OUR LADY OF FATIMA UNIVERSITY

Mac Arthur Highway, Marulas, Valenzuela City

POST STREPTOCOCCAL GLOMERULO NEPHRITIS (PSGN)

A Clinical Case Study Presented to the

Faculty of the College of Nursing

In partial fulfillment of the course requirements in

RLE 102 A

Prepared By:
Group 1 BSN 2Y2-1A

ABASOLA, Jemaross BOCAR, Maria Cathrina

BALAGTAS, Angel Lyka CAAMPUED,Rachiel
BALUNAN, Mikaella CABANIG, Monaliza
BENESISTO, Lirio DUAZO,Angelica Marie

Presented To:

Mrs. M. Cambel, RN,MAN

22 February 2019
 LEARNING OBJECTIVES

General Objective:

This study aims to broaden the student’s knowledge about Post Streptococcal Glomerulo
Nephritis (PSGN) and it is designed to enhance the skills and attitudes in the application of
different nursing processes and management of the patient with PSGN.

Specific Objectives:

 To gain knowledge and understanding about Post Streptococcal Glomerulo

Nephritis PSGN
 To review anatomy and physiology of the client who had Post Streptococcal
Glomerulo Nephritis PSGN
 To trace the pathophysiology of Post Streptococcal Glomerulo Nephritis PSGN
 To render the necessary nursing care and responsibilities that a client with Post
Streptococcal Glomerulo Nephritis PSGN needs
 To correlate the results of the diagnostic procedures to its normal values
 To formulate and present drug studies of medications given to a patient as a part
of treatment regimen
 To develop an effective nursing care plan in which the patient may benefit
 To provide health teaching to patient and significant others about PSGN
 INTRODUCTION

Post Streptococcal Glumerulo Nephritis (PSGN) is a kidney disease that develops 10 to

14 days after a skin or throat infection caused by Streptococcus (a type of bacteria). The main
symptoms are blood in your child’s wee and swollen ankles or puffy eyes.

The kidneys are two organs that sits underneath the ribs in the back and which are
responsible for filtering toxins from the blood and maintaining the balance of fluid and
electrolytes. If the small filtration units of the kidney (glomeruli) become inflamed and swollen,
this called glomerulonephritis. The dead bacteria and antibodies become trapped in the filters of
the kidneys. This causes inflammation, which slows down the filters of the kidneys, making it
harder for them to make urine and get rid of the waste. These are several possible causes,
including autoimmune conditions (when the immune system begins to mistakenly attack the
healthy body tissues), following an infection, and some medical conditions, including diabetes
and some cancers.

It may occur in people of any age, but the most commonly affected group are pre-school
and school-aged pediatric patients. PSGN occurs most often in males with a male-to-female ratio
of 1.5 to 2:1

We chose this study due to rare complication in child nowadays to know related
information and knowledge about the aforementioned disease condition. This case study will
serve as a guideline for us student nurses in assessing and providing proper nursing care to
patients with the same problem or disease.
 PATIENT’S PROFILE
NAME : J.S.G

AGE : 8 y/o

DATE OF BIRTH : November 26,2010

ADDRESS : Quezon City

STATUS : Single

RELIGION : Roman Catholic

DATE & TIME ADMITTED : February 7, 2019 @ 12:05 AM

CHIEF COMPLAINT : Abdominal pain

ADMITTING DIAGNOSIS : PSGN (Nephrotic-Nephritic)

Present Health History :

Past Medical History :

Family History :

Socio-Economic History :

Personal History :

Prenatal History :

Birth History :

