Assessment Diagnosis PlanningImplementatio

nRationale

EXPECTED OUTOME

S: “masakit ung pagihi ko”

pain scale 6/10

O: Facial

grimace noted Irritable at

times Limited

movement noted

Weak and pale in appearance

Acute pain r/t biological factors

After 30minutes of appropriate nursing intervention the patient will be able to lessen the pain as evidenced by:

Pain scale from 6 to 4

increase in physical activity

absent of facial grimace

placed patient to comfortable position

instruct to have deep breathing exercise

change the position of the patient

use positive approach in order to optimize patient response to analgesics

help patient to focus on activities

Health teaching as follows:eat nutritious food such as fruits vegetable give

medication as ordered

To gain comfort

Prevent further complication

To enhance blood circulation

To help patient to lessen perception of pain

To divert the attention of the patient

To increased the immunity of the patient

To relieve pain

After 30minutes of appropriate nursing intervention the patient would able to lessen the pain as evidenced by:

Pain scale at 4 increase in

physical activity

absent of facial grimace

Assessment Diagnosis Planning Implementation Rationale Expected outcome

S:” may prolema ako sa pagihi”

O: With pain in

urination With

involuntary urination

Chilling at times

Vomiting at times

Decrease physical activity

Urge urinary incontinence r/t irritation of bladder stretch receptor causing spasm

After 30 minutes of appropriate nursing intervention the patient will able to verbalize understanding regarding on her condition as evidence by:

Restating some health teaching

Establish rapport to the patient

Discuss to the patient the signs and symptoms of the disease

Instruct patient to have her proper perineal care

Instruct patient to monitor her

To gain the trust of the patient

To give her knowledge when to refer and to decrease anxiety

To prevent further complication

To prevent further complication like edema

After 30 minutes of appropriate nursing intervention the patient would able to verbalize understanding regarding on her condition as evidence by:Restating some health teaching

Weak and pale in appearance

i&o Discuss the

importance of monitoring the I&O

To prevent further complication like edema

Assessment Diagnosis Planning Implementation Rationale Expected outcome

S: “wala akong alam patungkol sa aking karamdaman”

O: Demonstrated

lack of knowledge regarding the disease

Not knowing how to do proper perineal care

Not knowing the importance of proper hygiene

Altered health maintenance r/tLack of knowledge

After 30 minutes of nursing intervention the patient will able to gain knowledge regarding the importance of proper hygiene as evidence by showing understanding.

Establish rapport to the patient

Place patient to comfortable position

Arrange the bedside of the patient

Discuss the importance of proper hygiene

Discuss on how to do the proper

Gain the trust of the patient

For patient’s comfort

For patient’s comfort and relaxation

For additional knowledge

To prevent further

After 30 minutes of nursing intervention the patient would able to gain knowledge regarding the importance of proper hygiene as evidence by showing understanding

perineal care Instruct

patient to take a bath everyday

Discuss to her the proper nutrition

Instruct to eat nutritios food such as fruits and vegetable

complication of the disease

To prevent further Complication

Additional knowledge on how to increase immunity

III. SOAPIE

Subjective Objective Analysis Planning intervention Evaluation

S: “mainit yung pakiramdam ko” Body

temperature at 38.3

Skin warm to touch

Flushed skin

Chilling at times

Vomiting at times

Altered body temperature r/t infection

After 1hour of appropriate nursing intervention the patient will able to decrease body temperature from 38.3 to 36.8 as evidence by:

Body temp at 36.8

Absence of chilling and vomiting

Increase

Established rapport to the patient

Placed patient to comfortable position

Arranging the bedside of the patient

Tsb rendered Losen the clothing

of the patient Provided proper

ventilation

After 1hour of appropriate nursing intervention the patient was able to decrease body temperature from 38.3to 36.8 as evidence by:

Body temp at 36.8

Absence of chilling and vomiting

Increased

Limited Weak

and pale in appearance

Irritable at times

physical activity

Given medication as doctors order

Health teaching such as:

Increase fluid intake 11 to 13 glasses per day

Eat nutritious food such as fruits and vegetable

Increase food rich in vitamin C

physical activity

Subjective objective Analysis Planning Intervention Evaluation

S:” may prolema ako sa pagihi”

With pain in urination

With involuntary urination

Chilling at times

Vomiting at times

Decrease physical activity

Weak and pale in appearance

Urge urinary incontinence r/t irritation of bladder stretch receptor causing spasm

After 30 minutes of appropriate nursing intervention the patient will able to verbalize understanding regarding on her condition as evidence by:

Restating some health teaching

Established rapport to the patient

Discussed to the patient the signs and symptoms of the disease

Instructed patient to have her proper perineal care

Instructed patient to monitor her i&o

After 30 minutes of appropriate nursing intervention the patient was able to verbalize understanding regarding on her condition as evidence by:Restating some health teaching

Discussed the importance of monitoring the I&O

Subjective Objective Analysis Planning Intervention Evaluation S: “wala akong alam patungkol sa aking karamdaman”

Demonstrated lack of knowledge regarding the disease

Not knowing how to do proper perineal care

Not knowing theimportance of proper hygiene

Altered health maintenance r/tLack of knowledge

After 30 minutes of nursing intervention the patient will able to gain knowledge regarding the importance of proper hygiene as evidence by showing understanding.

