Presentation 1

NURSING CARE PLAN Tn.
MNI With : Urinary Tract Infection at

SASMEC Kuantan Hospital Malaysia
FITRI ARIANI
NIM : 20211050006
1. Definition:
Urinary tract infection (UTI) is a state of infection characterized by the growth and
proliferation of bacteria in the urinary tract, including infection of the renal parenchyma to
the bladder with a significant amount of bacteriuria (Soegijanto, 2005).
2. Etiology & risk factors

 Mikroorganisme
 Comorbidities
 Diabetes meilitus
Urinary tract infections can be caused by high sugar levels of patients, poor white
blood circulation and improper bladder emptying processes resulting in urine
staying too long In the urinary tract and is a good breeding ground for bacteria
 Kidney Stones, If kidney stones clog the urinary tract, bacteria can be trapped in
the collected urinary water above the blockage, resulting in the proliferation of
bacteria and causing infection
CASE
September 21, 2022. Mr. M came to the hospital escorted by his family with
complaints of difficulty in delivering urine, and feeling hot in the urethral area.
The urine is excreted a little and mixed with blood. The patient feels worried
about his condition
-
When performed anamnesis the patient complains of pain in the area of the
urethra, feels hot , and burns. Pain is at degrees 5-6 . The patient's body felt
weak, tired and the patient said his body felt hot. Patients eat 3 times a day with
small portions, and patients drink as much as 8 glasses per day
-
Physical examination obtained: Body temperature 39.9oc, pulse: 122 bpm,
Blood Pressure: 130/77, Respiratory: 21 rpm and SP02: 96%. GDS : 180 mg/dl
-
The patient has a disease problem, namely, Daibetes meilitus and kidney stones.
20 years ago. His kidney stones are only traditionally treated.
-
CASE
Pemeriksaan fisik diperoleh : Suhu badan 39,9oc, nadi: 122 bpm, Blood
Pressure: 130/77, Respiratory : 21 rpm dan SP02: 96%.
-
Pasien memiliki riwyat penyakit yakni, Daibetes meilitus dan Batu ginjal. 20
tahun lalu . Batu ginjalnya hanya diobati secara tradisional.
-
Pada saat pemeriksaan laborotarium diperoleh hasil urine feme yakni :

Pada saat pemeriksaan laborotarium diperoleh hasil urine feme yakni :
Urine FEME
Biochemistry
Glucose 4+ In urine there is glucose (Glycocuria)
Protein 1+ protein leakage in the urine occurs
Bilirubin Negative Do not experience health problems
pH 5.5 such as liver disorders
Haemoglobin 2+
Ketone 2+
The occurrence of an increase in
Nitrite Negatif
ketones in the blood and urine
Leukocytes 2+
Clarity Clear
Spesific Gravity 1.02
Colour Yellow
Ascorbic Acid Negative
TREATMENT
No Nama Obat
1 Ural Effervescent granules 4g per sachet : 2 scachet unspecified Three Times a
day for 3 day
2 OMEprazole : 20 Mg capsule ONCE a day for 1 week
3 cefTRIAXone : 2g injection ONCE a day for 1 week
4 Insulin recombinant neutral human SHORT ACTING 100 IU/ml in Vial
(ACTRAPID) : 6U injection when reguired (PRN) for 1 week
5 Paracetamol 500mg : 1000mg tablet single dose (STAT) for 1 Day
6 cefUROXime sodium : 150 mg injection single dose (STAT) for 1 Day
7 Insulin recombinant neutral human SHORT ACTING 100 IU/ml in Vial
(ACTRAPID): 6U injection Single dose (STAT) for 1 Day
Nursing Care
Plan
Tanggal Data Fokus Etiologi Masalah Keperawatan
Subjective data Injury Agent pain

 The client says it is difficult
to excrete urine
 The client said pain, burning
at the time of removing
urine
 The patient says part of the
abdomen and lumbar pain
Objective Data
 The client appears to be
drying up the pain,
 Pain Scale 5-6
 The client appears to have a
catheter attached
Tanggal Data Fokus Etiologi Masalah Keperawatan
Subjective Data Disease Hypertermi

 The patient says his body process
feels hot, His body feels
tired, tired and
uncomfortableO
Objective Data :
 The client seems agitated
 The client is palpable his
body is hot-
 Vital signs : Temperature :
39.9ocPulse : 122 bpm
Blood Pressure:
130/77,Respiratory Rate : 21
rpm SP02: 96%
Diagnosis
1 Pain associated with infection of the urinary tract
Adrenal
Hyperthermy is associated with inflammatory
2
reactions
Nursing Care
Plan
NOC NIC
Pain associated with infection After nursing action for 3×24  Identify characteristics,
of the urinary tract hours, it is expected that the duration, frequency,
respiratory status will be quality, intensity-
Definition: Sensory and normal with the result Identification of pain
emotional unpleasant criteria: scales
experiences  able to control pain  dentification of non-verbal
 Reports that pain is pain responses
Limitations Characteristics: reduced by using pain  identify factors that
 Changes in blood pressure management aggravate and improve
 Reports of cues expressing  Able to recognize pain pain
behavior ( restlessness, (Scale, intensity, frequency,  Monitor side effects of
whining, crying)-Report and signs of pain analgesic use
pain verbally  Give nonpharmacological
acts ( Relaxation of a deep
breath)
 Analgesic collaboration
NOC NIC
Hyperthermia After 3×24 hours of nursing  Assess the presence of
Definition: Increase in body care are expected complaints or signs of a
temperature above the change in body
normal rangeLimitations  normal respiratory status temperature
Characteristics: with result criteria:  TTV observations,
 Increase in body  Body temperature within especially body
temperature above the normal rangeP temperature according to
the normal range  ulse and RR in the normal indications
 Normal Tachycardia range  Compress warm water on
 Normal Tachypnea  No skin discoloration and the forehead and both
 Skin feels warm no dizziness axilla
Related Factors : Course of  Collaboration on the
Disease administration of
antipyretic drugs
Rationale
Implementation
Pain Deep Breath
1
Diagnosis Relaxation
Rini Fahriani Zees. (2012). Effect of Relaxation Technique on Adaptation Response

in Appendectomy Patients in Room G2, Second Floor Class III Blud RSU Prof. DR. H.
Aloei Saboe, Gorontalo City. Journal Health & Sport, 5 Nomor 3.
Hypertermi Administration of warm

2
Diagnosis compresses to patients
Fadli, & Akmal, H. (2018). Effect of Warm Compresses on Decreased Body
Temperature of Febris Patients. 7 Number 2.
THANK YOU …

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NURSING CARE PLAN Tn.

MNI With : Urinary Tract Infection at

2. Etiology & risk factors

Pada saat pemeriksaan laborotarium diperoleh hasil urine feme yakni :

Subjective data Injury Agent pain

Subjective Data Disease Hypertermi

Rini Fahriani Zees. (2012). Effect of Relaxation Technique on Adaptation Response

Hypertermi Administration of warm

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