CUES SUBJECTIVE: Maul-ol it ak balakang ha may ligid ha wala nga dapit, as verbalized by the client Bagat gin-bubuno hiya

a ha sobra ka sakit, as verbalized by the client OBJECTIVE: Patient rated pain as 8 (in a scale of 0-10; 0 with no pain and 10 being the most painful) Vital signs HR: 111(Normal: 60-100 RR: 28cpm

NURSING DIAGNOSI S Acute pain related to inflammato ry process

SCIENTIFIC RATIONALE 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 inflammation. *MedicalSurgical Nursing 6th

OBJECTIVE SHORT TERM: After 8 hours of nursing intervention the client will be able to: a.) verbalize pain characteristics, duration, onset, quality, frequency or severity of pain b.) enumerate at least 4 non pharmacologic techniques c.) report pain relieved from pain rating scale of 9 to pain rating scale of 5 d.) able to

NURSING INTERVENTION INDEPENDENT 1. Establish rapport

RATIONALE

EVALUATION

to facilitate cooperation as well as to gain pts trust to obtain baseline data pain is a subjective experience and must be described by the client in order to plan effective treatment.

2. Monitor vital signs 3. Assess the pain characteristics Quality Severity Location Onset Duration

After 8 hours of nursing intervention the client was able to: a.) verbalized pain characteristics, duration, onset, quality, frequency or severity of pain b.) enumerated at least 4 non pharmacologic techniques

4. Observe non verbal cues and pain behaviour and other objectives defining characteristics as noted

Observation may not be congruent with verbal reports or may be the only indicator present when client is unable to verbalize

c.) reported pain relieved from pain rating scale of 9 to pain rating scale of 5

5. Teach the use of

d.) demonstrated

(Normal: 1520cpm) BP: 129/90 (Normal: 120/80) facial grimacing noted irritability noted anxiety and fatigue noted sleeplessness noted

Edition by Joyce M. Black, Jane Hokanson Hawks, Anabelle M. Keene Volume 1, Page 854-855*

demonstrate and practice relaxation technique e.) follow prescribe medicine

nonpharmacologic techniques such as, relaxation guided imagery music therapy distraction 6. Demonstrate and practice the relaxation technique with the patient such as deep breathing yawning abdominal breathing peaceful imaging 7. Create a quiet, nondisruptive environment with dim lights and comfortable temperature when possible.

the use of noninvasive pain relief measures can increase the release of endorphins and enhance the therapeutic effects of pain relief medications.

and practiced relaxation technique e.) followed prescribe medicine

return demonstrations by the participant provide an opportunity for the nurse to evaluate the effectiveness of teaching and also to distract attention and reduce tension Comfort and a quiet atmosphere promote a relaxed feeling and permit the client to focus on the relaxation technique rather than external

8. Encourage verbalization of

feelings about pain

distraction. Reduction of anxiety and fear can promote relaxation and comfort

COLLABORATIVE 9. Administer prescribe medicine for pain such as Ibuprofen 200 mg 1 tab now then every 6 hours prn

Ibuprofen inhibits prostaglandin synthesis thus decreasing pain and inflammation

CUES SUBJECTIVE: Waray ako gana pagkaon, as verbalized by the patient OBJECTIVE: Vomitus about 240ml composed of ingested food Weight is 40kg. (Normal is 44kg) Vomiting lasted for 3 days Weakness noted Pale conjunctiva and mucous membrane noted

NURSING DIAGNOSI S Imbalance nutrition: less than body requiremen t related to loss of appetite

SCIENTIFIC RATIONALE Gastrointestina l signs and symptoms are often associated with urologic conditions because of shared autonomic and sensory innervations and renointestinal reflexes. The proximity of the right kidney to the colon, duodenum, head of the pancreas, common bile duct, liver, and gallbladder may cause gastrointestina l disturbances. The proximity

OBJECTIVE

NURSING INTERVENTION INDEPENDENT 1. Establish rapport with the patient 2. Assess drug interactions and disease effects 3. Assess weight

RATIONALE

EVALUATION

SHORT TERM After 2 hours of nursing intervention the client will be able: a.) to reduce vomiting b.) enumerate at least 3 importance of adequate nutrition MEDIUM TERM After 3 weeks of nursing intervention the client will be able to: a) demonstrate progressive weight gain

To facilitate cooperation as well as to gain patients trust That may be affecting appetite, food intake, or absorption To establish baseline parameters Helps determine nutritional needs

