Assessment

Diagnosis

Planning

Implementation

Rationale

EXPECTED OUTOME After 30minutes of appropriate nursing intervention the patient would able to lessen the pain as evidenced by: Pain scale at 4 increase in physical activity absent of facial grimace

S: masakit ung pagihi ko pain scale 6/10 O: Facial grimace noted Irritable at times Limited movement noted Weak and pale in appearance

Acute pain r/t biological factors

After 30minutes of appropriate nursing intervention the patient will be able to lessen the pain as evidenced by: Pain scale from 6 to 4 increase in physical activity absent of facial grimace

placed patient to comfortable position instruct to have deep breathing exercise change the position of the patient use positive approach in order to optimize patient response to analgesics help patient to focus on activities Health teaching as follows: eat nutritious food such as fruits vegetable give medication as ordered

To gain comfort Prevent further complication To enhance blood circulation To help patient to lessen perception of pain

To divert the attention of the patient To increased the immunity of the patient To relieve pain

Assessment S: may prolema ako sa pagihi O: With pain in urination With involuntary urination Chilling at times Vomiting at times Decrease physical activity Weak and pale in appearance

Diagnosis Urge urinary incontinence r/t irritation of bladder stretch receptor causing spasm

Planning After 30 minutes of appropriate nursing intervention the patient will able to verbalize understanding regarding on her condition as evidence by: Restating some health teaching

Implementation Establish rapport to the patient Discuss to the patient the signs and symptoms of the disease Instruct patient to have her proper perineal care Instruct patient to monitor her i&o Discuss the importance of monitoring the I&O

Rationale To gain the trust of the patient To give her knowledge when to refer and to decrease anxiety To prevent further complication To prevent further complication like edema To prevent further complication like edema

Expected outcome After 30 minutes of appropriate nursing intervention the patient would able to verbalize understanding regarding on her condition as evidence by: Restating some health teaching

Assessment S: wala akong alam patungkol sa aking karamdaman O: Demonstrated lack of knowledge regarding the disease Not knowing how to do proper perineal care Not knowing the importance of proper hygiene

Diagnosis Altered health maintenance r/t Lack of knowledge

Planning After 30 minutes of nursing intervention the patient will able to gain knowledge regarding the importance of proper hygiene as evidence by showing understanding.

Implementation Establish rapport to the patient Place patient to comfortable position Arrange the bedside of the patient Discuss the importance of proper hygiene Discuss on how to do the proper perineal care Instruct patient to take a bath everyday Discuss to her the

Rationale Gain the trust of the patient For patients comfort For patients comfort and relaxation For additional knowledge To prevent further complication of the disease To prevent further Complication

Expected outcome After 30 minutes of nursing intervention the patient would able to gain knowledge regarding the importance of proper hygiene as evidence by showing understanding

proper nutrition Instruct to eat nutritios food such as fruits and vegetable III. SOAPIE Subjective Objective Analysis Planning

Additional knowledge on how to increase immunity

intervention

Evaluation

S: mainit yung pakiramdam ko

Body temperat ure at 38.3 Skin warm to touch Flushed skin Chilling at times Vomiting at times Limited Weak and pale in appearan ce Irritable at times

Altered body temperature r/t infection

After 1hour of appropriate nursing intervention the patient will able to decrease body temperature from 38.3 to 36.8 as evidence by: Body temp at 36.8 Absence of chilling and vomiting Increase physical activity

Established rapport to the patient Placed patient to comfortable position Arranging the bedside of the patient Tsb rendered Losen the clothing of the patient Provided proper ventilation Given medication as doctors order Health teaching such as: Increase fluid intake 11 to 13 glasses per day Eat nutritious food such as fruits and vegetable Increase food rich in vitamin C

After 1hour of appropriate nursing intervention the patient was able to decrease body temperature from 38.3to 36.8 as evidence by: Body temp at 36.8 Absence of chilling and vomiting Increased physical activity

Subjective S: may prolema

objective With pain in

Analysis Urge urinary

Planning After 30 minutes of

Intervention Established

Evaluation After 30 minutes of

ako sa pagihi

urination With involuntary urination Chilling at times Vomiting at times Decrease physical activity Weak and pale in appearance

incontinence r/t irritation of bladder stretch receptor causing spasm

appropriate nursing intervention the patient will able to verbalize understanding regarding on her condition as evidence by: Restating some health teaching

rapport to the patient Discussed to the patient the signs and symptoms of the disease Instructed patient to have her proper perineal care Instructed patient to monitor her i&o Discussed the importance of monitoring the I&O

appropriate nursing intervention the patient was able to verbalize understanding regarding on her condition as evidence by: Restating some health teaching

