NAME: Maris, Jessa A. CLINICAL INSTRUCTOR: Sir Andrew Steven Narona ASSESSMENT Subjective: “Ang sakit ng lower back ko sa kaliwang parte, pumipintig yung sakit” as stated by the patient Pain level: 6/10 Objective: (+) guarding behavior (+) facial grimace (+) changes in vital signs - BP: 130/90 - HR: 111 bpm - RR: 22 bpm (+) Urinalysis - several G+ and Gbacilli - occasional G+ cocci clusters with 40-50 pus cells/HPF DIAGNOSIS Acute pain related to inflammation of urinary tract as evidenced by pain level of 6/10, and guarding behavior. M ANALYSIS Acute pain is an unpleasant sensory and emotional experience which may be sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months. In patients with UTI, the bacteria that entered your urinary tract through the urethra can multiply and travel to the kidneys. This causes intense back pain since kidneys are normally located between the transverse processes of T12-L3 vertebrae. References: Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2012). Nurse’s Pocket Guide [E-book]. F. A. Davis Company. Chalouhy, C. E., MD. (2021, June 9). Kidney Anatomy: DATE: May 03, 2022 M SCORE: M PLANNING Short term: Within 6 hours of nursing intervention, ● Patient will report decreased and controlled pain by rating pain less than 3 on 1-10 scale. Long term: Within 3 days of nursing intervention, ● Patient will report absence of pain by hospital discharge IMPLEMENTATION RATIONALE EVALUATION 1. Apply a heating pad to the patient’s lower back (Independent) 1. Heat applied to the lower back might help reduce pain and spasms (GOAL MET) Heating pad was applied to the patient’s lower back Ice Packs vs. Warm Compresses For Pain. (2021, August 8). Johns Hopkins Medicine. https://www.hopkinsmedicine.org/he alth/treatment-tests-and-therapies/ice -packs-vs-warm-compresses-for-pain 2. Encourage the patient 2. To completely empty to urinate on a regular the bladder and avoid basis and when the urge bladder distention is felt. (Independent) C. Rn, A. B. (2022, March 5). (GOAL MET) Patient was encouraged to urinate on a regular basis. Told s/o to remind the pt to void. Pyelonephritis Nursing Diagnosis and Nursing Care Plans. NurseStudy.Net. https://nursestudy.net/pyelonephritisnursing-diagnosis 3. Encourage and recommend to use relaxation techniques such as guided imagery, watching TV, soft music (Independent) 3. These activities help shift away from the focus of the patient from the pain and into something else. Nazario, B. (2007, February 1). Stress Relaxation and Natural Pain Relief. WebMD. https://www.webmd.com/pain-manag ement/guide/stress-relief-for-pain (GOAL MET) Relaxation techniques were encouraged and recommended to the patient. Overview, Gross Anatomy, Microscopic Anatomy. MedScape. https://emedicine.medscap e.com/article/1948775 4. Provide or promote a quiet environment, calm activities (Independent) 4. To make the patient feel relaxed Maintaining a Quiet, Healing Environment - Hospital Stay - Patients & Families - Strong Memorial Hospital - University of Rochester Medical Center. (n.d.). UR Medicine. https://www.urmc.rochester.edu/stron g-memorial/patients-families/hospitalstay/healing-environment.aspx (GOAL MET) Dimmed the light and offered quiet, restful activities like reading or watching movies 5. To relieve moderate to 5. Administer medication (GOAL MET) Administered moderately severe pain Celecoxib as indicated as ordered by the Celecoxib Oral: Uses, Side Effects, physician: Celecoxib 400 Interactions, Pictures, Warnings & mg/capsule once a day Dosing - WebMD. (n.d.). WebMD. https://www.webmd.com/drugs/2/dru (Dependent) g-16851-2379/celecoxib-oral/celecoxib -solution-oral/details 6. Reassess patient’s perception of pain and vital signs (Independent) 6. To determine if pharmacological and non pharmacological management is effective Wells N, Pasero C, McCaffery M. (2008, Apr). Improving the Quality of Care Through Pain Assessment and Management. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US) https://www.ncbi.nlm.nih.gov/books/ NBK2658/ (GOAL MET) Patient reported acceptable level of pain of 2/10 and normal vital sign: - BP: 110/70 - HR: 89 bpm - RR: 18 bpm 7. Repeat urine culture (Collaborative) 7. To monitor for pyuria, (GOAL MET) Specimen was bacteria, and blood cells collected and brought to in the urine that is the laboratory. associated with the inflammation process during an infection and to evaluate effectivity of antibiotic treatment. Vera, M. B. (2022, April 13). 4 Urinary Tract Infection Nursing Care Plans. Nurseslabs. https://nurseslabs.com/urinary-tract-i nfection-nursing-care-plans/ 8. Monitor intake and output, and characteristic of urine (Independent) 8. To monitor signs of urinary continence. Urinary incontinence is usually associated with back pain Welk, B., & Baverstock, R. (2020). Is there a link between back pain and urinary symptoms? Neurourology and Urodynamics, 39(2), 523–532. https://doi.org/10.1002/nau.24269 (GOAL MET) Intake and output, characteristic of the urine were monitored every 2 hours.
