I. INTRODUCTION Urinary tract infections are caused by microorganisms in the urinary tract.

UTIs are generally classified as infection involving the upper or lower urinary tract. Lower UTIs includes bacterial cystitis, bacterial prostatitis and bacterial urethritis. Upper UTIs are much less common and include acute or chronic pyelonephritis, interstitial nephritis and renal abscess. Symptoms include frequent feeling and/or need to urinate, pain during urination, and cloudy urine. The main causal agent is Escherichia coli. Gastritis is the inflammation of the gastric or stomach mucosa, a common GI problem. Gastritis may be acute, lasting several hours to a few days, or chronic, resulting from repeated exposure to irritating agents or recurring episodes of acute gastritis. Acute gastritis is often caused by dietary indiscretion a person eats food that is irritating, too highly seasoned or contaminated with disease-causing microorganisms. Other causes of acute gastritis include overuse of aspirin and other nonsteriodal anti-inflammatory drugs (NSAIDs), excessive alcohol intake, bile reflux and radiation therapy. Acute gastritis also may develop in acute illness, especially if the patient has had major injuries; burns; severe infections; hepatic, renal or respiratory failure; or major surgery. Other symptoms are indigestion, abdominal bloating, nausea and vomiting and pernicious anemia. Some may have a feeling of fullness or burning in the upper abdomen. Acute bronchitis is an inflammation of the large bronchi (medium-size airways) in the lungs. Characteristic symptoms include cough, sputum (phlegm) production, and shortness of breath and wheezing related to the obstruction of the inflamed airways. Jenol Rivera Braceros, 19 years of age was admitted to Corpuz Clinic and Hospital with a chief complaints of fever, epigastric pain, left flunk pain, headache and cough. He was given IVF of PLRS 1L, ranitidine 500mg 1cap, lansoprazole 30mg 1tab OD, acetlycysteine 100mg 1tab OD, ciprofloxacin 500mg 1tab BID, tramadol 50mg 1tab and paracetamol 500mg 1tab q4. Urinalysis and complete blood count was done to him. He was discharged June 22, 2011 with the diagnosis of Urinary Tract Infection, Acute Gastritis and Acute Bronchitis. OBJECTIVES: 1) To accomplish assessment to gather pertinent data about the client as deemed relevant to the case. 2) To name the major health problem of the client. 3) To define the technical terms found in the course of the study to facilitate better understanding. 4) To present the anatomy and physiology involved in the study. 5) To discuss the pathophysiology of the clients pathological condition. 6) To present laboratory values conducted therein. 7) To present other ideas laboratory studies and their implication to support the diagnosis of the diseases. 8) To determine the appropriate nursing diagnosis for the clients diseases. 9) To create a plan of care appropriate for the clients condition. 10) To commit to effectively execute or implement nursing care plan for the client, including all nursing intervention suited. 11) To evaluate the efficiency of the nursing care provide according to the nursing care plan.

II.

BP: 110/80 mmHg Temp.: 36.4 C PR: 66 bpm RR: 20 cpm

PATIENTS PROFILE Name: Jenol Rivera Braceros Age: 19 y/o Ward: Sto. Nio 2 Sex: Male Address: Baracbac, Sinait, Ilocos Sur Birthday: November 14, 1991 Civil Status: Single Religion: Roman Catholic Nationality: Filipino Date of Admission: June 19, 2011 Chief Complaint: fever, epigastric pain, left flunk pain, headache and cough Diagnosis: T/C Urinary Tract Infection, Acute Gastritis, Acute Bronchitis Admitting Physician: Dr. Marrin V. Corpuz Hospital: Corpuz Clinic and Hospital Baseline Data:

III. NURSING HISTORY A. PAST Jenol Rivera Braceros, 19 years of age, was born on November 14, 1991. He lives in Baracbac, Sinait, Ilocos Sur with his father Mamerto, mother Vilma, brother Jay-vee and sister Jean Adrianne. Currently, he is a 4th year student of University of Northern Philippines, College of Technology taking Industrial Technology. He was born at home via normal spontaneous delivery and received complete immunization when he was a child as told by her mother. His common sickness may include fever, cough and colds and take precaution by taking overthe-counter drugs. He had no food and drug allergies. He has good appetite and fun of eating sweet, salty, spicy and junk foods. He also fun of drinking soft drinks and occasionally drinks alcohol. He has good elimination pattern; once or twice defecation and urinates with no burning sensation but he also experiences night urination. He has no difficulty of breathing. He sometimes works as a construction worker. He had no previous hospitalization. B. PRESENT Jenol got hospitalized at Corpuz Clinic and Hospital, June 19, 2011, with the chief complaints of fever, epigastric pain, left flunk pain, headache and cough. He had an on and off fever for two consecutive days and take paracetamol for relief. He had also 3 days body weakness due to his work as a construction worker. Upon admission, he was given PLRS 1L and medications Ranitidine 500 mg 1 cap, Lansoprazole 30 mg 1 tab OD, Acetylcysteine 100 mg 1 tab OD, Ciprofloxacin 500 mg 1 tab BID, Tramadol 50 mg 1 tab TID and Paracetamol 500 mg 1 tab q4. Diagnostic examination was done to him such as urinalysis, complete blood count and ultrasound. Theres no surgical intervention done to him. His attending physician was Dr. Marrin V. Corpuz. He was discharged June 22, 2011 with the diagnosis of Urinary Tract Infection, Acute Gastritis and Acute Bronchitis.

IV.

