ASSESSMENT DIAGNOSIS RATIONALE PLANNING IMPLEMENTATION RATIONALE EVALUATIONS> “ 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: 12th edition Brunner & Suddarth’s 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 patient’s 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.