Acute Pyelonephritis

ACTUAL & POTENTIAL Nursing Care Plan: ACUTE PYELONEPHRITIS

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ASSESSMENT Subjective: Mainit ang pakiramdam ko at giniginaw ako Objective: >Conscious and coherent >flushed skin >skin warm to touch >(+) profuse sweating >(+)chills >V/S taken BP: 130/90 RR:20 PR:90 Temp:39.4

DIAGNOSIS Hyperthermia related to inflammatory process

INFERENCE Endogenous Pyrogen releases from endotoxins and after phagocytosis by macrophages

PLANNING Short term: After 1 hour of nursing intervention patient will decrease from 39.4-37.5 C Long term: After 2 days nursing intervention patient will maintain normal core temperature.

INTERVENTION Independent: 1.Monitor condition

RATIONALE >To determine the need for intervention and the effectiveness of therapy. >To obtain comparative baseline data and to assess contributing factors. >To evaluate effects or degree of hyperthermia >To have a baseline data

EVALUATION Goal met. The temperature of the patient was decreased from 39.4 to 37.5

Stimulate IL-1

2.Assess underlying condition and body temperature

Stimulate Anterior Hypothalamus

Thermoregulati on set point

Heat conservation (vasoconstricti

3.Assess neurologic response, noting level of consciousness and orientation, reaction to stimuli and presence of posturing or seizures. 4.Monitor vital

>To assist with measures to

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on)
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signs

reduce body temperature >It supports circulating volume and tissue perfusion >To promote hydration >To regain energy

Heat production (involuntary muscle contraction)

5.Remove unnecessary clothing that could only aggravate heat 6.Encourage increase fluid intake 7.Promote adequate rest periods 8.Advise to increase calorie diet and provide tepid sponge bath Dependent: 9.Administer antipyretic as ordered or prescribed by the physician

Fever

>Helps in lowering the temperature and promote surface cooling >Aids in lowering down temperature

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ASSESSMENT Subjective: Bakit masakit at palagi ang pag-ihi ko? Objective: >Conscious and coherent >oriented >voicing inappropriate action towards illness

DIAGNOSIS Deficient Knowledge related to lack of information

INFERENCE High school graduate Inefficient Knowledge towards disease process Inappropriate management towards illness Neglect previous illness (UTI) Progress to complication Acute Pyelonephritis

PLANNING Short Term: After 1530mins of health teaching patient will verbalize understanding of condition, disease process and treatment. Long Term: After 2days of health teaching patient will assume responsibility for own learning and begin to look for information and ask questions. Patient will also perform

INTERVENTION 1.Determine clients ability to learn.

RATIONALE > to determine if patient is physically, emotionally or mentally capable at this time. >females are at high risk to develop urinary tract infection because of short urethra and absence of prostatic fluid. >to meet learners need. >to assess clients participation and learning towards health teaching.

EVALUATION Goal Met After 2days of Health teaching, patient understand how to prevent infection, the manifestations and interventions to do if recurrence happens as evidenced by the clients statements and no recurrence of infection.

2.Note personal factors (e.g. age, sex, level of education)

3.State objective clearly in learners terms 4. Encourage client to participate during health teaching by asking

Acute Pyelonephritis

Deficient knowledge

necessary procedures correctly and explain reasons for the actions.

questions. 5. Teach patient about predisposing factors like bladder over distention, sexual intercourse, loss of resistance to invading microorganism s and indwelling catheterization . 6. Teach patient about manifestations of pyelonephritis like frequency, urgency, dysuria, foul smelling urine, malaise, fever, and possibly bloody or cloudy urine. >to ensure that patient can recognize causes that can lead to urinary tract infection.

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>to ensure that patient can recognize the manifestatios of pyelonephritis and knows to seek prompt medical attention when these manifestations do occur. >Prevents contamination

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7. Provide information to patient about health an lifestyle measures to prevent pyelonephritis including perineal hygiene measures such as wiping from front to back, hand washing before/after using the toilet, wearing cotton underwear and emptying the bladder every 2-3hrs and immediately after sexual intercourse.

of the urinary meatus with the colonic bacteria from the anus. >Hand washing is the single most effective practice to prevent spread of microorganism s. >Cotton underwear are absorbent. Moisture enhances proliferation of microorganism . >Urinary stasis in the bladder enhances proliferation of microorganism and to prevent contamination of the urinary

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Acute Pyelonephritis

meatus by colonic bacteria from the anus. 8. Encourage patient to complete the full course of antibiotic therapy. >infection should subside with adequate antibiotic treatment.

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ASSESSMENT SUBJECTIVE: Palaging sumasakit ang tagiliran ko. OBJECTIVE: >patient awake on bed in lying position at semi-fowler position >conscious and coherent >responsive to physical and verbal stimuli >irritated >anxious >with narrowed focus >with sleep disturbance >dilated pupils >with facial grimace >with weakness and fatigue >diaphoresis >pale >with abdominal guarding behavior > with tenderness in left CVA >v/s are follows: T-38.4degree celcius(febrile) RR-22 cpm PR-103 bpm BP-130/70mmHg
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DIAGNOSIS Acute Pain related to acute renal inflammatory process

INFERENCE Tissue damage detect by sensory neurons Tissue injury Stimuli Noxious stimuli trigger release of biochemical mediators(e.g. prostaglandins, histamine,bradykinin) Inflammation sensitization of nocireceptors transmits pain sensation Response(pain perceived sympathetic nervous system response: PR,RR,BP

PLANNING

After 30minutes Acute Pyelonephritis to 1 hour of nursing intervention the clients painscale will decreases from 8/10 to 3/10.

NURSING INTERVENTIO N Independent: >Assess pain, including location, quality, duration and intensity.

RATIONALE

EVALUATI ON After 30minutes to 1 hour of nursing interventio n the clients painscale was decreased from 8/10 to 3/10. Client verbalized relief of pain.

>To know the severity , development and progression of pain and disease and to obtain baseline data and compared with the clients previous pain symptoms. >Non verbal cues may be both physiologic and psychologic and maybe used in conjunction with verbal cues to evaluate extent/severity of the problem. >Helpful in establishing diagnosis and treatment needs. >Reduction of anxiety, tension that can promote relaxation and comfort and distract attention of the client of pain.

>Assess nonverbal cues.e.g. abdominal guarding, tachycardia, diaphoresis.

Diaphoresis Dilated pupils >facial mask of pain (facial grimace) >restless, irritated and anxious >abdominal guarding(protective gesture)

>Assess and review factors that aggravate or alleviate pain. > Provide nonstimulating, calm and quiet environment and encourage client the use of relaxation technique e.g. music therapy. >Provide oral care,

>Painscale: Placement and Precipitating factor: - left and right flank pain

>Halitosis from stagnant oral