Nursing Care Plan for Pyelonephritis

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Cues

Nursing diagnosis

Nursing objective

Planning

Nursing intervention

Rationale

Subjective Cues: “Nahihirapa n akong umihi,, madalas sya pero pakonti konti lang » as verbalized by the client. Objective Cues: Distended abdomen Frequency Hesitancy T-38.3 P-105Bpm R-24 bpm BP-130/90 mmHg

Impaired Urinary Elimination r/t Inflammatio n of bladder mucosa As evidence by the objective cues. __________ _ Scientific Explanation : Disturbance in urine elimination.

After 8 hrs of nursing interventio n the client will be able to portray and verbalize improve urinary elimination pattern.

Plan of care to meet the desired outcome for the client. Make a teaching plan appropriate for the clients condition.

.Determine clients previous pattern of elimination and compare with current situation. Note reports of frequency, urgency, burning, incontinence, nocturia, enuresis. Palpate bladder Determine clients usual daily fluid intake(both amount, beverage choice and use of caffeine), note conditions of skin, mucus membrane and color of urine. Encourage fluid intake up to 3000- 4000 ml per day including cranberry juice. Instruct the client to void every 2-3 hours during the day and completely empty the bladder.

To assess degree of interference or disability. To assess retention To determine level of hydration. To help maintain renal function, prevent infection and formation of urinary stones This prevents over distention of the bladder and compromised blood supply to the bladder wall.

• Evaluation • After 8 hrs of nursing intervention the client was able to portray and verbalize improved urinary elimination pattern.

C u e s

Nur sing diag nosi s

Nu rsi ng obj ect ive

Pla nni ng

Nursing intervention

Rationale

E v al u a ti o n

Instruct the client to keep the perineal area clean and dry. Teach the client how to do kegel exercise and its importance. Teach clients to avoid intake of caffeine, alcohol, colas, and artificial sweeteners. Provide privacy for the client upon voiding. Provide sensory stimuli that may help the client relax. Pour warm water over the perineum of a female or have the client sit in a warm bath.U can also apply a hot water bottle to the lower abdomen. Turn on running water within the hearing distance of the client to stimulate the voiding reflex.

.To reduce the risk for further skin infection and skin breakdown To strengthen the perineal muscle. These are bladder irritants that may increase incontinence. Many people cannot void in the presence of another person. These promote muscle relaxation. Helps facilitate easier voiding.

Cues

Nursing diagnosis

Nursing objective

Planning

Nursing intervention

Rationale

Subjective: “Nung nkraang lingo pa masakit ang tagiliran ko” as verbalized by the client. Objective: Very severe pain--Client rate her pain as 8 from the range of 110(Having the rate of 10 as the most painful and 1 as the least painful) Guarding behavior Facial mask of pain Diaphoresis

T-38.3 P-105 Bpm R-24 bpm BP-130/90 mmHg

Acute pain r/t Acute inflammation of renal tissues as evidenced by verbal reports of pain,guarding behavior and diaphoresis. _______________ Scientific Explanation Unpleasant sensory and emotional experience arising from actual or potential tissue damage. It is a sudden onset of any intensity from mild to severe with duration of less than 6 months.

After 4 hrs of nursing intervent ion the client will be able to verbalize relief of pain from the rate of 8 to at least less than the rate of 4.

Plan techniques in which the clients level of pain will be alleviated primarily by using of independent nursing interventions. Plan with the significant others to cooperate in the pain management program for the client. Gather materials that can be helpful in pain management.

Perform a comprehensive assessment of pain to include location, characteristics, onset, duration, frequency,...
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