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.