Established rapport to the patient

Placed patient to comfortable position

Arranging the bedside of the patient

Discussed the importance of proper hygiene

Discussed on how to do the proper perineal care

Instructed

After 30 minutes of nursing intervention the patient was able to gain knowledge regarding the importance of proper hygiene as evidence by showing understanding

patient to take a bath everyday

Discussed to her the proper nutrition

Instructed to eat nutritios food such as fruits and vegetable

II. Planning NCP

Assessment Diagnosis Planning Implementation Rationale Expected outcome

S: “mainit yung pakiramdam ko”

O: Body

temperature at 38.3

Skin warm to touch

Flushed skin Chilling at

times Vomiting at

Altered body temperature r/t infection

After 1hour of appropriate nursing intervention the patient will able to decrease body temperature from 38.3 to 36.8 as evidence by:

Body temp at 36.8

Absence

Establish rapport to the patient

Place patient to comfortable position

Arrange the bedside of the patient

Tsb render Loses the

clothing of the patient

Provide proper

Gain the trust of the patient

Gain the comfort of the patient

To gain the comfort and relaxation of the patient

To decrease body temperature

To have a

After 1hour of appropriate nursing intervention the patient would able to decrease body temperature from 38.3 to 36.8 as evidence by:

Body temp at 36.8

Absence of chilling and vomiting

times Limited Weak and

pale in appearance

Irritable at times

of chilling and vomiting

Increase physical activity

ventilation Give medication

as doctors order Health teaching

such as: Increase fluid

intake 11 to 13 glasses per day

Eat nutritious food such as fruits and vegetable

Increase food rich in vitamin C

proper ventilation

To prevent further complication such as respiratory problem

To replace the fluid loses

To increase immunity of the patient

To increase immunity of the patient

Increase physical activity

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION EXPECTED OUTCOME

S: “mainit yung pakiramdam ko”

O: Warm to touch Temperature =

38.3 Weak and pale

in appearance Skinny in

appearance Irritable at times Restlessness

noted

Elevated body temperature r/t infection

Within 1 hour of appropriate nursing intervention the patient will able to decreased body temperature at 37 C

Placed patient to comfortable position like semi fowlers

To promote adequate breathing

Tsb rendered To decrease body

temp

Provided proper ventilation Patients comfort

Bedside care rendered Patients comfort

Instructed the mother to loosen the clothing of the patient

For easily ventilation

After 1 hour of appropriate nursing intervention the patient would be able to decreased body temperature at 37 C

Instructed the mother to kept the patients back dry

To alleviate the disease

Instructed the mother to increased fluid intake of the baby as tolerated

To decreased body temp

Given medication as doctors order

To alleviate the signs and symptoms of the disease

Health teachings such as: Give nutritious food

such as fruits and vegetable

Breastfeed the baby To increased the

immunity of the baby.

Diagnosis & laboratory procedures

Date ordered & date result

Purpose Normal Values (book based)

Results Interpretation

Urinalysis Date ordered : Nov. 14, 2009

Date result: Nov. 15, 2009

To determine urine composition &

possible abnormal components or

infection.

Color : straw amber, transparent

Color :cloudy Concentrated urine

Appearance: clear Appearance: turbid Concentrated urine

Specific gravity: 1.010-1.022 Specific

gravity:1.015w/ in the normal range

pH : 4.6-6.5 pH: 6.0 w/ in the normal range

protein : negative protein : negativew/ in the normal range

bacteria : negative bacteria : moderate presence of bacteria causing infection

NONE pus cells : 3-5 presence of bacteria causing infection

RBC 1-3 NONE

Amorphous urates few w/ in the normal range

Nursing Responsibility:

Before: collect the specimen for the client and assist the client when assistance is needed.During: Specimen must be free from any contamination.After: Make sure that the specimen is labeled & the laboratory requisition carry the correct information & attached them securely to the specimen.

Diagnosis & laboratory procedures

Date ordered & date result

Purpose Normal Values (book based)

Result Interpretation

Hematology Date ordered : Nov. 14, 2009

Date result: Nov. 15, 2009

RBC, hgb, Hct, is important to the oxygen carrying capacity of the

blood. WBC is an indicator of

immune infection.

