSING PATHOPHYSIOLOGY EXPECTED NURSING RATIONALE EVALUATION

DIAGNOSIS OUTCOME INTERVENTION
SUBJECTIVE: Excess fluid Reduced glomerular Within 24 hours of INDEPENDENT: After 24 hours of
volume related to filtration clinical duty, the clinical duty, the
"Sauna bago ko na excessive sodium patient will be able 1. Monitor blood To note any changes goal was partially
dala hospital pala intake as to: pressure level and progress of met.
kaon ko baboy og evidenced by regularly. patient's condition
tambok namian pod altered blood Decreased cardiac • Display As evidenced by:
ko mag kaon mga pressure output hemodynamic 2. Recommend To enhance safety
parat na pagkaon" stability specifically changing position and reduce
"Panalagsa gasakit in blood pressure: from supine to gravitational blood 1. Decreased blood
akung tahi, medyo standing slowly, pooling in the lower pressure (from
Increased antidiuretic As evidenced by:
kalihok nku pero avoiding standing extremities. 150/100 mmHg to
hormone production
mawad-an ko motionless or for long 130/80 mmHg).
gyapon pwersa, 1. Decreased blood periods of time, or
kinanglan pa nako pressure from sitting with legs
og alalay para maka 150/100 to 130/80 crossed.
Sodium/water retention
tindog og kalakat” mmHg.
as verbalized by the 3. Note client report It may indicate the
patient. • Demonstrate an of dizziness or blood pressure if
increase in activity fainting, blurred fluctuating
tolerance. vision, nausea, downward.
OBJECTIVE: Excess fluid volume shortness of breath
and thirst.
-pain scale: 6 out of
10 To reduce tissue
4. Promote early pressure and risk for
Vital Signs: ambulation. skin breakdown.
Temp: 36.8°C
BP: 150/100 mmHg
RR: 25 cpm
PR: 106 bpm DEPENDENT:
To lower blood
LAB: 1. Administered pressure by relaxing
RBS: 172 mg/dL Amlodipine 10 the blood vessels so
Sodium: 151 mEq/L mg/tab, 1 tab once a the heart does not
day as ordered. have to pump so
CBC hard.
Hemoglobin:
3.6 x10¹²/L 2. Administered To decrease both
Hematocrit: 0.29 L/L Losartan 100 mg/tab, arteriolar and venous
Platelet Count: 1 tab once a day as resistance by
115 x10⁹/L ordered. inhibiting
WBC: 14 x10⁹/L vasoconstrictive and
aldosterone-
Differential count secreting action of
Lymphocytes: angiotensin II.
13%
To treat bacterial
3. Administered infections
Piperacillin +
Tazobactam 4.5g IV
Q6 as ordered.

To provide a broad
4. Administered defense against the
Metronidazole 500mg bacteria that caused
IVTT Q8 as ordered. the infection.
To relieve pain
5. Administered
Celecoxib 200mg 1
tab BID x 7 days as
ordered.
 COLLABORATIVE:
For monitoring blood
1. Emphasize to the pressure and
patient and family disease/condition
member the trends and to provide
importance of regular for early intervention
and long term to reduce risk of
medical follow-up complications.
appointments,
To provide the
2. Encourage the patient with a
client's significant support group.
other(s) to help the
patient to cooperate
with interventions.

Reference:
Nurse’s Pocket Guide, Sixteenth Edition. F.A. Davis

LABORATORY RESULTS
Name: D, C. Chief Complaint: Abdominal pain
Age: 48 years old Diagnosis: Complicated UTI, AKI 2° t/c
Endometriosis

LABORATORY TEST NORMAL VALUE RESULT IMPLICATION NURSING CONSIDERATION

CHEMISTRY TEST

Random Blood Sugar 40-130 mg/dL 172 May indicate hyperglycemia Monitor for any signs of hypoglycemia such as
dizziness, shakiness, sweating, headache, pallor,
confusion, seizures, and mental status changes.
Encourage patient to exercise regularly and have
a healthy diet.

Sodium 135-148 mEq/L 151 May indicate hypernatremia Instruct the patient to restrict sodium intake. Avoid
eating foods that contains high salt such as
canned food and processed food. Educate patient
and family about sign and symptoms of high
sodium level and proper foods to eat.

CBC

Red Blood Cells Male: 4.5-5.5 x10¹²/L 3.6 May indicate anemia May indicate anemia.
Female: 4.0-5.2 x10¹²/L Instruct the patient to consume foods that is rich in
protein and iron. Encourage patient to exercise
regularly.

Hemoglobin Male: 130-180 g/L 103 May indicate low levels of oxygen
Female: 120-160 g/L

Hematocrit Male: 0.40-0.54 L/L 0.29 May indicate anemia Encourage the patient to eat foods high in protein
Female: 0.37-0.47 L/L and iron such as liver, egg yolk and dried fruits.

