II. NURSING CARE BASIC
CONCEPTS
A. ASSESSMENT
1. Genitourinary: cloudy urine, proteinuria, decreased urine output, hematuria.
2. Kardivaskular: hypertension.
3. Neurological: lethargy, irritability, seizures.
4. Gastrointestinal: anorexia, azotemia, hyperkalemia.
5. Integumentary: pale, edema.
B. NURSING DIAGNOSIS AND INTERVENTION
1. Changes in the pattern of urinary elimination (dysuria, urge, frequency, or nocturia) associated with a kidney infection.
Objective: urinary elimination pattern in the normal range (3-6 x / day).
Results Criteria: - Patients can urinate normally.
- There is no infection in the kidneys, no pain while urinating.
Intervention:
- Measure and record urine per micturition.
Rationale: To determine the changes in color and to determine the input / output.
- Suggest to urinate every 2-3 hours.
Rational: To prevent the buildup of urine in the urinary vesicles.
- Palpate bladder every 4 hours.
Rationale: To determine the presence of bladder distension.
- Assist clients to the restroom, use bedpans / urinals.
Rationale: To facilitate clients in urination.
2. Changes in nutrition less than body requirements related to anorexia.
Objective: Nutritional needs of patients are met adequately.
Criteria results: Clients will show marked improvement with a portion of the intake will be spent at least 80%.
Intervention:
- Provide high-carbohydrate foods.
Rationale: A diet high in carbohydrates are usually more appropriate and provide essential calories.
- Serve food a little but often, including the client's favorite foods.
Rationale: Serving food a little but often provide an opportunity for clients to enjoy the food, presenting favorite foods to increase appetite.
- Limit sodium and protein corresponding input order.
Rationale: Sodium can cause fluid retention, in some cases the kidneys can not metabolize protein, so it is necessary to restrict fluid intake.
3. The pain associated with kidney infection.
Goal: Pain is reduced or absent.
Results Criteria: - Client indicates a relaxed face.
- Infection can be overcome.
Intervention:
- Assess the intensity, location, and factors that aggravate and mitigate pain.
Rationale: Pain is a great sign of infection.
- Provide adequate rest periods.
Rationale: Clients can rest in peace and may relax the muscles.
- Encourage drinking plenty of 2-3 liters if there are no contraindications.
Rational: To assist clients in urination.
- Provide appropriate analgesic therapy program.
Rational: Analgesics can block the path of pain.
REFERENCES
Engram, Barbara. (1992). Medical Surgical Nursing Care Plans. Volume 1. EGC. Jakarta.
Lawler, William, et al. (1992). Book Smart Pathology For Dentistry. EGC. Jakarta.
Nettina, Sandra M. (2001). Guidelines for Nursing Practice. EGC. Jakarta.
Price, Sylvia, et al. (2005). Pathophysiology Clinical Concepts Disease Processes. Edition 6. EGC. JakArt
A. ASSESSMENT
1. Genitourinary: cloudy urine, proteinuria, decreased urine output, hematuria.
2. Kardivaskular: hypertension.
3. Neurological: lethargy, irritability, seizures.
4. Gastrointestinal: anorexia, azotemia, hyperkalemia.
5. Integumentary: pale, edema.
B. NURSING DIAGNOSIS AND INTERVENTION
1. Changes in the pattern of urinary elimination (dysuria, urge, frequency, or nocturia) associated with a kidney infection.
Objective: urinary elimination pattern in the normal range (3-6 x / day).
Results Criteria: - Patients can urinate normally.
- There is no infection in the kidneys, no pain while urinating.
Intervention:
- Measure and record urine per micturition.
Rationale: To determine the changes in color and to determine the input / output.
- Suggest to urinate every 2-3 hours.
Rational: To prevent the buildup of urine in the urinary vesicles.
- Palpate bladder every 4 hours.
Rationale: To determine the presence of bladder distension.
- Assist clients to the restroom, use bedpans / urinals.
Rationale: To facilitate clients in urination.
2. Changes in nutrition less than body requirements related to anorexia.
Objective: Nutritional needs of patients are met adequately.
Criteria results: Clients will show marked improvement with a portion of the intake will be spent at least 80%.
Intervention:
- Provide high-carbohydrate foods.
Rationale: A diet high in carbohydrates are usually more appropriate and provide essential calories.
- Serve food a little but often, including the client's favorite foods.
Rationale: Serving food a little but often provide an opportunity for clients to enjoy the food, presenting favorite foods to increase appetite.
- Limit sodium and protein corresponding input order.
Rationale: Sodium can cause fluid retention, in some cases the kidneys can not metabolize protein, so it is necessary to restrict fluid intake.
3. The pain associated with kidney infection.
Goal: Pain is reduced or absent.
Results Criteria: - Client indicates a relaxed face.
- Infection can be overcome.
Intervention:
- Assess the intensity, location, and factors that aggravate and mitigate pain.
Rationale: Pain is a great sign of infection.
- Provide adequate rest periods.
Rationale: Clients can rest in peace and may relax the muscles.
- Encourage drinking plenty of 2-3 liters if there are no contraindications.
Rational: To assist clients in urination.
- Provide appropriate analgesic therapy program.
Rational: Analgesics can block the path of pain.
REFERENCES
Engram, Barbara. (1992). Medical Surgical Nursing Care Plans. Volume 1. EGC. Jakarta.
Lawler, William, et al. (1992). Book Smart Pathology For Dentistry. EGC. Jakarta.
Nettina, Sandra M. (2001). Guidelines for Nursing Practice. EGC. Jakarta.
Price, Sylvia, et al. (2005). Pathophysiology Clinical Concepts Disease Processes. Edition 6. EGC. JakArt