Subjective S: wala akong alam patungkol sa aking

Objective Demonstrated lack of

Analysis Altered health maintenance r/t

Planning After 30 minutes of nursing

Intervention Established rapport to the

Evaluation After 30 minutes of nursing

karamdaman

knowledge regarding the disease Not knowing how to do proper perineal care Not knowing theimportance of proper hygiene

Lack of knowledge

intervention the patient will able to gain knowledge regarding the importance of proper hygiene as evidence by showing understanding.

patient Placed patient to comfortable position Arranging the bedside of the patient Discussed the importance of proper hygiene Discussed on how to do the proper perineal care Instructed patient to take a bath everyday Discussed to her the proper nutrition Instructed to eat nutritios food such as fruits and vegetable

intervention the patient was able to gain knowledge regarding the importance of proper hygiene as evidence by showing understanding

II. Planning NCP

Assessment S: mainit yung pakiramdam ko O: Body temperature at 38.3 Skin warm to touch Flushed skin Chilling at times Vomiting at times Limited Weak and pale in appearance Irritable at times

Diagnosis Altered body temperature r/t infection

Planning After 1hour of appropriate nursing intervention the patient will able to decrease body temperature from 38.3 to 36.8 as evidence by: Body temp at 36.8 Absence of chilling and vomiting Increase physical activity

Implementation Establish rapport to the patient Place patient to comfortable position Arrange the bedside of the patient Tsb render Loses the clothing of the patient Provide proper ventilation Give medication as doctors order Health teaching such as: Increase fluid intake 11 to 13 glasses per day Eat nutritious food such as fruits and vegetable Increase food rich in vitamin C

Rationale Gain the trust of the patient Gain the comfort of the patient To gain the comfort and relaxation of the patient To decrease body temperature To have a proper ventilation To prevent further complication such as respiratory problem

Expected outcome After 1hour of appropriate nursing intervention the patient would able to decrease body temperature from 38.3 to 36.8 as evidence by: Body temp at 36.8 Absence of chilling and vomiting Increase physical activity

To replace the fluid loses To increase immunity of the patient To increase

immunity of the patient

ASSESSMENT S: mainit yung pakiramdam ko

DIAGNOSIS Elevated body temperature r/t

PLANNING Within 1 hour of appropriate nursing

IMPLEMENTATION

EXPECTED OUTCOME Placed patient to comfortable After 1 hour of appropriate nursing position like semi fowlers

infection O: Warm to touch Temperature = 38.3 Weak and pale in appearance Skinny in appearance Irritable at times Restlessness noted

intervention the patient will able to decreased body temperature at 37 C

To promote adequate breathing Tsb rendered To decrease body temp Provided proper ventilation Patients comfort Bedside care rendered Patients comfort Instructed the mother to loosen the clothing of the patient For easily ventilation Instructed the mother to kept the patients back dry To alleviate the disease Instructed the mother to increased fluid intake of the baby as tolerated To decreased body temp Given medication as doctors order To alleviate the signs and symptoms of the disease Health teachings such as: Give nutritious food such as fruits and

intervention the patient would be able to decreased body temperature at 37 C

vegetable Breastfeed the baby To increased the immunity of the baby.

Diagnosis & laboratory procedures Urinalysis

Date ordered & date result Date ordered : Nov. 14, 2009 Date result: Nov. 15, 2009

Purpose To determine urine composition & possible abnormal components or infection.

Normal Values (book based) Color : straw amber, transparent Appearance: clear Specific gravity: 1.010-1.022 pH : 4.6-6.5 protein : negative

Results Color :cloudy Appearance: turbid

Interpretation Concentrated urine Concentrated urine

Specific gravity:1.015 pH: 6.0 protein : negative

w/ in the normal range w/ in the normal range w/ in the normal range

bacteria : negative

bacteria : moderate

presence of bacteria causing infection

NONE RBC Amorphous urates

pus cells : 3-5 1-3 few

presence of bacteria causing infection NONE w/ in the normal range

Nursing Responsibility:

Before: collect the specimen for the client and assist the client when assistance is needed. During: Specimen must be free from any contamination. After: Make sure that the specimen is labeled & the laboratory requisition carry the correct information & attached them securely to the specimen. Diagnosis & laboratory procedures Hematology Date ordered & date result Date ordered : Nov. 14, 2009 Date result: Nov. 15, 2009 Purpose Normal Values (book based) WBC- 4.5-10.0 x 0 9/L RBC- 3.6-8.0 x 10 /L Hgb- 120-170 g/L Hematocrit- 0.370.48 % Result Interpretation

RBC, hgb, Hct, is important to the oxygen carrying capacity of the blood. WBC is an indicator of immune infection.

