ASSESSMENT DIAGNOSIS RATIONALE PLANNING IMPLEMENTATION RATIONALE EVALUATION

S> Kung ano lang ung

dinadala nilang pagkain
yun lang yung kadalasan
kong kinakain. as
verbalized by the patient.

O>
Febrile
Temperature.
39.1
warm skin
good skin turgor
#4 PLRS 1L to run
for 10 hours
Side drip #2 PNSS
90cc + 40 meqs
KCl to run for 6
hrs
DAT diet
no episodes of
vomiting noted.

Hyperthermia r/t
inflammatory
process as
evidenced
increased
temperature of
39.1
Acute
Pyelonephritis is an
upper urinary tract
infection; this is a
bacterial infection
of the renal pelvis,
tubules and
interstitial tissue of
one or both
kidneys.

This is usually
manifested by
enlarged kidneys
with interstitial
infiltration of
inflammatory cells;
abscesses may be
noted within the
renal capsule and
at the
corticomedullary
junction.

Reference: 12
th

edition Brunner &
Suddarths
textbook of
Medical-Surgical
Nursing, pg. 1365
Short Term Goal:
After 8 hours of
nursing
intervention, client
will be able to
decrease
temperature to
normal ranges and
have an
enhancement in
comfort.

Long Term Goal:
After 2-3 days of
nursing
intervention,
patient will be able
to demonstrate
behaviours to
monitor and
promote
normothermia and
within normal
range of
temperature.
INDEPENDENT:
>Monitored vital
signs especially
temperature; I & O.

>Promote tepid
sponge bath and
every 15mintus
check for
temperature.

>Promote client
safety such as
maintain patent
airway, equipment
safety measures,
etc.
>Increase fluid
intake and replace
electrolytes lost.

>Maintain bedrest.


>Encourage a well-
balanced diet,
modified by the
dietician.

DEPENDENT:
>Administer
antipyretic
medications as
prescribed by the
doctor.

COLLABORATION:
>Collaborate with

>Establish a
baseline data and
check the patients
condition.
>Promote
decrease in
temperature



>Provide safety
and privacy.




>Support
circulating volume
and tissue
perfusion.
>Reduce
metabolic and
oxygen demands.
>To meet
increased
metabolic
demands.


>To relieve any
inflammatory
response and
decrease high
temperature.


>Modify the food
Short Term Goal:
After 8 hours of
nursing
intervention,
patient was able to
decrease
temperature to
normal ranges.

Long Term Goal:
After 2-3 days of
nursing
intervention,
patient was able to
demonstrate
behaviours to
monitor and
promote
normothermia and
within normal
range of
temperature.
dietician and other
health care team.

and other health
services
appropriate to the
pt.