PEARSON June 21, 2011 June 22, 2011

PSYCHOSOCIAL

19 years of age, 2 child

nd

Born on November 14, 1991 Lives in Baracbac, Sinait,

Ilocos Sur with his parents Mr. Mamerto and Mrs. Vilma Braceros, his brother Jayvee and sister Jean Adrianne. Identity vs Role Confusion - Ego quality: Fidelity - Concerned he they appear to others. - Ability to settle in school or occupational ability. - Development of sense of sexual identity and ponder the roles on how he will play in the adult world. - Experiences some role confusion mixed ideas and feelings about specific ways in which he will fit to society. Tries to be socially and verbally responsive to the student nurse while the student nurse asks some questions. ELIMINATION

among his 2 other siblings

Psychological Development:
Identity vs Role Confusion - Ego quality: Fidelity - Concerned he they appear to others. - Ability to settle in school or occupational ability. - Development of sense of sexual identity and ponder the roles on how he will play in the adult world. - Experiences some role confusion mixed ideas and feelings about specific ways in which he will fit to society.

Psychological Development:

Tries to be socially and

verbally responsive to the student nurse while the student nurse asks some questions.

Mayat met ti panagisbok,

Nasyaat met pay ti

awan met ti nasakit nu kasjay. Ngem managisbo nak met ti rabii as verbalized by the patient. panagtakkik as verbalized by the patient. within the shift with moderate in amount and whitish-yellowish in color. within the shift with solid

Ok latta met ti panagisbok

ken pati panagtakkik as verbalized by the patient. rabii added by the patient.

Namitlo nak sa im-misbo ti Patient urinates twice with Patient defecates once with No diaphoresis noted. No episodes of vomiting
moderate in amount and whitish in color.

Patient urinates 7 times

Patient defecates twice

solid formed stool, brownish in color.

 No diaphoresis noted. No episodes of vomiting

noted. noted.

formed stool, brownish in color.

noted.

No eye and nasal discharges No IFC attach.

noted.

No eye and nasal discharges No IFC attach. Lie on bed on semi-fowlers With full range of motion Sleeps 6-8 hours at night
and can move without assistance.

ACTIVITY/REST

position; turns from side to side.

Lie on bed on semi-fowlers With full range of motion Sleeps 6-8 hours at night
and can move without assistance.

position; turns from side to side.

continuously; wake ups only when there is a need to urinate for about 20-30 minutes safety room

continuously; wake ups only when there is a need to urinate.

Takes a nap at afternoon

SAFETY

On quiet and conducive for Secure on bed With pillows on head when No known allergies with
foods and drugs sleeping

On quiet and conducive for

safety room

Secure on bed With pillows on head when No known allergies with

foods and drugs sleeping

With good skin turgor noted With good skin turgor noted No lesions, bruises or scars No lesions, bruises or scars
noted noted

No edema noted With good capillary refill Medications given:

noted

No edema noted With good capillary refill With dizzy feeling Medications given:
noted

Ranitidine 500 mg 1 cap Lansoprazole 30 mg 1 tab OD Acetylcysteine 100 mg 1 tab OD Ciprofloxacin 500 mg 1 tab BID Tramadol 50 mg 1 tab TID Paracetamol 500 mg 1 tab q4 With an IVF of PLRS 1L

Ranitidine 500 mg 1 cap Lansoprazole 30 mg 1 tab OD Acetylcysteine 100 mg 1 tab OD Ciprofloxacin 500 mg 1 tab BID Tramadol 50 mg 1 tab TID Paracetamol 500 mg 1 tab q4

 Vital signs:
OXYGENATION

BP: 110/80 mmHg Temp.: 36.3C PR: 70 bpm RR: 21 cpm

Vital signs:

No O2 attach With fan inside the room Breaths in nose; no use of With non-productive cough No difficulty of breathing
noted noted accessory muscles

RR: 20 cpm No O2 attach With fan inside the room Breaths in nose; no use of No cough noted No difficulty of breathing No wheezes, crackles or
noted accessory muscles

BP: 100/80 mmHg Temp.: 36.6C PR: 68 bpm

With wheezes noted upon

auscultation at the right back area upon auscultation at the right back area good skin turgor

rales noted upon auscultation at the right back area good skin turgor

No crackles or rales noted With good capillary refill, With diaphoresis noted RR: 21 cpm With an IVF of PLRS 1L With good appetite noted Medications given:

With good capillary refill, RR: 20 cpm

NUTRITION

Increase oral fluid intake

Ranitidine 500 mg 1 cap Lansoprazole 30 mg 1 tab OD Acetylcysteine 100 mg 1 tab OD Ciprofloxacin 500 mg 1 tab BID Tramadol 50 mg 1 tab TID Paracetamol 500 mg 1 tab q4C

No IVF or heplock hooked With good appetite noted Medications given:

Increase oral fluid intake

Ranitidine 500 mg 1 cap Lansoprazole 30 mg 1 tab OD Acetylcysteine 100 mg 1 tab OD Ciprofloxacin 500 mg 1 tab BID Tramadol 50 mg 1 tab TID Paracetamol 500 mg 1 tab q4C

V. DIAGNOSTIC EXAMINATION A. IDEAL URINARY TRACT INFECTION Urine Culture To identify the specific organism present. A colony count of at least 105 colon-forming units (CFU) per millilitre of urine on a clean-catch midstream or catheterized specimen is a major criterion for infection along with antibiotic sensitive to guide antibiotic choice. Multiple-test dipstick Leukocyte esterase test and nitrite test to detect WBC count Urinary microscopy Shows multiple bacilli between white cells (bacteriuria and pyuria). Microscopic hematuria may be present to half of the patient having UTI. Urinalysis Looks for the presence of nitrites, leukocytes or leukocyte esterase. ACUTE GASTRITIS

