Cues 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 1-10(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-87 Bpm R-24 bpm BP-130/90 mmHg

Nursing diagnosis Acute pain r/t Acute inflammation of renal tissues as evidenced by verbal reports of pain, guarding behavior and diaphoresis.

Rationale Pyelonephritis is an inflammation of the kidney and upper urinary tract that usually results from noncontagious bacterial infection of the bladder (cystitis). It presents with dysuria (painful voiding of urine), abdominal pain (radiating to the back on the affected side) and tenderness of the bladder area and the side of the involved kidney ("renal angle tenderness"). In many cases there are systemic symptoms in the form of fever, rigors (violent

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

Nursing intervention  Perform a comprehensive assessment of pain to include location, characteristics, onset, duration, frequency, quality and severity as well as the precipitating factors  Encourage patient to verbalize concerns. Actively listen to these concerns and provide support by acceptance, remaining with patient and giving appropriate information.  Promote quiet environment. Identify all stressors and remove it if possible

Rationale  To establish baseline data that will be useful in monitoring improvement in clients level of pain.  Reduction of anxiety or fear that can promote relaxation and comfort.  Comfort and quiet environment promote relaxed feeling and permit the client to focus on the relaxation techniques rather than external distraction. To be able to lessen factors that could be an aggravating cause in clients pain.

Evaluation After 4 hrs of nursing intervention the client was able to verbalize relief of pain from the rate of 8 to the rate of 3.

ROSELLE P. FLORES BSNIV A07 CA25 . and headache.shivering while the temperature rises).

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