Feeding History :
 PHYSICAL ASSESSMENT
Patient JGS is a 8 years old male, with a PR of 100 BPM, O2 Sat of 97, RR 20
cycles/min, temperature of 36.5°C and a BP of 120/90 mmHg. He is awake, conscious, coherent
and not distress upon interaction.
Assessment
a. Head
Head is round in shape. Hair is short, thin and coarse, straight and evenly distributed.
Scalp is smooth and white in color, minimal lesions were noted.
b. Eyes
Her eyes are symmetrical, black in color, almond shape and anicteric sclera. Pupils
constricts when diverted to light and dilates when she gazes a far, conjuctivas are pink.
Eyelashes are equally distributed and skin around the eyes is intact.
c. Ears
Ears are clean, no ear wax noted and approximately of the same size and shape. Patient
can hear normally when spoken softly.
d. Nose
With narrow nose bridge, no discharges upon inspection. No swelling of the mucous
membrane and presence of nasal hairs were seen.
e. Mouth
She has a complete set of teeth with minimal dents noted. Oral mucosa and gingival are pink
in color, moist and there were no lesions nor inflammation noted. Tongue is pinkish and is free
of swelling and lesions. Lips are symmetrical, appear pale and dry with bits noted upon
observation.
f. Neck
Neck has strength that allows movement back and forth, left and right. Patient able to move
her neck freely.
g. Lungs and Thoracic Region
No reports of pain during the inhalation and exhalation. Absence of adventitious sounds upon
auscultation. RR is 19 cycles per minute.
h. Heart
Patient has an audible heart sound. Heart is pumping well with a pulse rate of 88 bpm.
 i. Abdomen
There was a pain scale of 7/10 verbalized by the patient.
j. Upper Extremities
Fair skin in color, presence of minimal scars of wound in the arms and legs. Her skin is moist
and soft to touch
k. Lower Extremities
No edema is present in her lower extremities.
 GORDON’S HEALTHSTATUS
Functional Health Before Hospitalization During Hospitalization
Pattern
A. Health She used to take herbal and She complies with the physician’s
perception and over the counter medicines and nurse’s health teachings.
health whenever she feels sick.
management
B. Nutritional and She has no known allergy. She was placed on a soft diet and
Metabolic She drinks 2,000-3,000ml experiencing weakness all
Pattern water everyday and she throughout the day.She used to to
drinks alcohol occasionally drink orange juice and milk.
and coffee in every morning
C. Elimination She defecates once daily Her output was being strictly
Pattern and urinates frequently. monitored. She did not defecate
after her surgery and her urine
output is approximately
2,500ml/day.
D. Activity- She used to do daily She can sit, stand and walk
Exercise household chores. slowly.
E. Sleep – Rest She used to sleep at 9pm She was unable to sleep at night
Pattern /and she wakes up 4am in due to painful incision and painful
the morning. urination from the catheter.
F. Cognitive- She had good sensory and She can easily comprehend
Perception auditory adequacy. No instructions and ideas.
Pattern difficulties in learning.
G. Self- Perception/ She is kind, generous and She shows respect and positive
Self- Concept affectionate attitude towards doctors and
Pattern nurses
H. Role- She has a close bond with She is being taken care of by her
Relationship her family. daughter.
Pattern
I. Sexually- She is menopause at the age She is menopause at the age of 59.
Reproductive of 59.
J. Coping/Stress She is engaging meditation She is able to manage her stress
Tolerance daily through praying with adequate rest.
before she sleeps
at night.
K. Value-Belief She is religious and have She believes in good deeds.
respect to different aspect of
cultures and she go to
church every Sunday.
 ANATOMY AND PHYSIOLOGY

The kidneys are two bean shaped organs of the renal system located on the posterior wall of the
abdomen one on each side of the vertebral column at the level of the 12 th rib. The left kidney is slightly
higher than the right. Human kidneys are richly supplied with blood vessels which give them their reddish
brown color. The kidneys measure about 10cm in length and, 5cm in breadth and about 2.5 cm in
thickness.
The kidneys are protected by three specialized layers of protected tissues. The outer layer consists
mainly of connective tissue which protects the kidneys from trauma and infection. This layer is often
called the renal fascia or fibrous membrane. The technical name for this layer is the renal capsule. The
next layer (second layer from the exterior) is called the fascia and it makes a fibrous capsule around the
kidneys. This layer connects the kidneys to the abdominal wall. The inner most layer is made up of
adipose tissue and is essentially a layer of fatty tissue which forms a protective cushions, the kidney and
the renal capsule fibrous sac) surrounds the kidney and protects it from trauma and infection.
The main function of the kidney is to maintain fluids, electrolyte and pH balance of the body by
filtering ions, macromolecules, water, and nitrogenous wastes from the blood based on the body’s
condition. Waters filtered out of the blood drains from canals in the kidney into the bladder as urine.
Blockage of the drainage system can cause the kidney to become congested, stretched, and potentially
scarred. Functioning kidneys are necessary to maintain life and one measure of their function is the
glomerular filtration rate. A loss of kidney function results in the need for dialysis, which is an artificial
method of removing wastes from the blood by running the blood from the body, through an artificial
kidney, and then back into the body.
 PATHOPHYSIOLOGY