Endoscopy

To check for stomach lining inflammation and mucous erosion Reveal a thickened, edematous, nonpliable wall with erosions and reddened gastric folds Biopsy Removal of a small piece of living tissue from an organ or part of the body for microscopic examination Blood test Blood cell count To detect presence of H. pylori Pregnancy Liver, kidney, gallbladder or pancreas function Complete blood count To assess for anemia, as acute gastritis can cause gastrointestinal bleeding Stool examination To look for blood in the stool Urinalysis To determine specific bacteria Double-contrast barium radiography Can demonstrate the nematodes that cause anisakidosis Tomography scan and Plain films of the abdomen Can demonstrate thickening of the gastric wall

ACUTE BRONCHITIS Physical examination Reveal decreased intensity of breath sounds, wheezing, rhonchi and prolonged expiration, presence of dry or wet cough Chest x-ray

 Reveals hyperinflation; collapse and consolidation of lung areas would support a diagnosis of pneumonia. Sputum test and culture Shows neutrophil granulocytes (inflammatory white blood cells) and shows pathogenic microorganisms such as Streptococcus species. Blood test Indicates inflammation (as indicated by a raised white blood cell count and elevated C-reactive protein) B. ACTUAL Urinalysis (06-19-11) PHYSICAL EXAMINATION Color Yellow Transparency S. Turbid CHEMICAL EXAMINATION Reaction Acidic Specific 1.005 Gravity Albumin Negative Sugar Negative MICROSCOPIC EXAMINATION WBC 0-2 RBC 1-3 Epithelial cells Few Crystals Few Mucus threads Few Bacteria Few

NURSING RESPONSIBILTY Check doctor's order. Obtain informed consent. Explain procedure to the patient. Instruct the patient to get at the midstream of her urine. Bring specimen to the laboratory immediately. Inform physician immediately as long as result is available.

Complete Blood Count (06-19-11)

PARAMETERS Hemoglobin Hematocrit WBC Neutrophils IMPLICATIO N 158 g/L Normal 0.48 g/L Normal 9 10.7 x10 /L Normal 89.6 % Increase, indicates bacterial infection 7.3 % 25-33 % Decrease, indicates lymphocytope nia 3.1 % 3-7 % Normal 9 9 235 x10 /L 150-350 x10 /L Normal 15.9 mg/dl 8-20 mg/dl Normal 1.5 mg/dl 0.5-1.7 mg/dl Normal RESULT NORMAL VALUES 135-180 g/L 0.40-0.54 g/L 4.5-11 x109/L 54-70 % NURSING RESPONSIBILTY Check doctor's order. Obtain informed consent. Explain procedure to the patient. Prepare the patient for examination. Obtain sterile technique when handling body position. Assist medical technologist in blood extraction. Bring specimen to

Lymphocytes

Monocytes Platelet Blood Urea Nitrogen Creatinine

the laboratory immediately. Inform physician immediately as long as result is available.

Ultrasound (06-20-11)

The right kidney measures 10.8 x 4.1 cm while the left measures 10.6 x 3.8 cm. Parenchymal thickness measures 8.4 mm in the right kidney and 10.3 mm in the left kidney. Parenchymal reflectivity is increase with fairly delineable cortico-medullary junctions. No lithiasis seen. The urinary bladder is distensible with no definite intraluminal echoes see. Its wall is not thickened. Pre-void urine volume measures 610.7 ml. post void seen shows complete vesical emptying. IMPRESSION: Reno-parenchymal change, both kidneys Normal urinary bladder

VI.

ANATOMY AND PHYSIOLOGY Urinary System

1. Human urinary system: 2. Kidney, 3. Renal pelvis, 4. Ureter, 5. Urinary bladder, 6. Urethra. (Left side with frontal section) 7. Adrenal gland

Vessels:

8. Renal artery and vein, 9. Inferior vena cava, 10. Abdominal aorta, 11. Common iliac artery and vein

With transparency:

12. Liver, 13. Large intestine, 14. Pelvis Latin

systema urinarium

Urinary system also called the excretory system the organ system that produces, stores, and eliminates urine. In humans it
includes two kidneys, two ureters, the bladder, the urethra, and two sphincter muscles. Physiology of urinary system

Kidney bean-shaped organs that lie in the abdomen, retroperitoneal to the organs
of digestion, around or just below the ribcage and close to the lumbar spine

Peri-nephric fat, and situated on the superior pole of each kidney is an adrenal gland receive their blood supply of 1.25 L/min (25% of the cardiac output) from the renal arteries which are fed by the abdominal aorta kidneys' main role is to filter water soluble waste products from the blood other attachment of the kidneys are at their functional endpoints the ureters, which lies more medial and runs down to the trigone of urinary bladder number of tasks, such as: concentrating urine, regulating electrolytes, and maintaining acid-base homeostasis excretes and re-absorbs electrolytes (e.g. sodium, potassium and calcium) under the influence of local and systemic hormones. pH balance is regulated by the excretion of bound acids and ammonium ions remove urea, a nitrogenous waste product from the metabolism of amino acidss end point is a hyperosmolar solution carrying waste for storage in the bladder prior to urination Humans produce about 2.9 litres of urine over 24 hours, although this amount may vary according to circumstances. Because the rate of filtration at the kidney is proportional to the glomerular filtration rate, which is in turn related to the blood flow through the kidney, changes in body fluid status can affect kidney function. Hormones exogenous and endogenous to the kidney alter the amount of blood flowing through the glomerulus. Some medications interfere directly or indirectly with urine production. Diuretics achieve this by altering the amount of absorbed or excreted electrolytes or osmalites, which causes a diuresis. Stomach

organ is about the size of a human fist and is surrounded by what is called

Human Stomach

The location of the stomach in the human body.

