[Pick the date] Acute Pyelonephritis

ACTUAL & POTENTIAL Nursing Care Plan: ACUTE PYELONEPHRITIS

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Hyperthermia Endogenous Short term: Independent: Goal met.
“Mainit ang related to Pyrogen releases After 1 hour of The temperature
pakiramdam ko at inflammatory from endotoxins nursing 1.Monitor >To determine of the patient was
giniginaw ako” process intervention condition the need for decreased from
and after
patient will intervention and 39.4 to 37.5
phagocytosis by
Objective: decrease from the effectiveness
>Conscious and macrophages 39.4-37.5 C of therapy.
coherent
>flushed skin Long term: After 2 2.Assess >To obtain
>skin warm to days nursing underlying comparative
Stimulate IL-1
touch intervention condition and baseline data and
>(+) profuse patient will body temperature to assess
sweating maintain normal contributing
>(+)chills Stimulate Anterior core temperature. factors.
>V/S taken
Hypothalamus
BP: 130/90 3.Assess >To evaluate
RR:20 neurologic effects or degree
PR:90 response, noting of hyperthermia
Temp:39.4 Thermoregulation level of
set – point consciousness and >To have a
orientation, baseline data
reaction to stimuli
and presence of
Heat posturing or
conservation seizures.
(vasoconstriction)
4.Monitor vital >To assist with
signs measures to
reduce body
[Pick the date] Acute Pyelonephritis

Heat production temperature

(involuntary
muscle 5.Remove >It supports
unnecessary circulating volume
contraction)
clothing that and tissue
could only perfusion
aggravate heat
Fever
6.Encourage >To promote
increase fluid hydration
intake

7.Promote >To regain energy

adequate rest
periods

8.Advise to >Helps in lowering

increase calorie the temperature
diet and provide and promote
tepid sponge bath surface cooling

Dependent:
9.Administer >Aids in lowering
antipyretic as down
ordered or temperature
prescribed by the
physician
[Pick the date] Acute Pyelonephritis

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Deficient Short Term: 1.Determine > to determine if Goal Met
“Bakit masakit at Knowledge High school After 15-30mins client’s ability to patient is
palagi ang pag-ihi related to lack of graduate of health teaching learn. physically, After 2days of
ko?” information patient will emotionally or Health teaching,
verbalize mentally capable patient
Objective: Inefficient understanding of at this time. understand how
>Conscious and Knowledge condition, disease to prevent
coherent towards disease process and 2.Note personal >females are at infection, the
>oriented process treatment. factors (e.g. age, high risk to manifestations
>voicing sex, level of develop urinary and interventions
inappropriate Long Term: education) tract infection to do if recurrence
action towards Inappropriate After 2days of because of short happens as
illness management health teaching urethra and evidenced by the
towards illness patient will absence of clients statements
assume prostatic fluid. and no recurrence
responsibility for of infection.
Neglect previous own learning and 3.State objective >to meet learners
illness (UTI) begin to look for clearly in learners need.
information and terms
ask questions.
Progress to Patient will also 4. Encourage >to assess clients
complication perform client to participation and
necessary participate during learning towards
procedures health teaching by health teaching.
Acute correctly and asking questions.
Pyelonephritis explain reasons
for the actions. 5. Teach patient >to ensure that
about patient can
Deficient predisposing recognize causes
knowledge factors like that can lead to
bladder over urinary tract
[Pick the date] Acute Pyelonephritis

distention, sexual infection.

intercourse, loss
of resistance to
invading
microorganisms
and indwelling
catheterization.

6. Teach patient >to ensure that

about patient can
manifestations of recognize the
pyelonephritis manifestatios of
like frequency, pyelonephritis
urgency, dysuria, and knows to seek
foul smelling prompt medical
urine, malaise, attention when
fever, and these
possibly bloody or manifestations do
cloudy urine. occur.

7. Provide >Prevents
information to contamination of
patient about the urinary
health an lifestyle meatus with the
measures to colonic bacteria
prevent from the anus.
pyelonephritis
including perineal >Hand washing is
hygiene measures the single most
such as wiping effective practice
from front to to prevent spread
back, hand of
[Pick the date] Acute Pyelonephritis

washing microorganisms.
before/after using
the toilet, wearing >Cotton
cotton underwear underwear are
and emptying the absorbent.
bladder every 2- Moisture
3hrs and enhances
immediately after proliferation of
sexual microorganism.
intercourse.
>Urinary stasis in
the bladder
enhances
proliferation of
microorganism
and to prevent
contamination of
the urinary
meatus by colonic
bacteria from the
anus.