PRECIPITATING FACTORS: PREDISPOSING FACTORS:

 Immune complexes formed  Age: (Peak at 7 years old)
glomerular filtration membrane  Higher incidence in male patients
between:  Childhood: common
o Antigen (in organism)  Diet
o Antibody (host)

POST-STREPTOCCOCAL INFECTION
(GROUP A, BETA HEMOLYTIC)

RELEASE OF MATERIAL FROM THE ORGANISM INTO CIRCULATION (ANTIGEN)

FUNCTION OF ANTIBODY

IMMUNE COMPLEX REACTION OF GLOMERULAR CAPILLARY

INFLAMMATORY REPONSE

PROLIFERATION OF EPITHELIAL CELLS LINING  EPITHELIAL CELLS – cresent formation (when severe,
GLOMEROLUS AND ENDOTHELIAL CELLS AND Browman’s space) (usually stimulated by fibrin)
EPITHELIUM OF CAPILLARY MEMBRANE  ENDOTHELIAL CELLS – capillary lumen ↓

SWELLING CAPILLARY MEMBRANE AND  NEUTROPHILS – activate inflammatory mediators

INFILTRATION (BY INFLAMMATORY CELLS)  LYMPHOCYTES
WITH LEUKOCYTES  MACROPHANGES

↑ PERMEABILITY OF BASE MEMBRANES

OCCLUSION OF THE CAPILLARIES OF

GLOMERULI VASOSPASM OF IFFERENT
VENTRIOLES  HEMATURIA
 AZOTEMIA – ↑
BUN (BLOOD,
↓ GLOMERULAR FILTRATION RATE UREA, NITROGEN) NEPHRITIC
 PROTENURIA SYNDROME
 OLIGURIA
↓ ABILITY TO FORM FILTRATE FORM  EDEMA
GLOMERULI PLASMA FLOW
 HYPERTENSION
ACUTE POST-
RETENTION OF H2O AND Na; HYPOVOLEMIA; STREPTOCOCCAL
CIRCULATORY CONGESTION  MASSIVE GLOMERULONEPHRITI
PROTYENURIA S
(>3.5g/day)
 HYPOALBUMINAE
MIA (plasma albumin
<3g/dL) NEPHROTIC
 GENERALIZED SYNDROME
EDEMA
 HYPERLIPIDEMIA
 LABORATORY EXAMS

COMPLETE BLOOD COUNT

LABORATORY REFERENCE RESULT RESULT INTERPRETATION

TEST RANGE (1/14/19) (1/15/10)