Diagram from cancer.gov: * 1. Body of stomach * 2. Fundus * 3. Anterior wall * 4. Greater curvature * 5. Lesser curvature * 6. Cardia * 9. Pyloric sphincter * 10. Pyloric antrum * 11. Pyloric canal * 12. Angular notch * 13. Gastric canal * 14. Rugal folds Latin Ventricular Nerve celiac ganglia, vagus Lymph celiac nodes preaortic lymph

Stomach a muscular, hollow, dilated part of the alimentary canal which functions as
an important organ of the digestive tract involved in the second phase of digestion, following mastication (chewing) located between the oesophagus and the small intestine. It secretes protein-digesting enzymes and strong acids to aid in food digestion, (sent to it via oesophageal peristalsis) through smooth muscular contortions (called segmentation) before sending partially digested food (chyme) to the small intestines

Anatomy of the stomach The stomach lies between the oesophagus and the duodenum (the first part of
the small intestine). It is on the left upper part of the abdominal cavity. The top of the stomach lies against the diaphragm. Lying behind the stomach is the pancreas. The greater omentum hangs down from the greater curvature.

 Two sphincters keep the contents of the stomach contained. They are the

esophageal sphincter (found in the cardiac region, not an anatomical sphincter) dividing the tract above, and the Pyloric sphincter dividing the stomach from the small intestine. The stomach is surrounded by parasympathetic (stimulant) and orthosympathetic (inhibitor) plexuses (networks of blood vessels and nerves in the anterior gastric, posterior, superior and inferior, celiac and myenteric), which regulate both the secretions activity and the motor (motion) activity of its muscles. In adult humans, the stomach has a relaxed, near empty volume of about 45 ml. Because it is a distensible organ, it normally expands to hold about 1 litre of food, but can hold as much as 2-3 litres. The stomach of a newborn human baby will only be able to retain about 30ml.

Sections The stomach is divided into 4 sections, each of which has different cells and
functions. The sections are: Cardia Fundus Body Corpus Pylorus or Where the contents of the oesophagus empty into the stomach. Formed by the upper curvature of the organ. The main, central region. The lower section of the organ that facilitates emptying the contents into the small intestine.

Sections of the stomach

Layers Like the other parts of the gastrointestinal tract, the stomach walls are made of
the following layers, from inside to outside: The first main layer. This consists of the epithelium and the lamina propria (composed of loose connective tissue), with a thin layer of smooth muscle called the muscularis mucosae separating it from the submucosa beneath. This layer lies over the mucosa and consists of fibrous connective tissue, separating the mucosa from the next layer. The Meissner's plexus is in this layer. Over the submucosa, the muscularis externa in the stomach differs from that of other GI organs in that it has three layers of smooth muscle

mucosa

submucosa muscularis externa

instead of two.

inner oblique layer: This layer is responsible for creating the motion

that churns and physically breaks down the food. It is the only layer of the three which is not seen in other parts of the digestive system. The antrum has thicker skin cells in its walls and performs more forceful contractions than the fundus. middle circular layer: At this layer, the pylorus is surrounded by a thick circular muscular wall which is normally tonically constricted forming a functional (if not anatomically discrete) pyloric sphincter, which controls the movement of chyme into the duodenum. This layer is concentric to the longitudinal axis of the stomach. outer longitudinal layer: Auerbach's plexus is found between this layer and the middle circular layer.

serosa

This layer is over the muscularis externa, consisting of layers of connective tissue continuous with the peritoneum.

Glands Different types of cells are found at the different layers of these glands:
Layer of stomach Isthmus of gland Body of gland Base of gland Name Mucous neck cells parietal (oxyntic) cells chief (zymogenic) cells Secretion mucus gel layer gastric acid and intrinsic factor pepsinogen Region of stomach Fundic, cardiac, pyloric Fundic only Fundic only Staining Clear Acidophilic Basophilic

hormones gastrin, histamine, enteroendocrin endorphins, Base of gland e (APUD) cells serotonin, cholecystokinin and somatostatin

Fundic, cardiac, pyloric

Bronchus

Bronchus

Conducting passages.

Front view of cartilages of larynx, trachea, and bronchi.

Bronchus (plural bronchi, adjective bronchial)

a passage of airway in the respiratory tract that conducts air into the lungs. The bronchus branches into smaller tubes, which in turn become bronchioles. No gas exchange takes place in this part of the lungs.

Anatomy trachea (windpipe)

divides into two main bronchi (also mainstem bronchi), the left and the right, at the level of the sternal angle at the anatomical point known as the carina

right main bronchus is wider, shorter, and more vertical than the left main
bronchus. The right main bronchus subdivides into three lobar bronchi, while the left main bronchus divides into two

 lobar bronchi divide into tertiary bronchi, also known as segmentalinic bronchi, bronchopulmonary segment is a division of a lung separated from the rest of the
each of which supplies a bronchopulmonary segment

there are ten segments per lung, but due to anatomic development, several

lung by a connective tissue septum. This property allows a bronchopulmonary segment to be surgically removed without affecting other segments segmental bronchi in the left lung fuse, giving rise to eight. The segmental bronchi divide into many primary bronchioles which divide into terminal bronchioles, each of which then gives rise to several respiratory bronchioles, which go on to divide into two to 11 alveolar ducts. is the basic anatomical unit of gas exchange in the lung

here are five or six alveolar sacs associated with each alveolar duct. The alveolus hyaline cartilage present in the bronchi, present as irregular rings in the larger
bronchi (and not as regular as in the trachea), and as small plates and islands in the smaller bronchi. Smooth muscle is present continuously around the bronchi.

mediastinum, at the level of the fourth thoracic vertebra, the trachea divides
into the right and left primary bronchi. The bronchi branch into smaller and smaller passageways until they terminate in tiny air sacs called alveoli.

cartilage and mucous membrane of the primary bronchi are similar to those in the
trachea. As the branching continues through the bronchial tree, the amount of hyaline cartilage in the walls decreases until it is absent in the smallest bronchioles. As the cartilage decreases, the amount of smooth muscle increases. The mucous membrane also undergoes a transition from ciliated pseudostratified columnar epithelium to simple cuboidal epithelium to simple squamous epithelium.

alveolar ducts and alveoli consist primarily of simple squamous epithelium, which

permits rapid diffusion of oxygen and carbon dioxide. Exchange of gases between the air in the lungs and the blood in the capillaries occurs across the walls of the alveolar ducts and alveoli.