8. Encourage >infection should

patient to subside with
complete the full adequate
course of antibiotic
antibiotic therapy. treatment.

ASSESSMENT DIAGNOSIS INFERENCE PLANNING NURSING RATIONALE EVALU

INTERVENTION
SUBJECTIVE: Acute Pain related to Tissue damage detect by After 30minutes to Independent: After
[Pick the date] Acute Pyelonephritis

“Palaging sumasakit ang acute renal sensory neurons 1 hour of nursing >Assess pain, >To know the 30minu
tagiliran ko.” inflammatory process intervention the including location, severity , 1 hour
Tissue injury client’s painscale quality, duration development and nursing
OBJECTIVE: will decreases from and intensity. progression of pain interve
>patient awake on bed in Stimuli 8/10 to 3/10. and disease and to the clie
lying position at semi- obtain baseline data painsca
fowler position Noxious stimuli trigger and compared with was
>conscious and coherent release of biochemical the client’s previous decrea
>responsive to physical mediators(e.g. pain symptoms. from 8
and verbal stimuli prostaglandins, 3/10.
>irritated histamine,bradykinin) >Assess nonverbal >Non verbal cues
>anxious cues.e.g. may be both Client
>with narrowed focus Inflammation abdominal physiologic and verbali
>with sleep disturbance guarding, psychologic and relief o
>dilated pupils sensitization of tachycardia, maybe used in
>with facial grimace nocireceptors diaphoresis. conjunction with
>with weakness and verbal cues to
fatigue transmits pain sensation evaluate
>diaphoresis extent/severity of
>pale Response(pain perceived the problem.
>with abdominal
guarding behavior sympathetic
> with tenderness in left nervous system response: >Assess and review >Helpful in
CVA factors that establishing diagnosis
>v/s are follows:  PR,RR,BP aggravate or and treatment needs.
T-38.4degree alleviate pain.
celcius(febrile)  Diaphoresis
RR-22 cpm > Provide non- >Reduction of
PR-103 bpm  Dilated pupils stimulating, calm anxiety, tension that
BP-130/70mmHg and quiet can promote
>facial mask of pain (facial environment and relaxation and
encourage client comfort and distract
[Pick the date] Acute Pyelonephritis

grimace) the use of attention of the

>Painscale: relaxation client of pain.
Placement and >restless, irritated and technique e.g.
Precipitating factor: anxious music therapy.
- left and right flank pain
-often increases with >abdominal >Provide oral care, >Halitosis from
movement guarding(protective gesture) diversional stagnant oral
activities and secretions is
Quality: comfort unappetizing and can
-sharp measures.eg. back aggravate nausea.
Radiation/Relief: rub, deep Reduces muscle
-non-radiating breathing and tension, promotes
-relieved by taking pain position changes. relaxation, and may
meds and rest. enhance coping
abilities.
Severity/Sign and
symptoms associated: >Encourage client >To conserve and
-Severe, pain scale of 8 to rest. restore energy
out of 10
- accompanied by fever,
chills, diaphoresis, nausea Collaborative:
and vomiting and muscle >Identify specific >To assist client to
weakness. signs/symptoms explore methods for
and changes in alleviation or control
Time/Onset pain characteristics of pain.
-pain was starting requiring medical
suddenly with episodes follow-up.
of pain typically lasting
for 1-2hours with Dependent:
recurring episodes of >Administer >Relieves pain,
similar pain medications as promotes general
indicated e.g comfort and rest.
[Pick the date] Acute Pyelonephritis

analgesics and
antibiotics.

ASSESSMENT DIAGNOSIS INFERENCE PLANNING NURSING RATIONALE EVALU

INTERVENTION
SUBJECTIVE: Impaired Urinary Urinary tract infection After 8 hrs of Independent: After 8
“Nahihirapan akong Elimination related to nursing >Assess clients >To assess degree of of nurs
umihi,, madalas sya pero Inflammation of intervention the previous pattern of interference or interve
pakonti konti lang” bladder mucosa . elimination and disability. the clie
Inflammation of bladder client will be able
was ab
to portray and compare with
OBJECTIVE: mucosa and renal tissues portray
>patient awake on bed in verbalize improve current situation. verbali
lying position at semi- urinary elimination Note reports of improv
fowler position pattern. frequency, urinary
>conscious and coherent Inflammatory response urgency, burning, elimina
>hesitancy on urination incontinence, pattern
>frequency on urination nocturia, enuresis.
>urgency on urination
Irritates bladder trigone and
>v/s are follows:
T-38.2degree urethra
celcius(febrile) >To assess retention
>Palpate bladder
>I and O-1600cc/day
Bladder contraction
>To determine level
>Determine clients
of hydration.
usual daily fluid
Pain is perceived intake(both
amount, beverage
choice and use of
caffeine), note
[Pick the date] Acute Pyelonephritis