WBC- 16.0 x 10 9/L RBC- 5.8 x 10 /L

Increase WBC Presence of infection w/ in the normal range

Hgb- 135 g/L Hematocrit- 0.40 %

w/ in the normal range w/ in the normal range

Nursing responsibility: Before: inform the client that he/she will going to undergone CBC. During: assist the client while getting blood After: Make sure that the specimen is labeled & the laboratory requisition carry the correct information & attached them securely to the specimen. Medications Route of Name of drugs Date ordered administration, General action of Indication & Client response to

(generic & brand name) Paracetamol (Acetaminophen)

Date started Date changed Date ordered : Nov. 14, 2009

dosage & frequency mechanism of administration 500 mg, 1 tablet q4h It reduce fever by direct action on the hypothalamus heat regulating system leading to vasodilation and sweating it also possibly by inhibiting the action of endogenous pyrogen.

Purposes Treatment for fever and for relief of mild to moderate pain associated with bacterial and viral infection

medication with actual seen Patient reports fever reduce with drug.

Nursing Responsibilities: Before administration: Monitor vital signs. Assist in administering medication. During the administration: Measure and record the vital signs, especially the temperature. After the medication: Monitor the clients body temperature. Be alert to adverse reactions and drug interaction.

Name of drugs (generic & brand

Date ordered Date started

Route of administration, dosage &

General action of mechanism

Indication & Purposes

Client response to medication

name) Ceftriazone

Date changed Nov. 14, 2009

frequency of administration 750 mg q8h (-) ANST

It exhibits bacteriocidal activity by inhibiting cell wall synthesis.

An antiinfective used for serious infections in genitourinary system.

with actual side effect Dizziness.

Nursing Responsibilities: Before administration: Monitor vital signs. Perform skin testing. Assist in administering medication. During the administration: Monitor vital signs. After the medication: Be alert to adverse reactions and drug interaction.

Drugs

Name of Drug

Date ordered/ Date started/ Date changed

Route/ Dosage/ Frequency of Administration Oral administration 500mg tablet once a day

General Mechanism of action Stimulates collagen formation and tissue repair involved in oxidation-reduction reaction is the cells. Boosts immune system.

Indication/ Purpose

Generic Name: Ascorbic Acid (Vit. C) Brand Name: Potencee

Date ordered; Nov.14, 2009

For stronger immune system and faster wound healing.

NURSING RESPONSIBILITIES: (Before) a) Explain the importance and action of drugs to the client of significant others. b) Tell possible reaction or side effect of the drugs. (After) c) Protect the medication from direct light and contamination. d) Monitor urinary pH levels.

Diet

Type of diet

Date ordered Date started Date changed Date ordered; Nov.14, 2009

General Description

Indication & Purposes

Specific foods taken Vegetables, fruits rich in vitamin C, fiber rich foods, whole grains, eggs, cheese, meat, poultry and tomatoes.

Diet as tolerated

Eating on what kind It contraindicated of food but limit with the patient with intake of fat and pyelonephritis. salt.

Client response and or reaction to the diet The clients condition increased energy.

IX.I.) PATHOPHYSIOLOGY (Book Based)

Ascending infection of the urinary tract (Escherichia Coli) Infection reaching pelvis and kidney Interstitial abscesses present in the parenchyma Renal tubules are damage by exudates Inflammation of renal pelvis and kidney (ACUTE PYELONEPHRITIS)

Signs and Symptoms: Hematuria, confusion, fever, weakness, chills, nausea, vomiting, low back pain, flank pain

Medical-surgical nursing book 11th edition Joice Black

Subjective

Objective

Analysis Acute pain r/t bladder spasm

Planning

Intervention

Evaluation

S: masakit ung pag-ihi ko

pain scale 6/10 Limited movement noted Facial grimace noted Irritable at times Weak and pale in appearance

After 30minutes of appropriate nursing intervention the patient will be able to lessen the pain as evidenced by: Pain scale from 6 to 4 increase in physical activity absent of facial grimace

placed patient to comfortable position instructed to have deep breathing exercise changing the position of the patient used positive approach in order to optimize patient response to analgesics help patient to focus on activities given medication as order Health teaching as follows: eat nutritious food such as fruits vegetable

After 30minutes of appropriate nursing intervention the patient was able to lessen the pain as evidenced by: Pain scale at 4 increased in physical activity absent of facial grimace