HOLY CHILD SCHOOL OF DAVAO

E. Jacinto St. Davao City

NURSING CARE PLAN
Name :Patient X Civil Status: Single Date Admitted:
Age:20 Religion:R.C Diagnosis: Acute Pyelonephritis
Sex:male Occupation: Attending Physician:
Date/Time of Assessment: Date/Time of Evaluation:

Dat Cues Need Nursing Diagnosis Planning Nursing Intervention Rationale Evaluation
e s
♦ Helps evaluate degree of ♦ After 8 hours
♦ After 8 hours of nursing ♦ Assess pain, noting discomfort and may reveal of nursing
SUBJECTIVE: Acute pain related to acute
interventions, the patient location, developing complications. interventions,
“Tulo ka adlaw nang sakit inflammation of renal tissues.
will verbalize relief or characteristics, ♦ Decreased flow may reflect the patient
kaau e ihi” (I have had
control of pain. intensity (0-10 urinary retention with increased was able to
painful urination for Inference:
scale). pressure in upper urinary verbalize
the past 3 days) as Pyelonephritis is an
♦ Note urine flow and tract. relief or
verbalized by the inflammation
characteristics. ♦ Reduction of anxiety or fear control of
patient. of the kidney and upper urinary
♦ Encourage patient that can promote relaxation and pain.
With a pain scale of 8 tract that usually results from
1 is the lowest 10 is the noncontagious bacterial to verbalize comfort.
higest. infection concerns. Active ♦ Reduces muscle
OBJECTIVE: of the bladder (cystitis). It listen these tension, promotes
♦ Guarding/ presents with dysuria (painful concerns and relaxation, and may enhance
distracting voiding of urine), abdominal provide support by coping abilities.
behaviors. pain acceptance, ♦ Reduces muscle or joint
♦ Self focusing. (radiating to the back on the remaining with stiffness.
affected side) and tenderness patient and giving and encourage ambulation.
of the appropriate ♦ Investigate and report
bladder area and the side of information. abdominal
the ♦ Provide comfort muscle rigidity, involuntary
involved kidney("renal angle measure like back guarding
tenderness"). In many cases rub or deep and reboundtenderness.
there breathing exercises. COLLABORATIVE:
are systemicsymptoms in the ♦ Assist with range of ♦ Administer medications as
form of fever, rigors (violent motion exercises and encourage indicated e.g analgesics and
shivering while the ambulation. antibiotics. Ambulation
temperature ♦ Investigate and report returns organs to normal
rises), and headache abdominal position
muscle rigidity, involuntary and promotes feeling of well
guarding being.
and rebound tenderness. ♦ Requiring prompt medical
COLLABORATIVE: intervention.
♦ Administermedications as ♦ Relieves pain, enhances
indicated e.ganalgesics and comfort and promotes rest.
antibiotics.