VII. PATHOPHYSIOLOGY URINARY TRACT INFECTION

Bacteria Gains access to the bladder Attaches and colonizes the epithelium Avoid host defense mechanism Initiate inflammation Fever Nocturia

Urinary Tract Infection

For infection to occur, bacteria must gain access to bladder, attach to and colonize the epithelium of the urinary tract to avoid being washed out with voiding. Evade host defense mechanism and initiate inflammation thus leading to urinary tract infection. The patient experienced fever for two days and night urination but no difficulty of burning urination. ACUTE GASTRITIS

Predisposing factors: Foods (sweet, spicy, salty and junk foods), Softdrinks Alcohol drinker Smoker (2 sticks a day)

Irritates gastric mucous membrane Gastric mucous membrane becomes edematous and hyperemic (congested with fluid and blood)

Undergoes superficial erosion

Secretes scanty amount of gastric juice Gastric acid contains very little amount of acid but much mucous

Superficial ulceration may occur Left flunk pain Epigastric pain Fever Headache Dizziness Acute gastritis (May also lead to haemorrhage)

Mucosa of the stomach and duodenum is normally protected from the proteolytic actions of gastric acid and pepsin by coating of mucous secreted by glands in the epithelial walls from the lower esophagus to the upper duodenum. The patient is fun of eating sweet, spicy, salty and junk foods. He is also drinks alcohol and softdrinks, and smokes 2 stick per day that is irritants to the gastric mucous membrane. The gastric mucous membrane becomes edematous and hyperemic. There is scanty secretion of gastric juice, containing very little amount of acid and mucous. Siperficial ulceration may occur that causes acute gastritis and may also lead to haemorrhage. The patient experienced left flunk pain and epigastric pain accompanied of fever, headache and dizziness. ACUTE BRONCHITIS

Predisposing Factors: Construction worker Smokes (2 sticks a day)

Irritants are inhaled including certain bacterias or viruses (Mycoplasma, Pneumococcus, Kleibsiella, Haemophilus)

Inner lining of the bronchial tubes become inflame Narrowing of the bronchial tubes Increase resistance

Difficult for air to move to and from the lungs Wheezing Coughing SOB Body attempts to expel secretions Increase production of secretion Secretion clog the bronchial tubes Secretion contains inflammatory cells Acute Bronchitis
The patients sometimes work as a construction worker and smoke 2 sticks a day. Irritants such as dust and smokes are inhaled including certain bacterias and viruses that predispose to inflammation of the inner lining of the bronchial tubes. As the bronchial tubes become inflamed, there is a narrowing of the bronchial tube. Thus increasing resistance and difficult for the air to move to and from the lungs. Patient experiences coughing and wheezing upon auscultation. Shortness of breathing may be also present. Secretions are increasing in production and the body attempts to expel this secretion thru coughing. Secretions may clog in the bronchial tubes and it contains inflammatory cells that cause acute bronchitis.

VIII. MANAGEMENT A. MEDICAL MANAGEMENT

IDEAL
URINARY TRACT INFECTION

Antibiotic therapy

Anti-microbial therapy

Ampicillin, amoxicillin, cotrimoxazole, ciprofloxacin, levofloxacin, phenazopyridine, nitrofurantoin Treatment regimen includes single-dose administration, short-course regimens (3-4 days) and 7-19 days regimens. Trimethoprim, cephalospoerins, nitrofurantoin, fluoroquinolones short or long term therapy Trimethoprim + sulfamethoxazole or fluoroquinolones = 3 days treatment Trimethoprim + nitrofurantoin = 7 days treatment Aminoglycosides (gentamicin) + beta-lactam (ampicillin or ceftriaxone) = 48 hours after fever subsides If there is a poor response to IV antibiotics (marked by persistent fever, worsening renal function), then imaging is indicated to rule out formation of an abscess either within or around the kidney, or the presence of an obstructing lesion such as a kidney stone or tumor. Treatment regimen for 3-4 days of full-dose angent. Third-generation cephalosporin such as ceftriaxone; fluoroquinolone, such as ciprofloxacin; or an aminoglycoside

For those with pernicious anemia, Vit. B12 injections are given. Adequate IV fluids to restore appropriate circulatory volume and
promote adequate urinary flow are also important. ACUTE GASTRITIS Antibiotics - Amoxicillin, tetracycline, metronidazole, clarithromycin, H2 Receptors

Medication:

- Competitive inhibition of histamine at the histamine 2 (H2) receptor - When used alone, they are frequently used as antisecretory drugs in H pylori therapy regimens

- Cimetidine, ranitidine, nizatidine, famotidine Antacids - Neutralize stomach and can provide fast pain relief. Proton pump inhibitor - Reduce acid by blocking the action of small pumps - Also appear to inhibit H. pylori activity - Omeprazole, lansoprazole, rabeprazole, esomeprazole Cryoprotective agents - Help protect the tissues that line the stomach and small intestine - Sucralfate, misoprostol, bismuth subsalicylate

If symptoms persist, intravenous fluids may need to be administered.

 If caused by ingestion of strong acids or alkalis, emergency treatment

If erosion is extensive or severe, emetics and lavage are avoided

because of the danger of perforation and damage to the esophagus. alcohol).

consists of diluting and neutralizing the offending agent. To neutralize acids, common antacids are used; to neutralize an alkali, diluted lemon juice or diluted vinegar is used.

