CUES SUBJECTIVE: Maul-ol it ak tak hawak ha may ligid ha wala nga dapit, as verbalized by the client Bagat ginbubuno

o hiya ha sobra ka sakit, as verbalized by the client OBJECTIVE: Patient rated pain as 10 (in a scale of 110; 1 being the lowest and 10 being the highest) facial grimacing noted Irritability noted anxiety and fatigue noted sleeplessnes s noted

NURSING DIAGNOSIS Acute pain related to accumulation of pus in the renal cortex secondary to infection

SCIENTIFIC RATIONALE Pain is a sensation characterized by a group of unpleasant perceptual and emotional experience. Bacterial inflammation results from the immediate and painful events. Bacteria spread to the kidney primarily by obstruction in the ureter. Blood and lymphatic circulation also provide for the organism. Therefore, stagnant urine allows organism to multiply, which is the common cause of infection. *MedicalSurgical Nursing 6th Edition by Joyce M. Black, Jane Hokanson Hawks, Anabelle M. Keene Volume 1, Page 854855*

OBJECTIVE

SHORT TERM: After 2 hours of nursing intervention the client will be able to: report pain is relieved or controlle d follow prescribe d pharmac ologic regimen LONG TERM: After 8 hours of nursing intervention the client will be able to: verbaliz e non pharma cologic method that provide relief

NURSING INTERVENTI ON INDEPENDENT 1. Establish rapport

RATIONALE

EVALUATION

2. Obtain vital signs 3. Perform a comprehen sive assessmen t of pain to include location, characteris tics, onset, duration, frequency, quality, intensity or severity, and precipitati ng factors of pain. 4. Teach the use of nonpharm acologic techniques (e.g., relaxation, guided imagery, music therapy, distraction, and massage) before, after, and if possible during painful activities; before pain occurs or increases; and along with other pain relief measures 5. Create a quiet, nondisrupti

to facilitate cooperatio n as well as to gain pts trust to maintain baseline data pain is a subjective experienc e and must be described by the client in order to plan effective treatment.

the use of noninvasiv e pain relief measures can increase the release of endorphin s and enhance the therapeuti c effects of pain relief medicatio ns.

ve environme nt with dim lights and comfortabl e temperatur e when possible.

6. Individualiz e the content of the relaxation interventio n (e.g., by asking for suggestion s about what the patient enjoys or finds relaxing). 7. Elicit behaviors that are conditione d to produce relaxation, such as deep breathing, yawning, abdominal breathing, or peaceful imaging 8. Demonstra te and practice the relaxation technique with the patient

comfort and a quiet atmospher e promote a relaxed feeling and permit the client to focus on the relaxation technique rather than external distraction . Each person may find different images or approache s to relaxation more helpful than others.

relaxation technique s help reduce skeletal muscle tension, which will reduce the intensity of the pain.

COLLABORATI

return demonstra tions by the participan

VE 9. Check the medical order for drug, dose, and frequency of analgesic prescribed. 10.Determine analgesic selections (narcotic, nonnarcoti c, or NSAID) based on type and severity of pain

t provide an opportunit y for the nurse to evaluate the effectiven ess of teaching Ensures that the nurse has the right drug, right route, right dosage, right client, right frequency Various types of pain (e.g., acute, chronic, neuropath ic, nociceptiv e) require different analgesic approache s. Some types of pain respond to nonopioi

