NURSING CARE PLAN

NURSING CARE PLAN- 1

Assessment Diagnosis Planning Intervention Evaluation

Subjective: Acute Pain r/t At the end INDEPENDENT Goal met

acute of 8 hour 1. Established rapport. as
katong na inflammation of shift, Rationale: To get patients cooperation. evidenced
admit ko kay renal tissues patient by
sakit kaayo secondary to will: 2. Monitored VS. decreased
akong kilid acute Rationale: To have baseline data. pain scale
as verbalized pyelonephritis - report from 8/10
by the decreased 3.Assessed for referred pain, as to 2/10
patient pain scale appropriate
from 8/10 Rationale: To help determine possibility
Objective: to 2/10 of underlying condition or organ
dysfunction requiring treatment.
- (+) Facial - (-) facial
grimace, grimace 4. Accepted clients description of pain.
guarding and Rationale: Pain is a subjective
behavior guarding experience and cannot be felt by others.
behavior
- Pain scale 5. Observed non-verbal cues and pain
of 8/10 behaviors and other objective defining, as
noted.
Rationale: Observations may not be
congruent with verbal reports or may be
only indicator present when client is
unable to verbalize.

6.Provided comfort measures

Rationale: To promote non
pharmacological pain management.

7. Instructed in and encourage case of

relaxation techniques.
Rationale: To distract attention and
reduce tension.
 8. encourage verbalization of feeling
about pain
Rationale: to evaluate coping abilities
and identify ideas of additional concern

9. Encouraged adequate rest period.

Rationale: To prevent fatigue that can
impair ability to manage pain.

DEPENDENT
10. Administered pain reliever as
necessary.
Rationale: To maintain acceptable level
of pain.

NURSING CARE PLAN- 2

Assessment Diagnosis Planning Intervention Evaluation

Objective: Hyperthermia After 8 hours INDEPENDENT Goal met as

r/t infection of nursing 1. Established rapport. evidenced by
Temperature and intervention: Rationale: To get patients decreased
of 38.8 inflammatory cooperation. temperature
process - the from 38.8 to
skin is warm secondary to patients 2. Monitor white blood cell (WBC) 37.1, (-)
to touch acute temperature count chills
pyelonephritis will decrease Rationale: An increasing WBC count
(+) chills from 38.8 to indicates the bodys efforts to combat
37 pathogens; Very low WBC count may
urinalysis indicate a severe risk for infection.
shows WBC -the patient
count of will 3. Assess and monitor nutritional
16.61 (high) demonstrate status, weight, history of weight loss,
behaviors to and serum albumin.
promote Rationale: Patients with poor
normal body nutritional status may be anergic or
temperature unable to muster a cellular immune
response to pathogens making them
susceptible to infection.

4. Provide high caloric diet or as

indicated by the physician.
Rationale: To meet the metabolic
demand of client.

5. Monitor patients temperature and

note for presence of chills/ profuse
diaphoresis
Rationale: temperature of greater
than 37.7 (99.8 F) may indicate
infection; very high temperature
accompanied by sweating and chills
may indicate septicaemia.

6. Adjust and monitor environmental

factors like room temperature and
bed linens as indicated.
Rationale: Room temperature may
be accustomed to near normal body
temperature and blankets and linens
may be adjusted as indicated to
regulate temperature of client.

7. perform tepid sponge bath as

needed
Rationale: TSP promotes heat loss
and therefore decreasing body
temperature

8. Educate client of signs and

symptoms of hyperthermia and help
him identify factors related to
occurrence of fever; discuss
 importance of increased fluid intake
to avoid dehydration.
Rationale: Providing health
teachings to client could help client
cope with disease condition and
could help prevent further
complications of hyperthermia

DEPENDENT
9. Administer antipyretics as ordered
Rationale: Antipyretics acts on the
hypothalamus, reducing
hyperthermia

10. Start intravenous normal saline

solutions or as indicated
Rationale: To replenish fluid losses
during shivering chills.

NURSING CARE PLAN- 3

Assessment Diagnosis Planning Intervention Evaluation

subjective: Activity At the end of INDEPENDENT Goal met as

luya kay intolerance r/t 8 hour shift, 1. Established rapport. evidenced by
akong decreased patient will: Rationale: To get patients normal vital
paminaw, hemoglobin cooperation. signs and
murag kog secondary to - Patient will patient being
katulogun acute exhibit 2. Assess the physical activity level able to
pyelonephritis tolerance and mobility of the patient. perform ADL
during Rationale: Provides baseline independently
Objective: physical information for formulating nursing and makes
activity as goals during goal setting. use of energy
Low evidenced conservation
hemoglobin by being 3. Assess the patients nutritional techniques.
of 118 g/L able to status.
perform ADL Rationale: Adequate energy
Fatigue and with minimal reserves are needed during
lethargy or without activity.
assistance
4. Observe and monitor the patients
- Patient will sleep pattern and the amount of
use energy- sleep achieved over the past few
conservation days.
techniques. Rationale: Sleep deprivation and
difficulties during sleep can affect
the activity level of the patient

5. Assess the need for ambulation

aids (e.g., cane, walker) for ADLs.
Rationale: Assistive devices
enhance the mobility of the
patient by helping him overcome
limitations.