WBC- 4.5-10.0 x 0 9/L

WBC- 16.0 x 10 9/L

Increase WBC Presence of infection

RBC- 3.6-8.0 x 10 /L

RBC- 5.8 x 10 /L w/ in the normal range

Hgb- 120-170 g/L Hgb- 135 g/L w/ in the normal range

Hematocrit- 0.37-0.48 %

Hematocrit- 0.40 %

w/ in the normal range

Nursing responsibility:

Before: inform the client that he/she will going to undergone CBC. During: assist the client while getting bloodAfter: Make sure that the specimen is labeled & the laboratory requisition carry the correct information & attached them securely to the specimen.Medications

Name of drugs(generic & brand

name)

Date orderedDate started

Date changed

Route of administration,

dosage & frequency of

administration

General action of mechanism

Indication & Purposes

Client response to medication

with actual seen

Paracetamol (Acetaminophen)

Date ordered : Nov. 14, 2009

500 mg, 1 tablet q4h It reduce fever by direct action on the hypothalamus heat regulating system leading to vasodilation and sweating it also possibly by inhibiting the action of endogenous pyrogen.

Treatment for fever and for relief of mild to moderate pain associated with bacterial and viral infection

Patient reports fever reduce with drug.

Nursing Responsibilities:

Before administration: Monitor vital signs. Assist in administering medication.

During the administration: Measure and record the vital signs, especially the temperature.

After the medication: Monitor the client’s body temperature.

Be alert to adverse reactions and drug interaction.

Name of drugs(generic & brand

name)

Date orderedDate started

Date changed

Route of administration,

dosage & frequency of

administration

General action of mechanism

Indication & Purposes

Client response to medication

with actual side effect

Ceftriazone Nov. 14, 2009 750 mg q8h (-) ANST

It exhibits bacteriocidal activity by inhibiting cell wall synthesis.

An antiinfective used for serious infections in genitourinary system.

Dizziness.

Nursing Responsibilities:

Before administration: Monitor vital signs. Perform skin testing. Assist in administering medication.

During the administration: Monitor vital signs.

After the medication: Be alert to adverse reactions and drug interaction.

Drugs

Name of Drug Date ordered/ Date

started/ Date changed

Route/ Dosage/

Frequency of

Administration

General Mechanism of

action

Indication/ Purpose

Generic Name:

Ascorbic Acid (Vit. C)

Brand Name:

Potencee

Date ordered;

Nov.14, 2009

Oral administration

500mg tablet once a day

Stimulates collagen

formation and tissue

repair involved in

oxidation-reduction

reaction is the cells.

Boosts immune system.

For stronger immune

system and faster

wound healing.

NURSING RESPONSIBILITIES:

(Before)

a) Explain the importance and action of drugs to the client of significant others.

b) Tell possible reaction or side effect of the drugs.

(After)

c) Protect the medication from direct light and contamination.

d) Monitor urinary pH levels.

Diet

Type of dietDate orderedDate started

Date changedGeneral

DescriptionIndication &

Purposes

Specific foods taken

Client response and or reaction to the

diet

Diet as tolerated Date ordered;

Nov.14, 2009

Eating on what kind of food but limit intake of fat and

salt.

It contraindicated with the patient with pyelonephritis.

Vegetables,fruits rich in vitamin C, fiber rich foods, whole grains, eggs, cheese, meat, poultry and tomatoes.

The client’s condition increased

energy.

IX.I.) PATHOPHYSIOLOGY(Book – Based)

Modifiable Factors: High – salt diet Lifestyle

Non – Modifiable Factors: Age Gender

Ascending infection of the urinary tract (Escherichia Coli)

Interstitial abscesses present in the parenchyma

Infection reaching pelvis and kidney

Renal tubules are damage by exudates

Signs and Symptoms: Hematuria, confusion, fever, weakness, chills, nausea, vomiting, low back pain, flank pain

Inflammation of renal pelvis and kidney(ACUTE PYELONEPHRITIS)

Medical-surgical nursing book 11th edition

Joice Black

Subjective Objective Analysis

Planning Intervention Evaluation

S: “masakit ung pag-ihi ko”

pain scale 6/10

Limited movement noted

Facial grimace noted

Irritable at times

Weak and pale in appearance

Acute pain r/t bladder spasm After 30minutes of

appropriate nursing intervention the patient will be able to lessen the pain as evidenced by:

Pain scale from 6 to 4

increase in physical activity

absent of facial grimace

placed patient to comfortable position

instructed to have deep breathing exercise

changing the position of the patient

used positive approach in order to optimize patient response to analgesics

help patient to focus on activities

given medication as order

Health teaching as follows:eat nutritious food such as fruits vegetable

After 30minutes of appropriate nursing intervention the patient was able to lessen the pain as evidenced by:

Pain scale at 4 increased in

physical activity

absent of facial grimace