After 2 hours of nursing intervention the client was be able: a.) to reduce vomiting b.) enumerated at least 3 importance of adequate nutrition

4. Assess age, body build, strength, activity and rest level

5. Discuss and enumerate at least Client may have 3 importance of inadequate or adequate nutrition inaccurate such as: knowledge regarding the contribution of a.) it provides good nutrition to energy overall wellness b.) it prevents illness c.) create a

After 3 weeks of nursing intervention the client was be able to:

a.) demonstrated progressive weight gain

of the left kidney to the colon, stomach, pancreas, and spleen may also result in intestinal symptoms. The most common signs and symptoms are nausea, vomiting, diarrhea, abdominal discomfort and abdominal distension. *Medical Surgical Nursing 12th edition Vol 2 Page 1301*

healthy lifestyle b) demonstrate behaviours, lifestyle changes to regain and/or maintain appropriate weight 6. Promote pleasant, relaxing environment, including socialization when possible 7. Prevent or minimize unpleasant odors or sights 8. Promote adequate and timely fluid intake. Limit fluids 1 hour prior to meal 9. Stay with client during meals COLLABORATIVE 10. Provide nutritional therapy within hospital treatment program b) demonstrated behaviours, lifestyle changes to regain and/or maintain appropriate weight

To enhance intake

May have a negative effect on appetite and eating To reduce possibility of early satiety

To assist as needed to offer support and encouragement Cure of the underlying problem cannot happen without improved nutritional status Having a variety of foods available

11. Provide diet and snacks with substitutions of preferred foods when available

enables client to have a choice of potentially enjoyable foods

CUES

NURSING DIAGNOSI S

SCIENTIFIC RATIONALE

OBJECTIVE

NURSING INTERVENTION

RATIONALE

EVALUATION

SUBJECTIVE: Hyperther It akon anak mia related nagbibinalik balik it to invasion hiranat, as of infection verbalized by the mother of the client OBJECTIVE: Flushed skin with body temperature of 39 degrees celcius (Normal: 36.537.5) Vital signs HR: 111(Normal: 60-100 RR: 28cpm (Normal: 1520cpm) BP: 129/90 (Normal: 120/80) Increase thirst Pyrogens, chemicals released by microorganism , neutrophil and other cells, stimulate fever production. Pyrogens affect the body temperature regulating mechanism in the hypothalamus of the brain. As a consequence, heat production and conservation increase, and body temperature. Fever promotes the activities of the immune system, such as phagocytosis,

SHORT TERM: After 2 hours of nursing intervention the client will be able to: a.) maintain normal body temperature b.) follow prescribed pharmacologic regimen MEDIUM TERM: After 1 week of nursing intervention the client will be able to: a.) prevent recurrence of fever

INDEPENDENT 1. Establish rapport with the patient 2. Monitor vital signs 3. Assess environmental factors (room temp.) 4. Measure intake and output

to facilitate cooperation as well as to gain patients trust to obtain baseline data Room temperature can affect patients temperature To monitor or potentiates fluid and electrolyte loses and to determine the clients hydration status To promote heat loss by evaporation and conduction To minimize shivering Facilitates heat loss

After 2 hours of nursing intervention the client was able to: a.) maintained normal body temperature b.) followed prescribed pharmacologic regimen

5. Apply tepid sponge bath 6. Provide blanket if the client feels cold 7. Remove extra blanket if the client feels warm and change client

After 1 week of nursing intervention the client will be able to: a.) prevent recurrence of fever

Loss of appetite Body weakness Drowsiness Shivering

and inhibits the growth of some microorganism . *Essential of Anatomy and Physiology 6th edition by Seeley Stephens Tate, Page 397*

clothing into lighter ones 8. Encourage client to increase fluid intake 9. Encourage client to rest

Water regulates body temperature and prevent dehydration To limit heat production and decrease oxygen demand To keep the mucous membrane moist and improve appetite

10. Provide oral hygiene COLLABORATIVE 11. Provide high caloric diet as indicated by the physician.

To meet the 12. Administe metabolic demand of r antipyretic the client such as Paracetamol 500mg every 4 Antipyretic acts on hours the hypothalamus thereby reducing 13. Administe

r antibiotic as prescribed for infection such as Ceforuxime 500 mg 1 tab Doxycycline 100 mg 1 cap BID

hypothermia

Binds to bacterial cell wall membrane, causing cell wall death Inhibits bacterial protein synthesis at the level of 30S Bacterial ribosome Inhibits protein synthesis in bacteria at level of 30S ribosome Binds to bacterial cell wall resulting to cell wall death