Discontinue the use of drugs known to cause gastritis (eg, NSAIDs, Nasogastric intubation is necessary. Bronchodilator Antibiotic

ACUTE BRONCHITIS

To reduce bronchospasm and to promote sputum expectoration Macrolides Useful in flushing bacteria from the lungs Mucinex, rubitossin Prednisone- enhances the anti-inflammatory effects of the steroids produced within the body by the adrenal glands Quit smoking completely in order to allow their lungs to recover from the layer of tar that builds up over time To mobilize secretions. If indicated To liquefy secretions

Expectorants

Adrenocorticosteroid hormone Smoking cessation

Chest physiotherapy Hydration

ACTUAL The patient was given PLRS 1L, Ranitidine 500 mg 1 cap, Lansoprazole 30 The patient instructed to increase fluid intake, provided complete rest
and comfort. SURGICAL MANAGEMENT mg 1 tab OD, Acetylcysteine 100 mg 1 tab OD, Ciprofloxacin 500 mg 1 tab BID, Tramadol 50 mg 1 tab TID and Paracetamol 500 mg 1 tab q4.

IDEAL
ACUTE GASTRITIS

Gastric resection or gastrojejunostomy

Surgical intervention is not necessary, except in the case of

Anastomosis of the jejunum to stomach to detour around the pylorus to treat pyloric obstruction

ACTUAL The patient had not undergone any surgical treatment.

phlegmonous gastritis. With this entity, surgical intervention with resection of the affected area may be the most effective form of treatment.

B. NURSING CARE PLAN Cues Nursing Diagnosis P> Acute Pain E> Related to infection in stomach lining S> As evidenced by patients pain verbalization at epigastic area w/ pain scale of 7/10, positioning at comfort, diaphoresis Analysis Predisposing factors Nursing Objectives June 21, 2011, 8:00 am Nursing Intervention Independent: Determine and document presence of possible pathophysiologi cal and psychological causes of pain. (inflammation in stomach lining) Assess for referred pain, as appropriate. Rationale Nursing Evaluation June 21, 2011, 9:00 am

Sbuj: Bigla

lattan nga nagsakit toy tiyan koas verbalized by the patient. Obj: Epigastric pain w/ pain scale of 7/10 Patient position self to comfort w/ diaphoresis noted VS: BP: 110/80 mmHg Temp.: 36.3C PR: 70 bpm RR: 21 cpm

Irritation occurs in stomach lining Edmatous and hypermic occurs Superficial ulceration Acute Pain

After 1 hour of
rendering nursing intervention, patients level of pain will decrease from 7/10 to 3/10.

To assess etiology of pain. Goal Met as evidenced by patients level of pain decreases to 4/10 from 7/10.

Obtain
patients assessment of pain, including

To help determine possibility of underlying condition or organ dysfunction requiring treatment. To rule out worsening of underlying condition or

location, characteristics , onset and duration, frequency, quality, intensity and precipitating factors. Use pain scale.

development of complications.

Accept
patients description of pain.

Observe nonverbal cues and pain behaviours.

Monitor skin
color and

To evaluate clients level of pain. Pain is subjective experience and cannot be felt by others. Observations may not be congruent with verbal reports or may be only indicator present when patient is unable to verbalize. Skin color and vital signs are

temperature and vital signs. Note when pain occurs.

Position patient
at comfort.

Subj: Adda

uyek ko ngem awan plemas nga rumwaras verbalized by the patient.

P> Ineffective Airway Clearance E> Related to secretions in the bronchi S> As evidenced by

Irritants enters the bronchi Inflammation occurs

After 4 hours
of rendering nursing intervention,

June 21, 2011, 8:00 am

encourage use of relaxation techniques such as listening music. Encourage adequate rest periods. Dependent: Administer analgesics, as ordered. Independent: Monitor respiration and breath sounds, noting rate and sounds

Instruct in and

usually altered in acute pain. To medicate prophylactically as appropriate. To promote nonpharmacological pain management. To distract attention and reduce tension.

To prevent fatigue.

To maintain acceptable level of pain. Indicative for respiratory Goal Met as distress and evidenced by accumulation of patient has no secretions. wheezes upon June 21, 2011, 12:05 am

 Obj: w/ non-

productive cough w/ wheezes noted upon auscultation RR: 21 cpm

patients verbalization of non-productive cough, wheezes upon auscultation

Narrowing of bronchial tubes Increase secretion Ineffective Airway Clearance

patient will be able to maintain airway patency.

(tachypnea, stridor, rales, crackles, wheezes). Evaluate To determine clients ability to gag/cough protect own reflex and airway. swallowing ability. Position head To open airway. appropriate for age and condition. Elevate head of To take bed and change advantage of position every gravity 2 hours. decreasing pressure on the diaphragm and enhancing drainage of/ventilation to different lung segment. Keep To reduce environment irritants. allergen free. Encourage deep To mobilize

auscultation.

breathing and coughing exercise. Encourage to increase fluid intake.

secretions.

reduction of smoking. Observe for s/symptoms of infection (increased dyspnea, fever, and change in sputum color). Provide opportunities to rest and limit activities to level of respiratory tolerance. Dependent: Give

Support

Hydration can help to liquefy viscous secretions and improve secretion clearance. To improve lung function. To identify infectious process and promote timely intervention.

Prevent fatigue and discomfort.

P> Risk for Ineffective Gastrointestinal Perfusion E> Related to inflammation in stomach lining

Predisposing factors Irritation happens Edema and hypermic stomach lining Superficial ulceration may occur Possible for bleeding

expectorants or bronchodilator as ordered. June 21, 2011, Independent: 8:00 am Note for presence of After rendering condition/s nursing affecting intervention, perfusion. patient will be Identify able to history of verbalize bleeding. understanding about the disease process Investigate reports of and engage in abdominal pain, behaviours and noting location, lifestyle intensity and changes to location. improve Note for circulation. history of smoking or alcohol drinking.

