Phinma Cagayan de Oro College

College of Nursing
NURSING CARE PLAN

NAME OF STUDENT: Malazarte, Annadale M. SECTION: B DATE:

C.I.: Mrs. Mitzi Lou Arboleras, RN
NAME OF PATIENT: Mrs K. ATTENDING PHYSICIAN: Dr. Rosita Gutierrez, RN, MD
DIAGNOSIS: Pyelonephritis
HOSPITAL/ROOM: #115

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective: Acute pain r/t acute Short Term: At the end of 3 hours Dependent: - The client used
inflammation of renal of nursing intervention, the client pharmacological and non-
Pain from RT loin to groin  Assess pain, noting location,
tissues as evidenced by will be able to; pharmacological strategies
and fever with chills 3 times a verbalizing pain. characteristics, intensity (0- to relieve pain. Fully-met
day as complaint by the  use pharmacological and 10). - The client verbalized relief,
client. non-pharmacological  Note urine flow and control or absence of pain.
strategies to relief of pain characteristics.
Objective:  Provide comfort measure like
back rub or deep breathing
 Nigh fever Long Term: At the end of 8 hours
exercises.
 H/O of nursing intervention, the client
 Encourage patient to verbalize
- Vomiting will be able to;
concerns. Active listen these
- Loose stools concerns and provide support
 Verbalize relief, control
- Dysuria or absence of pain. by acceptance, remaining with
 Guarding/distracting patient and appropriate giving
behavior of information.
 Self-focusing  Assist with range of motion
exercises and encourage
ambulation.
 Investigate and report
 abdominal muscle rigidity,
involuntary guarding and
rebound tenderness.
Independent:
 Administer medications as
indicated such as aspirin 150
mg to relieve pain as
physicians order.
 Phinma Cagayan de Oro College
College of Nursing
DRUG STUDY

NAME OF STUDENT: Malazarte, Annadale M. SECTION: B DATE: October 14, 2021 C.I.: Mrs. Mitzi Lou Arboleras, RN
NAME OF PATIENT: Patient L. ATTENDING PHYSICIAN: Dr. Rosita Gutierrez, RN, MD DIAGNOSIS: Diabetes Mellitus HOSPITAL/ROOM: #115
GENERIC BRAND NAME INDICATION MODE OF ACTION SIDE EFFECTS ADVERSE EFFECTS NURSING CONSIDERATION
Aspirin Aspilets, Bayer Aspirin is used Aspirin is a salicylate that  Skin swelling Significant:  Salicylate - For patients who have had
aspirin, Bayprin to reduce fever and exhibits analgesic, anti-  Bronchospasm sensitivity, tinnitus. oral or dental surgery or
relieve mild to inflammatory, and  Central nervous Blood and lymphatic tonsillectomy in the last
moderate pain from antipyretic activities. It is a system (CNS) system seven days avoid chewable
conditions such as selective and irreversible alteration disorders:  Anaemia, or dispersible aspirin
muscle aches, inhibitor of  Skin problems hypoprothrombinaemia, tablets, or aspirin in crushed
toothaches, common cyclooxygenase-1 (COX-1)  Gastrointestinal (GI) thrombocytopenia. tablets or gargles.
cold, and headaches. It enzyme resulting in direct pain, ulceration, Gastrointestinal -Assess pain and/or pyrexia
may also be used to inhibition of the bleeding disorders:  Dyspepsia, one hour before or after
reduce pain and biosynthesis of  Liver damage gastric irritation, nausea, medication.
swelling in conditions prostaglandins and  Hearing loss vomiting. - In long-term therapy
such as arthritis. thromboxanes from  Nausea Nervous system monitor renal and liver
arachidonic acid.  Platelet disorders:  Dizziness, function and ototoxicity.
Additionally, it also inhibits aggregation inhibition confusion. - Assess other medication
platelet aggregation.  Premature hemolysis Respiratory, thoracic and for possible interactions -
 Pulmonary mediastinal especially warfarin which is
edema (salicylate- disorders:  Asthma, a special hazard.
induced, non- bronchospasm, dyspnea, - Be aware that aspirin is a
cardiogenic) rhinitis. common constituent of a
 Rash Skin and subcutaneous variety of over-the-counter
 Kidney damage tissue disorders: Rash, medications.
 Hives urticaria.
 Vomiting
 Phinma Cagayan de Oro College
College of Nursing

GENERAL OBJECTIVE
(KNOWLEDGE, SKILLS, ATTITUDE)

At the end 8 hours of nursing intervention, I will be able to;

KNOWLEDGE:

 Formulate a nursing plan to address the client’s needs /problems.

 Determine the factors and its significance concerning the patient’s condition.
 Describe the signs and symptoms manifested and verbalized by the patient.
SKILLS:
 Assess a patient with problems on pyelonephritis with the use of specific treatments and interventions to address the patient’s problem.
 Conduct proper health assessment and nursing intervention based on the patient’s history present illness, past medical history, and chief complaints.
 Prepare health teaching discharge plan to educate and add information to the patient as to the following;
1. Keep your genital area clean. Use mild soap. Rinse with water.
2. Always wipe the genital area from front to back.
3. Urinate frequently. Avoid holding urine in the bladder for a long time.
4. Always urinate after sexual intercourse.

ATTITUDE:

 Manage the time properly and gains patient trust by establishing rapport relationship.
 Ensure good working relationship to other healthcare professional to attain collaboration.
 Phinma Cagayan de Oro College
College of Nursing

SPECIFIC OBJECTIVE
(KNOWLEDGE, SKILLS, ATTITUDE)

At the end of 5 hours of nursing intervention, I will be able to;

KNOWLEDGE:

 Prepare a nursing diagnosis such as acute pain r/t to acute inflammation of renal tissue to address Mrs. Ks’ needs and problems.
 Determine the factors and its significance concerning the patient’s condition.
 Describe the signs and symptoms manifested and verbalized by the client.
SKILLS:
 Assess the client’s description of pain, such as quality, nature, and severity of pain.
 Assess for signs and symptoms of urinary tract infection.
 Assess for risk factors for UTI.
 Monitor laboratory and diagnostic studies, as indicated:
- WBC count
- Urinalysis
- Bacteria in the urine
- Urine culture
- Computed tomography
- Ultrasound & kidney scans
 Administer aspirin 150 mg to relief pain.
ATTITUDE:

 Explain the procedure to the patient carefully to reduce his anxiety.

 Manage the time wisely and gain patients’ trust by establishing rapport relationship.
 Ensure good working relationship to other healthcare professional to attain collaboration.
 Phinma Cagayan de Oro College
College of Nursing
PATHOPHYSIOLOGY

NAME OF STUDENT: Malazarte, Annadale M. SECTION: B DATE:

C.I.: Mrs. Mitzi Lou Arboleras, RN
DISEASE: Pyelonephritis