Transcription of NURSING CARE PLAN
1 NURSING CARE PLAN. ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION. INDEPENDENT. SUBJECTIVE: Acute pain Pyelonephritis is After 8 hours Assess pain, noting Helps evaluate After 8 hours related to acute an inflammation of NURSING location, degree of of NURSING Tatlong araw ng inflammation of of the kidney and interventions, characteristics, discomfort and interventions, masakit ang pg- renal tissues. upper urinary the patient intensity (0-10 may reveal the patient ihi ko (I have had tract that usually will verbalize scale). developing was able to painful urination for results from relief or complications. verbalize the past 3 days) as noncontagious control of relief or verbalized by the bacterial infection pain. Note urine flow and Decreased flow control of patient. of the bladder characteristics. may reflect pain. (cystitis). It urinary retention OBJECTIVE: presents with with increased dysuria (painful pressure in Guarding/ voiding of urine), upper urinary distracting abdominal pain tract.
2 Behaviors. (radiating to the Self focusing. back on the Encourage patient Reduction of V/S taken as affected side) and to verbalize anxiety or fear follows: tenderness of the concerns. Active that can promote bladder area and listen these relaxation and T: the side of the concerns and comfort. P: 90 involved kidney provide support by R: 19 ("renal angle acceptance, BP: 120/80 tenderness"). In remaining with many cases there patient and giving are systemic appropriate symptoms in the information. form of fever, rigors (violent Provide comfort Reduces muscle shivering while measure like back tension, the temperature rub or deep promotes rises), headache breathing exercises. relaxation, and and may enhance coping abilities. Assist with range of Reduces muscle motion exercises or joint stiffness. and encourage Ambulation ambulation. returns organs to normal position and promotes feeling of well being.
3 Investigate and Requiring prompt report abdominal medical muscle rigidity, intervention. involuntary guarding and rebound tenderness. COLLABORATIVE: Administer Relieves pain, medications as enhances indicated comfort and analgesics and promotes rest. antibiotics.