Amikacin 500 mg IV drip OD ANST (-)

Ampicillin 1.5 mg IVTT every 8 hours ANST (-)

CUES

NURSING DIAGNOSIS

SCIENTIFIC RATIONALE

OBJECTIVE

NURSING INTERVENTION

RATIONALE

EVALUATION

SUBJECTIVE: Diri gad itun hiya nakakakaturo g hin tuhay kay ginkukurian hit iya balakang as verbalized by the mother of the client Bagat ginkukurumos tak ulo, as verbalized by the patient OBJECTIVE change in normal sleep pattern Decrease ability to function Restlessn ess Reports difficulty falling sleep Disturbed sleeping pattern related to flank pain Disruption in the individuals usual diurnal pattern of sleep and wakefulness may be temporary or chronic. Such disruptions may result in both subjective distress and impairment of functional abilities. Sleep patterns can be affected by environment, especially in hospital care units. These patients experience sleep disturbance secondary to pain, noisy and treatment regimen. *Nursing Care Plans 6th edition by Gulanick/Myers, page 177*

SHORT TERM After 3 hours of nursing intervention the client will be able to: a.) report improved sleep b.) report increase sense of well being and feeling rested c.) use relaxation techniques d.) Increase the comfort of regimen

INDEPENDENT 1. Establish rapport.

to facilitate cooperation as well as to gain patients trust ascertain intensity and duration of problems

2. Assess the clients usual sleep patterns and determine and compare with sleep disturbance. 3. Determine normal and usual sleeping habits and changes 4. Minimize sleepdisrupting factors (e.g. shut room door, adjust room temperature, reduce talking and other disturbing noise) 5. Create a new bedtime routine that included in the pattern of the old and new environment

After 3 hours of nursing intervention the client was be able to: a.) reported improve sleep

b.) reported Assessing the need increase sense of well being and and identify feeling rested appropriate intervention To promote readiness for sleep, and improve sleep duration and quality c.) use relaxation techniques d.) Increase the comfort of regimen

When the new routine contain as many aspects of old habits. Stress and anxiety related to pain is

CUES SUBJECTIVE Maul-ol gad it akon pagiihi, as verbalized by the client OBJECTIVE Urinary retention noted Urine is tea colored, odorless Female and 17 years old

NURSING DIAGNOSIS Impaired urinary elimination secondary to urinary tract infection

SCIENTIFIC RATIONALE Signs and symptoms of an uncomplicated lower UTI include burning on urination, frequency, urgency, nocturia, incontinence and suprapubic pain or pelvic pain. Hematuria and back pain may also be present. Medical-Surgical Nursing 12th edition Volume 2 Page1360-1361 by Brunner and Shuddarths

OBJECTIVE

SHORT TERM After 8 hours of nursing intervention the client will be able to: a.) verbalize understandin g of the condition MEDIUM TERM After 1 week of nursing intervention the client will be able to: b.) achieve improved elimination pattern emptying bladder, voiding in appropriate

NURSING INTERVENTION INDEPENDENT 1. Establish rapport with the patient 2. Assess urine output for its characteristics, color, appearance, amount, presence of pus 3. Note age and gender of the client

RATIONALE

EVALUATION

to facilitate cooperation as well as to gain patients trust to determine any abnormalities

After 8 hours of nursing intervention the client was able to: a.) verbalize understanding of the condition

4. Determine clients usual daily fluid intake and note condition of the skin, mucous membranes and color of urine 5. Encourage verbalization regarding understanding of the condition

incontinence and urinary tract infections are more prevalent in women to help determine level of hydration

After 1 week of nursing intervention the client was be able to: b.) achieved improved elimination pattern emptying bladder, voiding in appropriate amounts without retention

Reduction of anxiety and fear can promote relaxation and comfort

6. Assist client to assume normal position

Encourages the

amounts without retention

to void 7. Encourage client to void when urge is noted but not more than every 2 to 4 hours per protocol

passage of urine and promotes sense of normality Voiding with urge prevents urinary retention. Limiting void to every 4 hours, if tolerated, increases bladder tone and aids in bladder retraining. Maintain adequate hydration and renal perfusion for urinary flow Helps regain bladder control, minimizing incontinence

8. Encourage fluid intake to 2200 to 2500 ml as tolerated.

9. instruct client in perineal exercises, such as tightening buttocks and stopping and starting urine stream