Hemoglobin 120 - 160 136 133 NORMAL

Hematocrit 0.38 - 0.47 0.41 0.41 NORMAL

WBC 4.0 - 12.0 11.1 NORMAL

RBC 4.0 – 6.2 4.9 NORMAL

MCV 80 – 100 84.9 NORMAL

MCH 26.0 – 34.0 28.0 NORMAL

RDW 10 – 16 11.8 NORMAL

MCHC 310.0 – 355.0 330 NORMAL

Platelet Count 150 – 450 509 NORMAL

Neutrophil 0.50 – 0.80 0.78 NORMAL

Eosinophil 0.02 – 0.04 0.03 NORMAL
Lymphocytes 0.25 – 0.50 0.14 Due to bacterial infection
Monocytes 0.02 – 0.10 0.05 NORMAL
ESR 0 - 20 24 Due to Inflammation
 Drugs Action Rationale Adverse Nursing Consideration
Reactions/Side
Effects
Generic Name:  Binds  Given Dizziness,drowsi-  Evaluate for
PENIZILIN G to an enzyme to the patient ness,fatigue,head- response (relief of GI
Classification: on gastric to treat the ache,weakness symptoms) Question if
Therapeutic: parietal cells in symptoms of Chest pain GI discomfort, nausea,
Anti-ulcer agents the presence of gastroesophag Abdominal pain diarrhea occurs)
Pharmacologic:
acidic gastric eal disease, a
Proton-pump inhibitors pH, preventing condition in
the final which
Dosage: transport of backward
40mg IV hydrogen ions flow of acid
Frequency: into the gastric from the
OD lumen stomach
causes
Date given: 1/14/19 heartburn and
1/15/19 possible
injury of the
esophagus
Generic Name:  Inhibits  Given CNS:  Use caution with
KETEROLAC prostaglandin to the patient Drowsi- any physical
Brand Name: synthesis,prod to relieve ness,abnormal interventions that could
TORADOL ucing moderately thinking,dizziness increase bleeding,
peripherally severely pain, ,headache including wound
Classification: medicated usually pain debridement, chest
Therapeutic:
analgesia. Also that occurs percussion, joint
Non-steriodal anti- has antipyretic after an mobilization and
inflammatory and anti- operation or application of local
agents,non-opiod inflammatory other painful heat.
analgesics properties. procedure  Help patient to
Pharmacologic:
Pyrrolizine carboxylic explore other
acid pharmacologic methods
to reduce chronic pain,
Dosage: such as relaxation
30 mg IV techniques,exercise,
Frequency: counselling, and so
q6 hrs for 4 doses ANST forth.
 Always wash
Date given: 1/15/19 hands thoroughly and
disinfect equipment
(whirlpools, electo-
therapeutic devices,
treatment tables, and so
forth) to help prevent
the spread of
 infection.Employ
universal precautions or
isolation procedures as
indicated for specific
patients.
 Instruct patient
to notify physician
immediately of signs of
super infection,inclu-
ding black, furry
overgrowth on tongue,
vaginal discharge or
itching and loose or
foul-smelling stools.
Generic Name:  Inhibits  Given CNS:  Watch for GI
CELECOXIB the enzyme to the patient, Dizziness, bleeding including
Classification: COX-2.This post-operative heache,insomnia abdominal pain, vomi-
Therapeutic: enzyme is to work by GI: ting blood, blood in
Anti-rheumatics, non required for reducing GI bleeding, stools or black tarry
steriodal anti-inflam- the synthesis hormones that abdominal pain, stools and other GI
matoryagents of prostaglan- cause diarrhea,nausea, problems
Pharmacologic:
dins.Has anal- inflammation vomiting,cramps  Continually
COX-2 inhibitors gesic, anti- and pain in monitor for signs of MI
inflammatory, the body (sudden chest pain) pain
Dosage: and antipyretic radiating into the arm or
200 mg/cap properties. jaw, SOB, dizziness,
1cap sweating, anxiety,
Frequency: nausea and stroke. Seek
2x a day immediate medical
assistance if patient
Date given: develop these signs
1/15/19  Assess pain to
1/20/19 document whether this
drug is successful in
helping manage the
patient’s pain and
decreasing impairments.
Generic Name:  Block  Given Drowsiness,  Guard against
METECLOPROMIDE dopamine to the patient anxiety, falls and trauma (hip
Classification: receptors in to increased depression, fractures, head injury
Therapeutic: chemoreceptor muscle irritability, and so forth) caused by
Antiemetics trigger zone of contractions hypertension, drowsiness, blurred
Pharmacologic:
the CNS. in the upper Constipation, vision or extrapyramidal
Dopamine Receptor Stimulates digestive tract diarrhea, dry symptoms; implement
antagonists motility of the and to treat mouth, nausea fall prevention
upper GI tract any heartburn strategies
 that accelerates  Because of the
Dosage: gastric risk of ECG changes
200 mg/cap emptying and abnormal BP
1cap 2x a day responses, use caution
during aerobic exercise
and other forms of
therapeutic exercise.
Assess exercise
tolerance frequently
(BP, heart rate, fatigue
levels), and terminate
exercise immediately if
any untoward occurs.
Generic Name:  Binds  Given Diarrhea,nausea,  Monitor bowel
CEFUROXIME to the bacterial to the patient vomiting,cramps sounds
Brand Name: cell wall to treat a wide  Safety and effect
CEFTIN,ZINACEF membrane, variety of -iveness of drug haven’t
causing cell bacterial been established for
Classification: death infections. theraphy lasting longer
Therapeutic:
than 12 weeks
Anti-infectives  Monitor patient
Pharmacologic:
Second generation for involuntary
cephalosporins movements of face,
tongue and extremities
Dosage: which may indicate
750 mg IV tardive dyskinesia
q8 hrs ANST (-) x24hrs  Monitor patient
500 mg for fever, CNS
1 tab/ 2x a day for 7 days symptoms,irregular
pulse,cardiac arrhyth-
Date given: 1/15/19 mias,or abnormal BP
which may indicate
neuroleptic malignant
syndrome
 Monitor patient
for dizziness, headache
or nervousness after
metoclopramide is
stopped;these may
indicate withdrawal
Generic Name:  Elevate  To CNS:  Assess history of
FERROUS SULFATE the serum iron treat iron May cause allergy to any ingredient
Classification: concentration,a deficiency additive CNS sulfte;hemolytic
Iron preparation nd is converted effects.Avoid anemia, normal iron
Dosage: to Hgb or using together balance and peptic ulcer
1 tab/day trapped in the DRUG-LIFESTYLE:  Assess for
Alcohol use;may
 Frequency: reticuloendoth cause additives presence of skin lesions.
OD elial cells for CNS effects.  Give drug with
storage and Discourage use meals (avoiding
Date given: 1/15/19 eventual together. milk,eggs,coffee and
conversion to a tea) if GI upset is
usable form of severe.
iron
Generic Name:  Binds  Given constipation,  Help patient
TRAMADOL to mu-opioid to the patient nausea, abdominalexplore other
Classification: receptors. to help relieve pain, anorexia,nonpharmacologic
Therapeutic: Inhibits moderate to diarrhea, dry methods to reduce
Analgesics (centrally reuptake of moderately mouth, dyspepsia,chronic pain, such as
acting) serotonin and severe pain flatulence, relaxation techniques,
Pharmacologic:
norepinephrine vomiting. exercise, counseling and
Opioid agonists
in the CNS. menopausal so forth.
symptoms, urinary  Guard against
Date given: 1/15/19
retention/fre-falls and trauma (hip
quency fractures, head injury).
Implement fall –
prevention strategies,
especially if patient
exhibits sedation,
dizziness or blurred
vision
Generic Name:  Inhibits  Given visual  Concurrent use
TRANEXAMIC ACID activation of to the patient abnormalities. of clotting factor
Classification: plasminogen, to inhibit hypotension, complexes may ↑ the
Therapeutic: thereby fibrinolysis in thromboembolism, risk of thrombotic
Hemostatic agents preventing the the severely thrombosis. complications (give
Pharmacologic:
conversion of injured diarrhea, nausea tranexamic acid 8 hr
Antifibrinolytics, plasminogen to patient. and vomiting. following clotting factor
plasminogen inactivators plasmin. replacement therapy)
Dosage:
500mg IV
Frequency:
q8hrs

