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CUES SUBJECTIVE: “Maul-ol it ak tak hawak ha may ligid ha wala nga dapit”, as verbalized by the client “ Bagat ginbubuno

hiya ha sobra ka sakit”, as verbalized by the client OBJECTIVE: • Patient rated pain as 10 (in a scale of 110; 1 being the lowest and 10 being the highest) • facial grimacing noted • Irritability noted • anxiety and fatigue noted • sleeplessnes s noted

NURSING DIAGNOSIS Acute pain related to accumulation of pus in the renal cortex secondary to infection

SCIENTIFIC RATIONALE Pain is a sensation characterized by a group of unpleasant perceptual and emotional experience. 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 infection. *MedicalSurgical Nursing 6th Edition by Joyce M. Black, Jane Hokanson Hawks, Anabelle M. Keene – Volume 1, Page 854855*

OBJECTIVE

SHORT TERM: After 2 hours of nursing intervention the client will be able to: • report pain is relieved or controlle d • follow prescribe d pharmac ologic regimen LONG TERM: After 8 hours of nursing intervention the client will be able to: • verbaliz e non pharma cologic method that provide relief

NURSING INTERVENTI ON INDEPENDENT 1. Establish rapport

RATIONALE

EVALUATION

2. Obtain vital signs 3. Perform a comprehen sive assessmen t of pain to include location, characteris tics, onset, duration, frequency, quality, intensity or severity, and precipitati ng factors of pain. 4. Teach the use of nonpharm acologic techniques (e.g., relaxation, guided imagery, music therapy, distraction, and massage) before, after, and if possible during painful activities; before pain occurs or increases; and along with other pain relief measures 5. Create a quiet, nondisrupti

to facilitate cooperatio n as well as to gain pt’s trust to maintain baseline data pain is a subjective experienc e and must be described by the client in order to plan effective treatment.

the use of noninvasiv e pain relief measures can increase the release of endorphin s and enhance the therapeuti c effects of pain relief medicatio ns.

Each person may find different images or approache s to relaxation more helpful than others. 7.. which will reduce the intensity of the pain. Individualiz e the content of the relaxation interventio n (e. Demonstra te and practice the relaxation technique with the patient comfort and a quiet atmospher e promote a relaxed feeling and permit the client to focus on the relaxation technique rather than external distraction . Elicit behaviors that are conditione d to produce relaxation. 6.g. or peaceful imaging 8. • COLLABORATI return demonstra tions by the participan .ve environme nt with dim lights and • comfortabl e temperatur e when possible. • • relaxation technique s help reduce skeletal muscle tension. abdominal breathing. by asking for suggestion s about what the patient enjoys or finds relaxing). such as deep breathing. yawning.

nociceptiv e) require different analgesic approache s. or NSAID) based on type and severity of pain t provide an opportunit y for the nurse to evaluate the effectiven ess of teaching • Ensures that the nurse has the right drug.g.. acute. nonnarcoti c. neuropath ic. right frequency Various types of pain (e. Some types of pain respond to nonopioi • . dose. 10. and frequency of analgesic prescribed.VE 9. chronic. right dosage. Check the medical order for drug. right client.Determine analgesic selections (narcotic. right route.

CUES NURSINGDIAGN OSIS SCIENTIFIC RATIONALE OBJECTIVE NURSING INTERVENTION RATIONALE EVALUATIO N .

5-37. chemicals released by microorganis m. and inhibits the growth of some microorganis m. Assess environme ntal factors (room temp. stimulate fever production. heat production and conservation ncrease.) 4. As a consequence. Provide oral hygiene • 9. Measure intake and output • • 8. Establish rapport with the patient 2. Encourage client to increase fluid intake 6. Provide dry clothing and clean linens 10. and body temperature. suchu as phagocytosis. Encourage client to rest • • 7. Page 397* SHORT TERM: After 2 hours of nursing intervention the client will be able to: • decrease or maintain normal body temperatu re • stabilize and normalize respirator y rate LONG TERM: After 8 hours of nursing intervention the client will be able to: • INDEPENDENT 1. *Essential of Anatomy and Physiology 6th edition by Seeley Stephens Tate. Monitor vital signs 3.SUBJECTIVE: “It akon anak nagbibinalik balik it hiranat”. neutrophil and other cells. Pyrogen affects the body temperature – regulating mechanism in the hypothalamus of the brarin.5) • RR: 28 cpm (Normal: 15-20 cpm) • Increase thirst • Loss of appetite • Body weakness • Drowsiness • Restlessne ss Hyperthermia related to invasion of infection Pyrogens. Apply tepid sponge bath • to facilitate cooperation as well as to gain pt’s trust to establish baseline data Room temperature can affect patients temperature To promote heat loss by evaporation and conduction Water regulates body temperature and prevent dehydration To limit heat production and decrease oxygen demand To monitor or potentiates fluid and electrolyte loses To determine the clients hydration status To keep the mucous membrane moist and improve appetite To reduce complaints of feeling cold To meet the metabolic demand of the client • • • 5.Provide high caloric diet as indicated • • . as verbalized by the mother of the client OBJECTIVE: • Flushed skin with body temperatur e of 39 degrees celcius (Normal: 36. Fever promotes the activities of the immune system.

Maintain IVF as ordered by the physician 13.Administer antipyretic as prescribed by the physician 12.by the physician DEPENDENT 11.Discuss condition of the patient with other members of the health care team • Antipyretic acts on the hypothalam us thereby reducing hypothermi a To prevents dehydration Treats underlying cause Indicates presence of infection and dehydration Ensures continuous intervention • • • • .Monitor hematologi c test and other pertinent lab records 15.Administer antibiotic as ordered 14.

and calorie count • RATIONALE EVALUATION SHORT TERM After 2 hours of nursing intervention the patient will: • Vital signs. frequent feedings including a bedtime snack. Establish rapport with the client 2. blood pressure. weight gain during hospitaliz ation 5.CUES SUBJECTIVE: “Diri man ako gingaganahan yana pagkaon”. Monitor vital signs 3. as verbalized by the client OBJECTIVE: • Vomitus about 240 ml noted composed of currently ingested food Weight is 40kg. and laborator y serum studies are within normal limits Client is able to verbalize importanc e of adequate nutrition and fluid intake • to facilitate cooperatio n as well as to gain pt’s trust to establish baseline data this informatio n is necessary to make an accurate nutritional assessmen t and to maintain client safety weight loss or gain is important assessmen t informatio n client is more likely to eat foods that she particularl y enjoys Large amounts of food may be objectiona ble. (Normal is 44kg) Pale conjunctiv ae noted Weakness NURSING DIAGNOSIS Risk for imbalance nutrition: less than body requirement related to loss of appetite SCIENTIFIC RATIONALE OBJECTIVE NURSING INTERVENTION INDEPENDENT 1. or even intolerable to the client • • • • • 4. Determine client’s likes and dislikes and collaborate with dietician to provide 6. output. Stay with client during meals • • . the client will: • Client will shown a slow progressi ve. rather than three larger meals 7. Weigh client daily • LONG TERM After 8 hours of nursing intervention. Ensure the client receives small. Keep strict documenta tion of intake.

8. Explain the importance of adequate nutrition and fluid intake • • To assist as needed and to offer support and encourage ment Client may have inadequat e or inaccurate knowledge regarding the contributio n of good nutrition to overall wellness .

CUES SUBJECTIVE “ NURSING DIAGNOSIS Inadequate tissue perfusion related to poor blood circulation SCIENTIFIC RATIONALE OBJECTIVE SHORT TERM NURSING INTERVENTION RATIONALE EVALUATION .