Disturbance in elimination conditions of skin,

mucus membrane
and color of urine.

Dysuria Urgency Urinary

& Hesitancy >Encourage fluid

Frequ…ency intake up to 3000- >To help maintain
4000 ml per day renal function,
including cranberry prevent infection and
juice. formation of urinary
>Instruct the client stones.
to void every 2-3 >This prevents over
hours during the distention of the
day and completely bladder and
empty the bladder. compromised blood
supply to the bladder
Collaborative: wall.
>Send urine
specimen (mid-
stream clean >Identify presence of
voided) for culture signs of UTI-cloudy,
and sensitivity. foul odor; bloody
urine.

Dependent:
>Administer
[Pick the date] Acute Pyelonephritis

medications as
indicated e.g >Relieves pain,
analgesics and promotes general
antibiotics. comfort and rest.

ASSESSMENT DIAGNOSIS INFERENCE PLANNING NURSING RATIONALE EVALU

INTERVENTION
OBJECTIVE: Risk for deficient fluid Hypermetabolic Short-term Independent: After 8
>patient awake on bed in volume related to state(fever), vomiting, and >Note possible >to assess causative/ of nurs
lying position at semi- hypermetabolic state After 15-30 conditions/ contributing factors. interve
fowler position and excessive losses minutes of nursing processes that may , the pa
>conscious and coherent intervention, client mainta
lead to
>nausea and vomiting Excessive losses of fluid will able to an ade
>diaphoresis deficits;1)fluid loss fluid vo
demonstrate e.g. fever ,vomiting
>v/s are follows: as evid
T-38.4 degree behaviors changes ,sweating;heatstro by moi
celcius(febrile) dehydration to prevent ke. 2) decreased mucou
RR-23cpm development of oral fluid intake. membr
PR-104bpm fluid volume deficit. good s
BP-130/70mmHg > Hypotension, turgor,
>Assess vital signs.
Risk for Deficient fluid tachycardia, fever
I & O: 1600cc/day Long-term Blood pressure, capillar
volume can indicate response refill.
pulse and
After 8 hours of to and or effect of
temperature
nursing fluid loss.
interventions, the
patient will
maintain an >Observe for
>Indicates excessive
adequate fluid excessively dry skin
[Pick the date] Acute Pyelonephritis

volume and mucous fluid loss or resultant

membranes, dehydration.
decreased skin
turgor, slowed
capillary refill.

> Determine >Very young and

effects of age extremely elderly
individuals are
quickly affected by
fluid volume deficit,
and are least able to
express needs.

>Monitor intake > To ensure accurate

and output (I&O). fluid status and
Note number, provides information
character, and about overall fluid
amount of stools. balance, renal
Estimate insensible function, and bowel
fluid losses like disease control, as
diaphoresis. well as guidelines for
Measure urine fluid replacement.
specific gravity and
observe for
oliguria.
[Pick the date] Acute Pyelonephritis

>Encourage oral
intake. Provide
water and other >to prevent
occurrence of deficit
fluid needs to a
minimum amount
daily ( up to
2.5L/day or
amount
determined by
health care
provider for client’s
age,weight, and
condition)

> Encourage client

to increase fluid
intake when
>to prevent
exercising or during
hot weather. occurrence of deficit
Encourage to
maintain diary of
foods/fluid intake;
number and
amount of voiding
and stools; and so
forth.

>Provide
supplemental fluids
like PNSS 1L as fluid > To promote
[Pick the date] Acute Pyelonephritis

replacement also. hydration.

Collaborative:
>Monitor
laboratory studies.

> Determines
replacement needs
Dependent: and effectiveness of
>Administer therapy.
Antiemetics and
antipyretics as >Used to control
indicated nausea and vomiting
in acute attack and to
relieve fever.