To mobilize secretions.

To identify risk factors.

Goal Met as

To identify risk for potential bleeding problems. To identify risk factors. Smoking can potentiate vasoconstrictio n and alcohol which can cause general inflammation of the stomach musosa and potentiate risk of GI bleeding; or liver involvement and

evidenced by patient verbalizes understanding about measures to decrease risk for GI perfusion.

 Auscultate
abdomen.

Percuss

abdomen for fixed or shifting dullness over regimen that normally contain air. Encourage rest after meals. Dependent: Collaborate in treatment of underlying condition.

esophageal varices. To evaluate peristaltic activity. Can indicate accumulated blood or fluid.

To maximize blood flow to digestive system. To correct or treatment disorders that could affect GI perfusion.

C. PROMOTIVE AND PREVENTIVE URINARY TRACT INFECTION Promotive and Preventive Measures Prolonged course (6 mons.-1 yr.) of low-dose antibiotics is effective in reducing the frequency of UTIs in those with recurrent UTIs. Cranberry juice or capsule) may decrease the incidence of UTI in those with frequent infection. Use of condoms or birth control pills and voiding after sex. The type of under wear used and personal hygiene methods used after voiding or defecating. Nursing Management Relieving pain. Anti-microbial/antibiotic agent Heat application Instruct patient to increase fluid intake. Instruct patient to avoid irritants like coffee, tea, citrus, spices, colas and alcohol. Encourage patient for frequent voiding. Instruct patient for strict hygienic measures. ACUTE GASTRITIS Promotive and Preventive Measures Instructing patient to refrain from alcohol and food until symptoms subside. Non-irritating diet Nursing Management Reducing anxiety. Using calm approach when answering questions of the patient Explaining all procedures and treatments based on the patients level of understanding Promoting optimal nutrition. Patient should not take foods or fluids by mouth possibly for a few days until the symptoms subsides thus allowing gastric mucosa to heal. Intravenous therapy is necessary. After the symptoms subside, introduction of ice chips followed by clear liquids. Monitor fluid intake and output along with the serum. Relieving pain. Discourage intake of caffeinated beverages, alcohol use and smoking. ACUTE BRONCHITIS Promotive and Preventive Measures Ambulation, deep breathing and coughing exercise to mobilize secretions. Adequate fluid intake to liquefy secretions and prevent dehydration caused by fever and tachypnea. Enough sleep and rest.

 Avoidance of bronchial irritants. Good diet to facilitate recovery. Nursing Management Provide adequate fluid intake and nutrition. Provide rest and comfort. Provide quiet and clean environment. Instruct the patient to take the full course of prescribed antibiotics

and explain of effect on meals on drug absorption. Caution patient on using over-the-counter cough suppressants, antihistamines and decongestant, which may cause drying and retention of secretions. However, cough preparations containing the mucolytic guaifenesin may be appropriate. Advise the patient that a dry cough may persist after bronchitis because of irritation airways. Suggest avoiding dry environments and using humidifier at bedside. Encourage smoking cessation. Teach the patient to recognize and immediately report early signs and symptoms of acute bronchitis.

IX. DRUG STUDY Name of Drugs Dose and Frequency Ranitidine 500 mg I cap OD

Mechanism of Indication Action Inhibits histamine Used in the at H2 receptor management of site in the gastric various GI parietal cells, disorders such which inhibits as GERD, gastric acid gastritis, secretion. gastric and duodenal ulcer.

Contraindication

Side Effects Diarrhea Dizziness Headache Rashes Nausea Itching Tiredness Dry mouth

Nursing Responsibility Observe rules in drug administration. Careful monitoring of the patients condition. Providing education as it relates to the prescribe drug treatment. Advise patient to eat foods rich in Vit. B12. Keep all scheduled laboratory visits for liver and kidney function tests. Advise patient not to take other prescription drugs, OTC drugs, herbal remedies, or vitamins or minerals without notifying healthcare provider. Advise patient not to drink or smoke while taking the drug.

Hypersensitivity Acute porphyria

Lansoprazole

30 mg I tab OD

Suppresses
gastric acid secretion by inhibiting hydrogen/potassi um ATPAse enzyme system located in the secretory surface of the parietal cells of the stomach. It blocks the final step of acid production. Both basal and stimulated gastric acid secretions are inhibited regardless of stimulus.

Treatment of
peptic ulcer disease and other condition where inhibition of gastric acid secretion may be beneficial.

Hypersensitivity

Nausea Diarrhea Abdominal pain Headache Rash

Observe rules in drug administration. Careful monitoring of the patients condition. Providing education as it relates to the prescribe drug treatment. Monitor liver function periodically. Instruct patient to take medication before meals, preferably before breakfast. Instruct patient not to crush, break or chew medication. Instruct patient to avoid smoking, alcohol use and foods that cause gastric discomfort. Instruct patient to report GI bleeding, abdominal pain, heartburn and pain when urination for

Acetylcysteine

100 mg 1 tab OD

Decreases
viscosity of respiratory tract secretion and promote their removal by breaking disulphide bonds.

Treatment for
respiratory affections characterized by thick and viscous hyper secretions.

Hypersensitivity

Pyrosis Nausea Vomiting Urticaria Bronchospasm Rhinitis Stomatitis

Ciprofloxacin

500 mg BID

Inhibits bacterial Used in the

DNA gyrase thus preventing replication in susceptible bacteria.

treatment of wide range infection.

Hypersensitivity

Dizziness Lightheadedn ess Headache Nervousness Drowsiness Insomnia Abdominal pain Abdominal discomfort Mild diarrhea

immediate referral. Instruct patient to eat foods with beneficial bacteria such as yogurt. Head elevated 30 when experiencing heartburn. Observe rules in drug administration. Careful monitoring of the patients condition. Providing education as it relates to the prescribe drug treatment. Observe rules in drug administration. Careful monitoring of the patients condition. Providing education as it relates to the prescribe drug treatment. Advise patient to complete full course of the treatment.