6. Establish guidelines and goals of

activity with the patient and/or SO.
Rationale: Motivation and
cooperation are enhanced if the
patient participates in goal setting.

7. Have the patient perform the

activity more slowly, in a longer
time with more rest or pauses, or
with assistance if necessary.
Rationale: Helps in increasing the
tolerance for the activity.

8. Gradually increase activity with

active range-of-motion exercises
in bed, increasing to sitting and
then standing.
Rationale: Gradual progression of
the activity prevents overexertion.

9. Encourage physical activity

consistent with the patients
energy levels.
 Rationale: Helps promote a sense of
autonomy while being realistic
about capabilities.

10. Encourage active ROM

exercises. Encourage the patient
to participate in planning activities
that gradually build endurance.
Rationale: Exercise maintains
muscle strength, joint ROM, and
exercise tolerance. Physical
inactive patients need to improve
functional capacity through
repetitive exercises over a long
period of time.

NURSING CARE PLAN- 4

Assessment Diagnosis Planning Intervention Evaluation
After 8 hours
Subjective: Risk for of nursing INDEPENDENT Goal met as
Impaired intervention: 1. Established rapport. evidenced by
Patient urinary Rationale: To get patients patient being
verbalized elimination r/t -the patient cooperation. able to
hapdus ug inflammation/ will be able maintain
sakit magihi irritation of to maintain a 2. Monitored VS. normal
bladder normal Rationale: To have baseline data. elimination
Objective: mucosa elemination pattern and
secondary to pattern 3. determine clients usual daily intake demonstrated
-High acute Rationale: to help determine level of behaviors and
creatinine pyelonephritis -the patient hydration techniques to
level of 167 will prevent
umol/L demonstate 4. ascertain clients previous pattern of urinary
techniques urine elimination infection
-Dysuria to prevent Rationale: for comparison with
urinary current situation
-Urinary infection 5. Encourage fluid intake of 2,000 to
frequency 3,000 mL of water per day, unless
contraindicated
Rationale: Fluids promote diluted
 urine and frequent emptying of
bladder reducing the stasis of
urine and flushing
microorganisms

6. encourage client to verbalize fears

and concerns
Rationale: open expression allows
client to deal with feelings and
begin problem solving

7. check frequently for bladder

distention
Rationale: To reduce risk of infection
and/or autonomic hyperreflexia.

8. Instruct the female client to wipe the

area from front to back and the
avoidance of bath tubs.
Rationale: Proper perineal care helps
in minimizing the risk of
contamination and re-infection.

9. Encourage the client to void every

2-3 hours.
Rationale: To prevent the
accumulation of urine thus limiting
the number of bacteria.

10. Palpate the clients bladder every

4 hours.
Rationale: To determine the presence
of urinary retention.
 NURSING CARE PLAN- 5
Assessment Diagnosis Planning Intervention Evaluation

Objective: Risk for At the end INDEPENDENT Goal met as

electrolyte of 8 hour 1. Established rapport. evidenced
Sodium level imbalance r/t shift, patient Rationale: To get patients cooperation. by patient
is 139 renal will: being able to
mmol/L dysfunction 2. Monitored VS. Maintain
secondary to - Maintain Rationale: To have baseline data. electrolyte
Potassioum acute electrolyte levels within
level is 4.19 pyelonephritis levels within 3. Assess level of consciousness and the normal
mmol/L the normal neuromuscular function, including limits and
limits sensation, strength, and movement. verbalized
Calcium level Rationale: Client is usually conscious interventions
is 1.22 - Identify and alert; however, muscular to promote
mmol/L health paresthesia, weakness, and flaccid balance.
situations paralysis may occur.
that
increase 4. Encourage frequent rest periods;
risk for assist with daily activities, as indicated.
electrolyte Rationale: General muscle weakness
imbalance decreases activity tolerance.
and
verbalize 5. Assess patients uid status
intervention Rationale: Patients who demonstrate
s to uid volume alterations are likely to
promote have electrolyte alterations as well
balance.
6. Monitor patient for physical signs of
electrolyte imbalance
Rationale: Many cardiac, neurological,
and musculoskeletal symptoms are
indicative of specic electrolyte
abnormalities.

7. Collect and evaluate serum

electrolyte results as ordered
Rationale: to allow for prompt diagnosis
and treatment of any abnormalities
8. Educate patient and family regarding
risks for electrolyte dis- turbances
associated with their particular medical
condition and possible interventions if
symptoms occur
Rationale: Early identication and inter-
vention may prevent life-threatening
complications of electrolyte imbalance.

9. Provide support and encouragement

to patient and family in their efforts to
participate in the management of the
condition.
Rationale: Positive feedback will
increase self-condence and feeling of
partnership in care

10. provide safe environment for the

patient
Rationale: Electrolyte imbalances can
cause poor coordination, weakness,
and altered gait.