NURSING CARE PLAN

Name: MCB Gender: female

Diagnosis: UTI t/c DF
 Assessment Diagnosis Planning Implementation Rationale Evaluation

Subjective: Acute pain Short Term: Independent: After 8 hours

- “Tatlong araw related to After 8 hours of nursing
ng acute of nursing - apply hot water -it serve as interventions,
masakit ang inflammation interventions, bottle on the site cutaneous the patient
pagihi of the patient of pain stimulation was able to
ko”as renal tissues will verbalize verbalize
verbalized by relief or -teach a specific -non invasive relief or
the control of relaxation pain- reliever control of
patient. pain strategy like deep measures pain.
-pain scale of 6 breathing
-flank pain
Long Term: -teach method of -divert her
Objective : Client will not destruction of attention to
−Guarding develop pain like listening other rather
behaviors possible to music, reading than thinking of
-facial grimace recurrence of magazines, pain
UTI watching
television

-advice her to rest - helps to

during the day alleviate pain
and with periods
of uninterrupted
sleep at night

-encourage client -activities

to plan activities diminishes pain
around periods of
greatest comfort
whenever
possible

Dependent:
It will lessen the
- administer a pain
pain reliever as
prescribed by the
 Assessment Diagnosis Planning Implementation Rationale Evaluation

Subjective: Hyperthermia Short Term: Independent: After 8 hours of

-“Mainit ang related to After 4 hrs. Of nursing
pakiramdam ko” disease nursing -Monitor core -To evaluate intervention,
as verbalized by process interventions, temperature ranges of goal is met. The
the patient. the patient (rectal and temperature. patient
will tympanic maintained his
Objective : maintain core temperature most core
-Flushed skin, temperature closely temperature
warm to within normal approximate core within normal
touch. range. temperature. -To note level of range of 36.4°C.
-Restlessness consciousness.
-Temp- 38.1 Long Term: -Assess -
client will able neurologic Hyperventilation
to manage response. may initially be
possible -Monitor present.
complication respiration
of -Oliguria or
hyperthermia Renal failure
may occur due
- Monitor/record to hypotension.
all sources of fluid
loss such as
urine, or other - Body attempts
insensible losses. to increase heat
loss.
-Note presence or
absence of
sweating. - To promote
surface cooling.
- Provide cool
environment,
sponge baths. -To reduce
metabolic
- Maintain bed demands or
rest. oxygen
consumption.

Dependent: - For Fever.

 Assessment Diagnosis Planning Implementation Rationale Evaluation

Subjective: . Activity Short Term: Independent: Patient reveals an

- “Nanghihina intolerance After 8 hours of increase in
ako,hindi aq related to nursing -Assess patient’s -Influences choice activity
makalilos ng imbalance interventions ability to perform of tolerance,
maayos”as between the patient will: normal task or interventions or demonstrating a
verbalized by oxygen activities of daily needed reduction in
the patient. supply − Report an living. assistance. physiological
. (delivery) increase in signs of
and demand activity − Note changes in − May indicate intolerance
Objective : tolerance balance/ gait neurological
-body weakness including disturbance, muscle changes
−limited ROM activities of daily weakness. associated
living with vitamin B12
deficiency,
− Demonstrate affecting
a patient safety or
decrease in risk
physiological of injury.
signs of
intolerance.. − Recommend quiet −Enhances rest to
atmosphere, bed lower body’s
rest if indicated. oxygen
requirements, and
reduces strain on
the heart and
lungs.

− promote venous
−elevate the legs return.

−Although help
− Provide or may
recommend be necessary, self
assistance with esteem is
activities or enhanced
ambulation as when patient does
necessary, allowing some things for
patient to do as self
much
as possible.