 Mild nausea Vomiting

Tramadol

50 mg TID

Centrally acting

analgesic not chemically related to opioids bot binds to mu-opioid receptors and inhibibits reuptake of norepinephrine and serotonin.

Treatment for

acute or chronic pain of serious and mild illness.

Heart failure Acute alcoholism Head injury Increase ICP

Respiratory depression Palpitation Hypotension Arrhythmia Circulatory failure Nausea Vomiting Constipation Drowsiness

Monitor WBC count because it may decrease leukocytes. Careful monitoring with liver and renal dysfunction. Monitor urine output. Instruct patient to increase fluid intake to decrease risk for crystalluria. Advise patient to refrain from physical exercise. Instruct patient to immediately report tendon pain and inflammation. Observe rules in drug administration. Careful monitoring of the patients condition. Providing education as it relates to the prescribe drug treatment. Instruct patient to take medication with

Paracetamol

500 mg I tab q 4

Decreases fever
by inhibiting the effects of pyrogens on the hypothalamic heat regulating centers and by a hypothalamic action leading to sweating and vasodilation. Relieves pain by inhibiting prostaglandin synthesis at the CNS .

Relief of fever,
minor aches and pain.

Anemia Cardiac disease Pulmonary

disease

Confusion Tremor Headache Fatigue Sweating Dysuria Dry mouth Fever Allergic skin reaction GI disturbances

foods and plenty of fluids to prevent GI upset. Instruct patient to immediately report blood in the urine or stool and history of bleeding disorders. Observe rules in drug administration. Careful monitoring of the patients condition. Providing education as it relates to the prescribe drug treatment. Instruct patient to take medication with foods and plenty of fluids to prevent GI upset.

X. DISCHARGE PLAN MEDICINE The patient was given home meds of multivitamins. EXERCISE Mild to moderate exercise TREATMENT Take the full course prescribed medication treatment. Good hygienic measures and hand washing measures. Avoiding irritants. HEALTH Relieve pain by taking prescribed medication or heat application therapy. TEACHINGS Increase fluid intake and avoid irritants. Take enough rest and position self at comfort. Do deep breathing and coughing exercise. Clean environment. OPD Follow-up check-up after 1 week of discharge (June 29, 2011). DIET Good nutritional diet. Increase fluid intake and cranberry juice. Avoid irritants such as coffee, tea, citrus, spices, colas and alcohol. XI. BIBLIOGRAPHY Books Doenges, Moorhouse, Murr: Nurses Pocket Guide (12th Edition) Doenges, Moorhouse, Murr: Nursing Care Plans, Guidelines for Individualizing Client for Care Across the Life Span (7th Edition) Philippine Pharmaceutical Dictionary, 2010/2011 (10th Edition) Bare, Cheever, Hinkle, Smeltzer: Brunner & Suddarths Textbook of MedicalSurgical Nursing (12th Edition) Lippincot, Williams and Wilkins: Pathophysiology Adams, Bostwick, Holland Jr: Pharmacology for Nurses, A Pathophysiological Approach Internet Wikipedia.com E-medicine.com Nursingcrib.com Mims.com

XII. UPDATES Protein Possibly Linked to Asthma and Bronchitis Discovered by Gopalan on March 05, 2009 at 11:53 AM Swedish scientists say they have discovered a new protein KCNRG that is possibly linked to ashtma and bronchitis. Researchers at Uppsala University say the previously unknown protein is found in the cells of lower air ways. The protein is also important to the immune system in an autoimmune lung disorder that is often fatal, according to the Uppsala research team. The researchers used an unusual hereditary autoimmune disorder, autoimmune polyendocrine syndrome type 1 (APS-1), as a model. Patients with this disease are afflicted by the immune system erroneously attacking several tissues, such as the liver, insulin-producing cells, and adrenal glands. "Only now have we understood that the lungs are attacked as well and that in many cases this is the most serious component of the disease APS-1," says Dr. Mohammad Alimohammadi. "It's our hope that the discovery of the protein that the immune system targets, besides making early diagnosis possible, will also be possible to use in understanding the mechanism behind the occurrence of common public health disorders like asthma and chronic bronchitis." The findings have been published in the latest web edition of the U.S. journal Proceedings of the National Academy of Sciences. Source-Medindia GPL/L http://www.medindia.net/news/Protein-Possibly-Linked-to-Asthma-and-BronchitisDiscovered-48251-1.htm

Republic of the Philippines University of Northern Philippines Tamag, Vigan City College of Nursing

Case study On Urinary Tract Infection Acute Gastritis Acute Bronchitis (Corpuz Clinic and Hospital) ________________________________________________________ Presented to: Julius Laureta, RN, MAN (Clinical Instructor) ______________________________________________________ In Partial fulfilment Of the Requirements in Related Learning Experience ________________________________________________________

Presented by: Grace Bernadette A. Pamani BSN IV-Delphinium July 21, 2011

Republic of the Philippines UNIVERSITY OF NORTHERN PHILIPPINES Tamag, Vigan City COLLEGE OF NURSING CASE STUDY GRADING SHEET PARAMETERS Introduction Patient's Profile Nursing History (Past and Present Illnesses) PEARSON Assessment Diagnostic Procedures (Ideal and Actual) Anatomy and Physiology Pathophysiology (Algorithm and Explanation) Management a. Medical and Surgical b. NCP c. Promotive and Preventive DRUG Study Discharge Plan Updates Bibliography TOTAL 5 20 5 5 5 5 5 100 15 5 5 15 PERCENTAGE % 5 5 ACTUAL GRADE

REMARKS: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Julius Laureta, R.N. MAN Clinical Instructor