The patient presented with a fever of 38.2°C, weakness, and complaints of headache and feeling feverish. The nursing diagnosis was hyperthermia related to an infection. Goals were to reduce the patient's temperature to normal range within 3 days and maintain a normal temperature with interventions. Interventions included monitoring vitals, skin temperature, administering antipyretics and tepid baths to promote heat loss.
The patient also reported pain with urination and had dark urine. The nursing diagnosis was acute pain related to a urinary tract infection. Goals were to relieve pain within 8 hours and decrease the pain scale to less than 4 out of 10 within 1 hour. Interventions included assessing pain,
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The patient presented with a fever of 38.2°C, weakness, and complaints of headache and feeling feverish. The nursing diagnosis was hyperthermia related to an infection. Goals were to reduce the patient's temperature to normal range within 3 days and maintain a normal temperature with interventions. Interventions included monitoring vitals, skin temperature, administering antipyretics and tepid baths to promote heat loss.
The patient also reported pain with urination and had dark urine. The nursing diagnosis was acute pain related to a urinary tract infection. Goals were to relieve pain within 8 hours and decrease the pain scale to less than 4 out of 10 within 1 hour. Interventions included assessing pain,
The patient presented with a fever of 38.2°C, weakness, and complaints of headache and feeling feverish. The nursing diagnosis was hyperthermia related to an infection. Goals were to reduce the patient's temperature to normal range within 3 days and maintain a normal temperature with interventions. Interventions included monitoring vitals, skin temperature, administering antipyretics and tepid baths to promote heat loss.
The patient also reported pain with urination and had dark urine. The nursing diagnosis was acute pain related to a urinary tract infection. Goals were to relieve pain within 8 hours and decrease the pain scale to less than 4 out of 10 within 1 hour. Interventions included assessing pain,
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The patient presented with a fever of 38.2°C, weakness, and complaints of headache and feeling feverish. The nursing diagnosis was hyperthermia related to an infection. Goals were to reduce the patient's temperature to normal range within 3 days and maintain a normal temperature with interventions. Interventions included monitoring vitals, skin temperature, administering antipyretics and tepid baths to promote heat loss.
The patient also reported pain with urination and had dark urine. The nursing diagnosis was acute pain related to a urinary tract infection. Goals were to relieve pain within 8 hours and decrease the pain scale to less than 4 out of 10 within 1 hour. Interventions included assessing pain,
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NCP
HYPERTHERMIA Nursing diagnosis Hyperthermia related to invasion of infection S: ang sakit ng ulo ko! Nilalagnat ata ako as verbalized by patient. O: -Temp. is 38.2C -weakness -V/S taken as follows: T: 38.2 P: 86 R: 1920 BP: 150/100 Analysis Hyperthermia is when the bodys temperature is above the usual range, i.e. 36-37, occurs due to a defense mechanism against infection. Goals and objectives After 3 days of nursing intervention the patients body temperature will fall within the normal range as evidenced by vital signs. After 30 minutes of nursing intervention the patient will maintain normal core temperature as evidenced by vital signs within normal limits and normal WBC level. Intervention -Monitor vital signs -Assess skin color and temperature -monitor WBC count, hematocrit value and other pertinent lab reports for indication of infection or dehydration. -remove excess blankets when the client feels warm, but provide extra warmth when the client feels chilled. -provide adequate nutrition and fluids Rationale -To have a baseline data -To determine the need for intervention and the effectiveness of therapy. Evaluation The patient shall maintain normal core temperature as evidenced by normal vital signs and normal laboratory results.
-so that the client feels comfortable and to prevent further complications
- To meet the increased metabolic demands and prevent dehydration.
-Measure intake and output
-to monitor fluid intake and output,
to to determine the need for intervention and the effectiveness of therapy. -Reduce physical activity -to limit heat production, especially during the flush stage. -to reduce elevated body temperature.
-Administer antipyretics as ordered -provide a tepid sponge bath
-to promote heat loss through evaporation and conduction. -to prevent chills from occurring
-provide dry clothing and bed linens. -provide oral hygiene
-to keep the mucous membranes moist to promote hydration
ACUTE PAIN
Nursing Diagnosis Acute pain related to biological factors such as activity of disease process. S: masakit talaga pagumiihi ako. As verbalized by the patient. O: -pain upon urination -dark yellow urine -V/S taken as follows: T: 38.2 P: 86 R: 1920 BP: 150/100
analysis A urinary tract infection is an infection of any of the organs in the urinary tract, which consist of the bladder, the ureter, the urethra, and the kidneys. A urinary tract infection (UTI) may occur in the: Bladder - Cystitis is an infection of the bladder. Urethra Urethritis is infection/inflammation of the urethra. Ureter -Ureteritis is infection of a ureter. Kidney Pyelonephritis is an infection of the kidney itself. Most UTIs result from ascending infections by bacteria that have entered through the urinary meatus but some may be caused by hematogenous spread. UTIs are much common in females because the shorter female urethra makes them more vulnerable to entry of
Goals and objectives After 8 hours of Nursing interventions, the patients pain will be relieved. After 1 hour of nursing intervention Patient will report a decrease in her pain scale of <4 out of 10.
rationale information to aid in determining choice or effectiveness of interventions. hydration flushes bacteria and toxins. may develop, causing tissue distention ( bladder or kidney), and potentiates risk for further infection. uremic waste and electrolyte imbalances may be toxic to the CNS. relaxation, refocuses attention, and may enhance coping abilities.
evaluation After 8 hours of nursing interventions, the patients pain will be relieved and feel more comfortable.
-Encourage increased fluid intake. of bladder fullness.
changes in mental status, behavior or level of consciousness. mfort measure like back rub, helping and Patient assume position of comfort. Suggest use of relaxation technique and deep breathing exercises.
organisms from surrounding structures.
of sitz baths, warm soaks to the perineum. Anti-bacterial drug as prescribed.
relaxation.
bacteria present in urinary tract and those introduced by drainage system.