Date given: 1/14/19

Generic Name:  Alters  Given GI:abdominal  Assess patient
BISACODYL fluid and to the patient pain,diarrhea, for abdominal
Brand Name: electrolyte for bowel nausea and distention, presence of
DULCOLAX transport elimination vomiting. bowel sounds and usual
Classification: producing pattern of bowel
Laxatives fluid elimination
accumulation  Assess color,
Dosage: in the colon character, consistency
 1Omg tab and amount of stool
Frequency: produced.
q8hrs PO

Date given: 1/18/19

 COURSE IN THE WARD
DAY 1: JANUARY 14, 2019 – TUESDAY (NO DUTY)
A 63 year old female no unknown Co-morbid was admitted as care of ONG benign,
ambulating with chief complaint of abdominal mass. She was associated with pain which started
18 years, prior to admission. Admission care rendered. Impression: impaired fasting glucose.
Monitored CBG TID pre-meals and recorded, (-) polyphagia, (-) polyuria, (-) delayed wound
healing, FHX: (-) DM, FBS: 119.3 mg /dl, monitored vital signs q4. Patient was watched on
Ward and oriented regarding hospital policies for Total Abdominal Hysterectomy with Bilateral
Salphing-oophorectomty (TAHBSO) on January 15, 2019. Informed consent for the procedure
was secured and advised patient for total body hygiene. Emotional and moral was provided and
advised the relatives to secure 2u of PRBC for possible OR. She instructed on clear liquids and
then NPO for post-midnight. She was referred to IM-RS for clearance and seen and examine,
IM-endo clearance was secured. Doctor ordered D5LR 1L IVF x8 hrs. once in NPO and fleet
enema at 4am for TAHBSO on 1/15/19. Doctor ordered cefuroxime 1.5g TIV ANST one hr.
prior to OR, Omeprazole 40mg once on NPO, Tranexamic acid 1gm IV as loading dose at 12am
then 300mg Noveril 8hrs. x 3doses. Anesthesia Pre-OP was ordered, patient was seen and
examine and PE history and laboratories was reviewed. Anesthesia plan, risk and possible
complications was explained and understood by the patient.

