Far Eastern University Institute of Nursing Submitted by: Abrillo, Theresa Noelle Jade Section: BSN214 Group 53 bacteremia

CUES Interaction 3 days PTC: + on and off fever documented at 38C-39C 1 day PTC: + consult done and found out having infection due to resistance prompted to seek consultation and hence admitted Drug therapy: PKI second month treatment and ends on July 8, 2011 Observation Skin is warm to NURSING DIAGNOSIS Hyperthermia related to infection as manifested by a temperature of 38.3C ANALYSIS Name & age of Patient: J.A./ 4 years old Initial /Final Medical Diagnosis: UTI, PKI,

Nursing Care Plan GOAL AND NURSING OBJECTIVES INTERVENTIO N Immediate GOAL: Cause: After 8 hours of WBC fights nursing against the intervention, invading foreign the client will object and this maintain core causes an temperature increase in within normal metabolic rate range (36.5C and thus, an 37.5C) Collaborative increase in body Facilitative temperature as OBJECTIVES: Administer the body paracetamol as produces heat. After 30 prescribed by minutes of the physician Intermediate nursing Cause: intervention, This bacteria clients causes an temperature will Independent infection to the decrease from Facilitative urinary tract 38.3C to Perform tepid and increases 37.5C sponge bath the WBC as the until fever bodys normal subsides response to invading foreign bodies (bacteria)

RATIONALE

EVALUATION

To reduce body temperature Doenges, et. al, (2008). Nurses Pocket Guide. 11th Edition. F.A. Davis Company. p. 385. To reduce body temperature by evaporation Doenges, et. al, (2008). Nurses Pocket Guide. 11th Edition. F.A. Davis Company.

Clients temperature decreased from 38.3C to 37.5C

touch Tachycardia Body weakness + harsh breath sounds The client is very timid Measurement T: 38.3 C PR: 128 bpm RR: 25 cpm BP: not applicable Urinalysis: Pus cells 36/HPF Hematology: WBC 18.7 Independent After 4 hours of nursing intervention, the client will be able to regain her strength. Root Cause: Bacteria lodge into the urinary tract and because females have shorter ureters, they have a greater risk of harboring bacteria into their urinary system Black, et.al. (2005).Medical Surgical Nursing. 7th Edition.Elsevier PTE LTD.p 1861. Collaborative Facilitative Administer antibiotics Collaborative After 30 minutes of nursing intervention, the client will decrease the underlying cause of her fever Independent After 5 minutes of nursing intervention, the client will be free of chills and shivers.

p. 386. To cure the infection Doenges, et. al, (2008). Nurses Pocket Guide. 11th Edition. F.A. Davis Company. p. 386. To minimize shivering Doenges, et. al, (2008). Nurses Pocket Guide. 11th Edition. F.A. Davis Company. p. 386. To prevent dehydration Doenges, et. al, (2008). Nurses Pocket Guide. 11th Edition. F.A. Davis Company. p. 387. The client was able to decrease the underlying cause of her fever

Independent Facilitative Wrap extremities with bath towels

The client was free of chills and shivers

Independent Facilitative Strictly monitor the intake and output Supplemental Discuss the importance of adequate fluid intake Developmenta l Advice client to maintain bed rest

The client was able to regain her health

To reduce metabolic demands Doenges, et. al, (2008). Nurses Pocket Guide. 11th Edition. F.A.

Independent After 15 minutes of discussion, the client will be able to verbalize a positive outlook in life

Developmenta l Provide opportunity for client to express feelings.

Davis Company. p. 386. Loss of normal body functions and can lead to feelings of powerlessness, anger, and grief. Open expression of these feelings can help client begin coping. Black, et.al. (2005).Medical Surgical Nursing. 7th Edition.Elsevier PTE LTD.p 1861.

The client was able to verbalize a positive outlook in life