NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

INDEPENDENT
SUBJECTIVE: Acute pain Pyelonephritis is ♦ After 8 hours ♦ Assess pain, noting ♦ Helps evaluate ♦ After 8 hours
related to acute an inflammation of nursing location, degree of of nursing
“Tatlong araw ng inflammation of of the kidney and interventions, characteristics, discomfort and interventions,
masakit ang pg- renal tissues. upper urinary the patient intensity (0-10 may reveal the patient
ihi ko” (I have had tract that usually will verbalize scale). developing was able to
painful urination for results from relief or complications. verbalize
the past 3 days) as noncontagious control of relief or
verbalized by the bacterial infection pain. ♦ Note urine flow and ♦ Decreased flow control of
patient. of the bladder characteristics. may reflect pain.
(cystitis). It urinary retention
OBJECTIVE: presents with with increased
dysuria (painful pressure in
♦ Guarding/ voiding of urine), upper urinary
distracting abdominal pain tract.
behaviors. (radiating to the
♦ Self focusing. back on the ♦ Encourage patient ♦ Reduction of
♦ V/S taken as affected side) and to verbalize anxiety or fear
follows: tenderness of the concerns. Active that can promote
bladder area and listen these relaxation and
T: 37.6 the side of the concerns and comfort.
P: 90 involved kidney provide support by
R: 19 ("renal angle acceptance,
BP: 120/80 tenderness"). In remaining with
many cases there patient and giving
are systemic appropriate
symptoms in the information.
form of fever,
rigors (violent ♦ Provide comfort ♦ Reduces muscle
shivering while measure like back tension,
the temperature rub or deep promotes
rises), headache breathing exercises. relaxation, and
and may enhance
coping abilities.

♦ Assist with range of ♦ Reduces muscle

motion exercises or joint stiffness.
 and encourage Ambulation
ambulation. returns organs to
normal position
and promotes
feeling of well
being.

♦ Investigate and ♦ Requiring prompt

report abdominal medical
muscle rigidity, intervention.
involuntary guarding
and rebound
tenderness.

COLLABORATIVE:

♦ Administer ♦ Relieves pain,

medications as enhances
indicated e.g comfort and
analgesics and promotes rest.
antibiotics.