DAY 2: JANUARY 15, 2019 – WEDNESDAY (NO DUTY)

The patient is for TAHBSO as ordered and on NPO diet. She was conscious and coherent
and instructed for total body hygiene. Informed consent for TAHBSO was secured. Fleet enema
was done by duty-nurse at 4am with informed consent. 2u PRBC properly type and cross
matched was secured. Cefuroxime 1.5gTIV after negative skin test 1hr. prior to OR and
Omeprazole 40mg NPO, Tranexamic 500mg IV every 8hrs. as LD was given by duty-nurse. She
was continued monitoring of CBG every 6hrs.on NPO and 30mins. prior to OR. Elected
TAHBSO was oriented to OR policy on NPO maintained. IM-RS and IM-endo clearance noted.

SURGICAL PROCEDURE: With informed consent for TAHBSO, @ 2pm patient to OR per
stretcher and was seen and examine. Induction of Anesthesia was done by the doctor, IFC
inserted aseptically, pelvic examination under anesthesia done, providone iodine scrub and
antiseptic used for vaginal, perineal and skin preparation, sterile drapes applied, initial count of
syringe needle was done, surgical incision started @ Midline suprapubic infraumbilical incision
and carried down to the perirtoneum, specimen exposed. TAHBSO with utero sacral suspension
done by the Doctor, specimen was obtained . Count of surgical needle and puncture acknowledge
completed by the Doctor. Binders were checked. Abdominal capes sutured until closed,
antiseptic and dressing applied. Procedure ended.

 ANESTHESIA POST-OPERATION. Patient hooked on O2 inhalation 2-3L/m in Nasal

Canula. Vital sign was monitored q15mins for 1st hour., then q30 for 2nd hour., q1 until
 stool then q4. Patient advised on NPO diet. IVF PLRS 1L to run for 100u/hr. was
regulated as ordered. Doctors ordered medications Tramadol drips, Tramadol 300mg +
D5W 500ml to run for 24hours, Tramadol 500mg/ SIVF q6 PRN for Mod-severe pain,
Omeprazole 40mg IV OD, Keterolac 30mg IV q6 x 4 doses ANST, Antibiotic c/o main
service. Monitored WOF signs of Mophine Toxicity: BP=<90/60, PR=<50, RR=<12,
UO=<0.5ml/kg/hr. decrease Sensory, Nausea and Vomiting, Pruritis. Give
Diphemydromine 50mg IV PRN for Pruritis, Metoclopromide 10mg IV PRN for Nausea
and Vomiting. Epidural catheter was pulled out blue tip seen by the patient. Kept the
patient flat on bed for 4-6 hours and kept thermo-regulated, provide warmth and comfort.
Cefuroxime 750mg IV q8 was given continuously by duty-nurse.

S/P TAHBSO. Patient was transferred from OR per stretcher with abdominal drain, clean and
dry and transferred to bed safely. She was conscious and coherent and advised to used abdominal
girdle and dangle her leg before going out to bed. She was also instructed to ambulate gradually
and full body hygiene was emphasized.

Patient was back to ward and monitored vitals sign with BP 110/70, PR 80, RR 18,Temp.
30, O2 99.1, Soft Abdomen with (-) Flatus. (-)BM and adequate and clear UO. IVF was given as
ordered then heplock. She was instructed for clear liquid diet. Patient was verbalized the pain
scale 6/10 and encourage her to do deep breathing and least the pain scale to 3/10. Doctor
ordered Cefuroxime 750mgIV after negative skin test q 24hrs. and then shift to Cefuroxime
500mg/tab TID for 7 days. Start Ferrous Sulphate OD, Ascorbic Acid OD, Celoxib 200mg/cup
BID once IV pain meds consumed. IFC was ordered to be removed at 2pm 1/16. Due medication
was given as ordered. CBG was monitored TID per meals. Intake and Output was also
monitored and recorded.