Platelet 150-400 x10⁹/L 115 May indicate anemia. Encourage the patient to increase the
consumption of vitamin C since it can help her
existing platelet function better. Instruct to add
fresh oranges in her diet
 Monitor patient's vital signs. Educate patient to
White Blood Cells 4.5-11 x10⁹/L 14 May indicate infection.
avoid foods rich in sugar, fat and salt.
Differential count
Instruct the patient to add foods rich with vitamin in
May indicate adaptive immune
Lymphocytes 25-35% 13 her diet. Encourage the patient to have an adequate
response of body to infection.
rest.

DRUG STUDY
Name: D,C.
Age: 48 years old
Diagnosis: Complicated UTI, AKI 2° t/c Endometriosis

Name of Drug Classification Mechanism of Indication Adverse Effects Nursing Consideration Patient Teaching
Action

Generic: Therapeutic Inhibits calcium ion Hypertension CNS: headache, somnolence, Monitor BP frequently Caution patient to
Amlodipine class: influx across fatigue, dizziness. during initiation of report all adverse
besylate cardiac and therapy. reactions and to
Antihypertensive smooth-muscle CV: edema, flushing, palpitations continue taking drug,
cells, dilates Notify prescriber if even when feeling
Dosage: Pharmacologic coronary arteries GI: nausea, abdominal pain signs of HF occur, such better.
class: and arterioles, and as swelling of hands
10 mg decreases BP and Respiratory: pulmonary edema, and feet or shortness of
Calcium channel myocardial oxygen dyspnea breath
blockers demand.
Route of Skin: pruritus, rash
Administration:

Per Orem

Frequency:

Once a day

Timing:

8 am
Name of Drug Classification Mechanism of Indication Adverse Effects Nursing Consideration Patient Teaching
Action

Generic: Therapeutic Inhibits Hypertension Patients with hypertension or left Obtain BP, apical Advise the patient to
class: vasoconstrictive ventricular hypertrophy pulse, immediately immediately report
Losartan Antihypertensive and aldosterone- before each dose in swelling of face,
potassium secreting action of CNS: dizziness, asthenia, fatigue, addition to regular eyes, lips or tongue
head- ache, insomnia. CV: edema,
angiotensin II by monitoring. or any breathing
chest pain. EENT: nasal congestion,
blocking sinusitis, pharyngitis, sinus disorder.
difficulty.
Dosage: Pharmacologic angiotensin II Monitor patient’s BP
GI: abdominal pain, nausea,
class: receptors on the diarrhea, dyspepsia. closely to evaluate Instruct the patient
100mg surface of vascular Musculoskeletal: muscle cramps, effectiveness of to comply with the
Ace inhibitor smooth muscle myalgia, back or leg pain. therapy. dosage schedule.
tissue and other Respiratory: cough, upper respiratory
Route of tissue cells. infection. Other: angioedema. Maintain hydration
Administration: (offer fluids frequently).
Patients with nephropathy CNS:
Per Orem asthenia, fatigue, fever,
hypoesthesia. CV: chest pain,
hypotension, orthostatic hypotension.

Frequency: EENT: sinusitis, cataract. GI:

diarrhea, dyspepsia, gastritis. GU:
UTI Hematologic: anemia. Metabolic:
Once a day
hyperkalemia, hypoglycemia, weight
gain. Musculoskeletal: back pain, leg
or knee pain, muscle weakness.
Timing: Respiratory: cough, bronchitis. Skin:
cellulitis. Other: flu like syndrome,
8 am diabetic vascular disease,
angioedema, infection, trauma,
diabetic neuropathy.
Name of Drug Classification Mechanism of Indication Adverse Effects Nursing Patient Teaching
Action Consideration

Generic: Therapeutic Direct-acting Bacterial CNS: headache, seizures, fever, vertigo, ataxia, Monitor LFT Tell patient to avoid
class: trichomonacide and infections dizziness, syncope, incoordination, confusion, results in alcohol and alcohol
Metronidazole amebicide that caused by irritability, depression, weakness, insomnia, older adults containing drugs
Antiprotozoal works inside and anaerobic encephalopathy, peripheral neuropathy. and patient during and for at
outside the microorganism with hepatic least 3 days after
Dosage: Pharmacologic intestines. It's CV: prolonged QT interval, flattened T wave,
edema, flushing, thrombophlebitis after IV
impairment. treatment course.
class: thought to enter the infusion. EENT: rhinitis, sinusitis, pharyngitis.
500mg cells of Observe Tell patient that a
Nitroimidazoles microorganisms that Gl: nausea, abdominal pain, stomatitis, epigastric patient for metallic taste and
contain nitro distress, vomiting, anorexia, diarrhea, edema dark or brown-red
Route of reductase, forming constipation, proctitis, dry mouth, metallic taste. urine may occur.
Administration: unstable Record
compounds that GU: vaginitis, darkened urine, polyuria, dysuria, number and Advise patient to
IVTT bind to DNA and cystitis, dyspareunia, dryness of vagina and character of report all adverse
inhibit synthesis, vulva, vaginal candidiasis, genital pruritus, UTI, stools reactions
dysmenorrhea, decreased libido. immediately,
causing cell death.
especially neurologic
Frequency: Hematologic: transient leukopenia, neutropenia.
symptoms (seizures,
Q8 hours peripheral
Musculoskeletal: transient joint pains.
neurophaty).
Respiratory: URI.

