University of San Carlos College of Nursing Cebu City NURSING CARE PLAN Patients health profile: Received patient

lying on bed with ongoing #2 PNSS 1L @ 30 gtts/min, infused @ left arm. Initial Complaint: Fever for 3 weeks, abdominal pain Diagnosis/Impression: Acute Pyelonephritis

Name: M.C.H.

Sex: Male

Age: 57 y.o. Occupation: Farming Date of Admission: 7/31/11 Religion: Roman Catholic Status: Single Needs/Nursing Diagnosis Physiologic need Hyperthermia related to infectious process S: Pag-abot namu dinhi dai pirte naman ana niyang inita hangtud karon wala pa gihapon mahuwasi, as verbalized by the S.O. O: -Increased body temperature above normal range, Temp: 38.1 degree Celsius -Warmth felt when touched -Increased respiration above normal range, Scientific Analysis

Nursing Objectives Interventions After 8 hours of nurse- INDEPENDENT: The most common form of patient interaction, the kidney disease is the patient will be able to: inflammation of the kidney, or commonly called 1. Explain the Assess the clients pyelonephritis. Most possible present health inflammation is caused by causes/contribut status. bacterial infections. That is ing factors of why patient with this kind of elevated body illness manifests elevated temperature body temperature due to using his own the occurrence of the words based on Discussion of the infection in the body his level of possible causes of wherein proteins called understanding. elevated body pyrogens are released due temperature. to the white blood cells that fights the microorganisms 2. Assess the responsible of the illness. patients health Assess clients Increased pyrogen greatly status following body temperature. increases body the actions done temperature. by the nurse. Reference: Fundamentals of nursing by Harry and Perry Check respirations.

Rationale

This would serve as the baseline data for the evaluation of care after the implementation of the planned care. Knowledge about the causes of a particular complication will be a preventive measure.

Body temperature of more than 38.5 degree Celsius may lead to seizures and needs immediate action. Hyperventilation may initially be present, but ventilator effort

Evaluation After 8 hours of nursepatient interaction, the objectives were met. The patient was able to explain possible causes of increased body temperature related to the presence of infection. The client was able to assess the health status of the patient like checking of the body temperature. The client was able to demonstrate behaviors to promote normal body temperature like performing Tepid Sponge Bath as evidenced by reduction of body temperature from 38.1 to 37.0 degree Celsius. The client pays attention to the health teachings provided when she gave adequate fluid intake to her patient.

Own Analysis: The patient is admitted due to acute pyelonephritis. In which there is an infection that happens within the body and the bodys defense is to raise body temperature as a sign that the body is trying to fight the microorganisms responsible for the illness. That is why patient may manifest elevated body temperature. 3. Demonstrate behaviors to manage increased body temperature basing on bodys normal temperature of 36.5-37.5 degree Celsius. Monitor and record all sources of fluid loss.

may be impaired by seizures, shock. Oliguria and or renal failure may occur due to hyperthermia, dehydration and tissue necrosis. Helps reduce elevated body temperature.

Perform Tepid Sponge Bath. Instruct the S.O. not to leave the patient unattended. Discuss importance adequate intake.

4. Pay attention into the health teachings done by the nurse through active participation.

To promote safety and prevent heat injury.

the of fluid

To prevent dehydration.

DEPENDENT: Administer antipyretics, orally/rectally, as ordered. Take note for signs and symptoms indicating need for emergent/further evaluation and follow-up care. Measures to reduce body temperature.

To avoid complications if there are early detections of signs and symptoms.

COLLABORATIVE: Provide caloric diet. high To meet increased metabolic demands. Support circulating volume and tissue perfusion.

Administer replacement fluids and electrolytes.

Nurses pocket guide diagnoses, prioritized interventions and rationalesDoenges et.al., 11th editionF.A Davis companyCopyright 2008- pages 382387.