DAY 3: JANUARY 16, 2019 – WEDNESDAY (NO DUTY)

S/P TAHBSO. Patient still on Ward with abdominal dressing, conscious and coherent and
advised to continue use abdominal girdle , gradual ambulation, dangle her leg before going out to
bed. Full body hygiene was also emphasized to patient. IFC was removed by duty-nurse. Vital
sign was monitored q4. She was advised to eat SBF jelly and crackers, soft diet with (+) Flatus
@ 5:30pm. Encouraged to continued deep breathing exercise to least the pain from the inscision
site. Cefuroxime 500mg 1/tab BID for 7 days, Ferrous Sulfate OD, Ascorbic Acid OD,
Celocoxib 200mg/cup BID was given as ordered.

DAY 3: JANUARY 17, 2019 – THURSDAY (ON DUTY)

S/P TAHBSO. Patient was conscious and coherent, with abdominal dressing, with pain
noted. Vital signs was monitored with PR 88, O2 97, Temp. 36.3 C, BP 120/80. She was
advised to maintain abdominal girdle, maintained heplock, encouraged to ambulate, deep
breathing exercise. Total body hygiene was emphasized. Daily wound care was also advised and
instructed for soft diet while still waiting for BM. I and O was monitored and recorded.
DAY 4: JANUARY 18, 2019 - FRIDAY (ON DUTY)

S/P TAHBSO. Patient vital sign was monitored. She was noted for 4 days (-) BM. She
was encouraged for soft diet that high in fiber, encouraged ambulation and promote adequate
fluid intake. She was verbalized understanding of method for preventing and treating the
constipation. Doctor ordered Bisacodyl. Due medication was given as ordered and safety
precaution was advised.

DAY 5: JANUARY 19, 2019 - SATURDAY (NO DUTY)

S/P TAHBSO. Patient was conscious and coherent, vital sign was monitored, full body
hygiene was advised, encouraged to ambulate, safety precaution was observed. Due medication
was given as ordered.

DAY 6: JANUARY 20, 2019 – SUNDAY (NO DUTY)

Patient instructed to eat nutritious food. Proper wound care and total body hygiene was
emphasized. Vital sign and I&O was monitored and recorded. Due medication was given by
duty-nurse as ordered. Patient safety was ensured.

DAY 7: JANUARY 21, 2019 – MONDAY (NO DUTY)

Patient was seen active and oriented. Monitored vital sign and instructed to eat nutritious
food. Emphasized medication compliance and kept rested. Intake and Output was also monitored
and recorded and conducted patient health teaching.
 RECOMMENDATION SUMMARY
Medications : Ascorbic Acid 500mg 1 tab/day

Exercise : Tell patient to avoid exerting too much effort on

muscles such as doing strenuous exercises to avoid injury. Avoid places that
are stress provoking to facilitate fast recovery of the patient.

Treatment : Tell patient to follow advice of physician or any

other health care provider

Health Teachings : Encouraged client to provide adequate rest periods

to avoid stress. Instructed patient to clean wound daily and dress it
properly to avoid infection. Encouraged patient to be more hygienic

Out-patient department : Remind patient and family that frequent check-ups

are important to improve her condition and maintain optimum balance of
wellness. Inform family to report for any abnormalities as soon as possible
to prevent further complications

Diet : Advised patient to eat healthy food such as fruits

and vegetables and less intake of fatty food. Advised patient to drink milk
3 times a day to provide calcium to her body and have stronger bones.
Advised client to eat food rich in protein to aid in tissue repair since she
had her post operation for fast recovery.

Spiritual : Encouraged the patient to go to church every

Sunday. Seek guidance to our Lord.
No.1 NURSING CARE PLAN (ACUTE FLANK PAIN)

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Acute Pain After an hour of  Monitored  To have a After an hour of

“”Äng sakit sakit related to flank nursing interventions vital signs. baseline data. nursing intervention
ng tagiliran ko”, as pain.. the patient will be  Provided  To promte the patient had
verbalized by the able to experience comfort measures such comfort and experienced gradual
patient. gradual as positioning. relaxation. reduction/relife of
reduction/relief of  Encouraged the pain as evidenced
Objective: pain. client to do deep  To shift by smiling and
 Facial breathing exercises. clients’s attention cooperative patient
 V/S as taken:  Suggested from the pain he to her significant
T – 36.5 client to socialize to felt. other and healthcare
BP – 150/110 their significant others providers.
PR – 100  Encouraged  May relieve Therefore, goal was
RR - 20 early ambulation. pain and enhance met!
Grimacing circulation
 Guarding
position