CUES

NURSINGDIAGN OSIS

SCIENTIFIC RATIONALE

OBJECTIVE

NURSING INTERVENTION

RATIONALE

EVALUATIO N

SUBJECTIVE: It akon anak nagbibinalik balik it hiranat, as verbalized by the mother of the client OBJECTIVE: Flushed skin with body temperatur e of 39 degrees celcius (Normal: 36.5-37.5) RR: 28 cpm (Normal: 15-20 cpm) Increase thirst Loss of appetite Body weakness Drowsiness Restlessne ss Hyperthermia related to invasion of infection Pyrogens, chemicals released by microorganis m, neutrophil and other cells, stimulate fever production. Pyrogen affects the body temperature regulating mechanism in the hypothalamus of the brarin. As a consequence, heat production and conservation ncrease, and body temperature. Fever promotes the activities of the immune system, suchu as phagocytosis, and inhibits the growth of some microorganis m. *Essential of Anatomy and Physiology 6th edition by Seeley Stephens Tate, Page 397* SHORT TERM: After 2 hours of nursing intervention the client will be able to: decrease or maintain normal body temperatu re stabilize and normalize respirator y rate LONG TERM: After 8 hours of nursing intervention the client will be able to: INDEPENDENT 1. Establish rapport with the patient 2. Monitor vital signs 3. Assess environme ntal factors (room temp.) 4. Apply tepid sponge bath to facilitate cooperation as well as to gain pts trust to establish baseline data Room temperature can affect patients temperature To promote heat loss by evaporation and conduction Water regulates body temperature and prevent dehydration To limit heat production and decrease oxygen demand To monitor or potentiates fluid and electrolyte loses To determine the clients hydration status To keep the mucous membrane moist and improve appetite To reduce complaints of feeling cold To meet the metabolic demand of the client

5. Encourage client to increase fluid intake 6. Encourage client to rest

7. Measure intake and output

8. Provide oral hygiene

9.

Provide dry clothing and clean linens 10.Provide high caloric diet as indicated

by the physician DEPENDENT 11.Administer antipyretic as prescribed by the physician 12.Maintain IVF as ordered by the physician 13.Administer antibiotic as ordered 14.Monitor hematologi c test and other pertinent lab records 15.Discuss condition of the patient with other members of the health care team Antipyretic acts on the hypothalam us thereby reducing hypothermi a To prevents dehydration Treats underlying cause Indicates presence of infection and dehydration Ensures continuous intervention

CUES
SUBJECTIVE: Diri man ako gingaganahan yana pagkaon, as verbalized by the client OBJECTIVE: Vomitus about 240 ml noted composed of currently ingested food Weight is 40kg. (Normal is 44kg) Pale conjunctiv ae noted Weakness

NURSING DIAGNOSIS
Risk for imbalance nutrition: less than body requirement related to loss of appetite

SCIENTIFIC RATIONALE

OBJECTIVE

NURSING INTERVENTION
INDEPENDENT 1. Establish rapport with the client 2. Monitor vital signs 3. Keep strict documenta tion of intake, output, and calorie count

RATIONALE

EVALUATION

SHORT TERM After 2 hours of nursing intervention the patient will: Vital signs, blood pressure, and laborator y serum studies are within normal limits Client is able to verbalize importanc e of adequate nutrition and fluid intake

to facilitate cooperatio n as well as to gain pts trust to establish baseline data this informatio n is necessary to make an accurate nutritional assessmen t and to maintain client safety weight loss or gain is important assessmen t informatio n client is more likely to eat foods that she particularl y enjoys Large amounts of food may be objectiona ble, or even intolerable to the client

4. Weigh client daily

LONG TERM After 8 hours of nursing intervention, the client will: Client will shown a slow progressi ve, weight gain during hospitaliz ation

5. Determine clients likes and dislikes and collaborate with dietician to provide 6. Ensure the client receives small, frequent feedings including a bedtime snack, rather than three larger meals 7. Stay with client during meals

8. Explain the importance of adequate nutrition and fluid intake

To assist as needed and to offer support and encourage ment Client may have inadequat e or inaccurate knowledge regarding the contributio n of good nutrition to overall wellness

CUES SUBJECTIVE

NURSING DIAGNOSIS Inadequate tissue perfusion related to poor blood circulation

SCIENTIFIC RATIONALE

OBJECTIVE SHORT TERM

NURSING INTERVENTION

RATIONALE

EVALUATION