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Subjective Cues: After 2 hours of ¦Plan ways ¦Identify ¦To assess After 2 hours
³Nung isang araw Hyperthermia r/t nursing on how to underlying causative factors of nursing
pa mainit ang inflammatory intervention lessen cause. intervention
to the clients fever
pkramdam ko´ as process as The clients body clients body The clients
verbalized by the evidenced by temperature will temperature thus formulation body
client increase body decrease to a ¦Formulate of appropriate temperature
temperature,flush normal range health nursing is decreased
ed and warm to teachings intervention. to a normal
Objective Cues: touch skin and that would range
increase be helpful
¦½ody temperature ¦This areas has high
respiration rate. to lessen the ¦Put local
above normal blood flow and
range.
clients ice packs
putting ice packs
¦Warm to touch. temperature especially in
would be helpful.
¦Flushed skin ______________ . groin and
¦Tachycardia Scientific axillae.
¦Diaphoresis Explanation: ¦Provide ¦To increase heat
T-38.3 ½ody temperature tepid sponge loss through
P-105½pm elevated above bath. conduction
R-24 bpm
½P-130/90 mmHg normal range.
¦Teach ¦To support
client to circulating volume
increase and tissue perfusion.
fluid intake.
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¦Establish cool environment ¦Heat loss by

by opening air vents and convection.
window panes.
¦Advise relatives not to cover ¦to avoid
the client with a blanket, and further increase
use less restrictive clothing¶s of clients
temperature.

¦Administer Anti pyrectics as ¦For immediate

prescribed alteration of
body
temperature
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Subjective Impaired After 8 hrs of ¦Plan of care ¦.Determine clients ¦To assess degree After 8 hrs of
Cues: Urinary nursing to meet the previous pattern of of interference or nursing
³Nahihirapan Elimination intervention desired elimination and compare disability. intervention the
akong umihi,, r/t the client will outcome for with current situation. client was able to
madalas sya Inflammatio be able to the client. Note reports of portray and
pero pakonti n of bladder portray and ¦Make a frequency, urgency, verbalize
konti lang » mucosa verbalize teaching plan burning, incontinence, improved urinary
as verbalized As evidence improve appropriate nocturia, enuresis. elimination
by the client. by the urinary for the clients ¦Palpate bladder ¦To assess retention pattern.
Objective objective elimination condition.
Cues: cues. pattern. ¦To determine level
¦Distended __________ ¦Determine clients of hydration.
abdomen _ usual daily fluid
¦Frequency Scientific intake(both amount,
¦Hesitancy Explanation: beverage choice and use
T-38.3 Disturbance of caffeine), note
P-105½pm in urine conditions of skin,
R-24 bpm elimination. mucus membrane and
½P-130/90 color of urine. ¦To help maintain
mmHg ¦Encourage fluid intake renal function,
up to 3000- 4000 ml per prevent infection
day including cranberry and formation of
juice. urinary stones

¦This prevents over

¦Instruct the client to distention of the
void every 2-3 hours bladder and
during the day and compromised blood
completely empty the supply to the
bladder. bladder wall.
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¦Instruct the client to keep the perineal area clean ¦.To reduce the risk for
and dry. further skin infection and
skin breakdown
¦To strengthen the
¦Teach the client how to do kegel exercise and its perineal muscle.
importance.
¦These are bladder
¦Teach clients to avoid intake of caffeine, alcohol, irritants that may increase
colas, and artificial sweeteners. incontinence.

¦Many people cannot

void in the presence of
¦Provide privacy for the client upon voiding. another person.

¦These promote muscle

relaxation.
¦Provide sensory stimuli that may help the client
relax. Pour warm water over the perineum of a
female or have the client sit in a warm bath.U can
also apply a hot water bottle to the lower abdomen.

¦Turn on running water within the hearing ¦Helps facilitate easier

distance of the client to stimulate the voiding voiding.
reflex.
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 Acute pain r/t After 4 hrs ¦Plan ¦Perform a ¦To establish After 4 hrs of
³Nung nkraang lingo Acute of nursing techniques in comprehensive baseline data that will nursing
pa masakit ang inflammation of intervention which the assessment of pain be useful in intervention
tagiliran ko´ as renal tissues as the client clients level of to include location, monitoring the client was
verbalized by the evidenced by will be able pain will be characteristics, improvement in able to
client. verbal reports of to verbalize alleviated onset, duration, clients¶ level of pain. verbalize relief


 pain,guarding relief of pain primarily by frequency, quality of pain from
¦oery severe pain-- behavior and from the rate using of and severity as the rate of 8 to
Client rate her pain diaphoresis. of 8 to at independent well as the the rate of 3.
as 8 from the range rrrrrrrrrrrrr least less nursing precipitating
of 1-10(Having the rr than the rate interventions. factors
rate of 10 as the most Scientific of 4. ¦Plan with the ¦Encourage ¦Reduction of
painful and 1 as the Explanation significant patient to verbalize anxiety or fear that
least painful) Unpleasant others to concerns. Actively can promote
¦Guarding behavior sensory and cooperate in the listen to these relaxation and
¦Facial mask of pain emotional pain concerns and comfort.
¦Diaphoresis experience management provide support by
arising from program for the acceptance,
actual or client. remaining with
potential tissue ¦Gather patient and giving
T-38.3 damage. It is a materials that appropriate
P-105 ½pm sudden onset of can be helpful in information.
R-24 bpm any intensity pain ¦Promote quiet ¦Comfort and quiet
½P-130/90 mmHg from mild to management. environment. environment promote
severe with relaxed feeling and
duration of less permit the client to
than 6 months. focus on the
relaxation techniques
rather than external
distraction.
¦Identify all ¦To be able to lessen
stressors and factors that could be
remove it if an aggravating cause
possible. in clients¶ pain.
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¦Encourage practice of ¦To help client shift

diversional
activities(watching To,
listening to music, reading
magazines)
¦Instruct comfort
measures such as back
rubbing and deep breathing
exercise.
¦Encourage adequate rest
periods.
her focus of attention
to other things.
¦To reduce muscle
tension and promote
relaxation.
¦To prevent fatigue
and prevent further
stimulation of pain.

Dependent Nursing ¦For immediate pain

Management: relief .
¦Administer analgesics as
prescribed.