Skin: rash.
Timing:
Other: decreased libido; over growth of non-
8am-4pm-12am susceptible organisms, candidiasis; flulike
symptoms.
Name of Drug Classification Mechanism of Indication Adverse Effects Nursing Consideration Patient Teaching
Action

Generic: Therapeutic Thought to inhibit Acute pain CNS: headache, dizziness, Watch for signs and Tell patient to
class: prostaglandin insomnia symptoms of overt and promptly report signs
Celecoxib synthesis, impeding rash of GI bleeding such
NSAIDs cyclooxygenase-2, CV: HTN, peripheral edema as blood in vomit,
to produce anti- Watch for and urine, or stool: black,
Dosage: Pharmacologic inflammatory, EENT: pharyngitis, rhinitis, immediately evaluate tarry stools
class: analgesic, and sinusitis signs and symptoms of
200mg/1tab antipyretic effects. heart attack or stroke Advise patient to
Cyclooxygenase- GI: abdominal pain, diarrhea, immediately report
2 inhibitors dyspepsia, flatulence, GI reflux, Assess patient for CV rash, unexplained
Route of nausea risk factors before weight gain, or
Administration: therapy swelling.
Musculoskeletal: back pain
Per Orem Drug may be Instruct patient to
Respiratory: dyspnea, URI hapatoxic; watch for take drug with food if
signs and symptoms of stomach upset
Skin: erythema malformed, liver toxicity occurs
Frequency: exfoliative dermatitis, SJS, toxic
epidermal necrolysis, rash
BID
Other: accidental injury

Timing:

8am-12pm
 Name of Drug Classification Mechanism of Indication Adverse Effects Nursing Consideration Patient Teaching
Action

Generic: Therapeutic Inhibits cell-wall Peritonitis CNS: headache, insomnia, fever, Drug may cause CDAD Tell patient to report
class: synthesis during seizures, agitation, anxiety, ranging in severity from allergic and other
Piperacilin bacterial dizziness, pain mild to fatal colitis. adverse reactions
sodium + Antibiotics multiplication Monitor patient for promptly
Tazobactan CV: chest pain, edema, HTN, diarrhea and initiate
sodium Pharmacologic tachycardia therapeutic measure as Tell patient to report
class: needed. discomfort at the IV
EENT: rhinitis, oral candidiasis site
Dosage: Extended- Serious skin reactions
spectrum GI: diarrhea, constipation, nausea, can occur, if rash
4.5 g penicilins-beta- abdominal pain, dyspepsia, stool develops, monitor
lactimase changes, vomiting patient closely and
inhibitors discontinue if lesion
Route of GU: candidiasis, interstitial progresses.
Administration: nephritis
Monitor hematologic
IV Hematologic: leukopenia, and coagulation
neutropenia, thrombocytopenia, parameters
Frequency: anemia, eosinophilia

Q6 hours Skin: pruritus, rash

Other: hypersensitivity reactions,

Timing: inflammation, phlebitis at IV site.
8am-2pm-8pm

References: Nursing 2023 drug handbook (43rd ed.). Wolters Kluwer. Philippine Edition.
 DISCHARGE PLAN

Problem Health Teaching Rationale

HYGIENE Recurrence of PROMOTIVE

increased blood
1. Proper Handwashing 1. Instruct the patient to exercise regularly. 1. To maintain normal body weight.
pressure
2. Maintain good oral hygiene
3. Wear light and comfortable 2. Instruct patient to practice proper 2. To deter the spread of
clothes personal hygiene. microorganism.

ACTIVITY
1. Light to moderate exercises PREVENTIVE
such as walking 1. Instruct patient to avoid wearing tight 1. To allow the skin to breath and
2. Breathing exercises clothes. avoid hampering of blood
circulation.
DIET 2. Instruct patient to avoid eating foods that
is rich salt. 2. To lessen sodium intake in the
1. Include fresh green leafy 3. Instruct the patient to avoid consuming body.
vegetables in the diet saturated fats, fatty foods and fried
2. Eat foods rich in iron foods. 3. To decrease the level of cholesterol
3. Avoid salty foods such as in the blood.
dried fish and canned foods
4. Take fruits rich in vitamin C
such as oranges at least once CURATIVE
a day. 1. Take going home meds as ordered:
INSTRUCTION a. Amlodipine 10 mg/tab, 1 tab once
1. Comeback 1 week after a day
b. Losartan 100 mg/tab, 1 tab once a. Amlodipine as Antihypertensive
discharge for follow up check-
up a day drug.
2. Take going home meds as c. Celecoxib 200mg 1 tab BID x 7
b. Losartan as Antihypertensive drug.
days
c. Celecoxib as NSAIDs
prescribed.

REHABILITATIVE
1. Instruct to come back for follow-up
check-up 1 week after discharge.
2. Instruct S/O to visit the nearest health 1. To check on the progress of the
center to check the patient’s blood patient’s condition.
pressure.
2. To maintain normal blood pressure.