1. Planning
1.1. Patient pain will have decreased/ or free of pain
1.1.1. Patient temperature will revert back to normal
1.1.1.1. Urine will be clear and no presence of blood
2. Homeostasis Disturbed
3. Nursing Diagnosis:-Fluid Volume excess related to decrease glomerular filtration rate and sodium retention.
4. Implementation
4.1. Administer pain, antipyretic, antibiotic meds as ordered, Monitor Urine output (note characteristics, colour, consistency, odor). Monitor for urine specific gravity
4.1.1. Encourage patient to perform deep breathing exercises, meditation & muscle relaxation to reduce anxiety.
4.1.1.1. Maintain calm manner when working with the patient
4.1.1.1.1. Establish rapport to build trust with patient, using silence and listening actively, demonstrating empathy, respecting client's personal space
5. Acute Kidney Injury
6. Decreased Blood Flow to Kindeys
6.1. Decreased filtration pressure
6.1.1. Decreased filtrate and urine production
6.1.1.1. Increased production of renin
6.1.1.1.1. Formation of angiotensin I, activation of angiotensin II
7. Increased Systematic Blood Pressure
8. Priority Assessment
8.1. Vital Sign, Pain, Fever, Bloody Urine, anxiety
8.1.1. Assess Skin for any areas of edema and evaluate the degree
8.1.1.1. Auscultate for heart and lung sounds+ assess LOC -level of consciousness
9. Evaluation
9.1. Patient is pain free
9.1.1. Normal Temperature
9.1.1.1. Patient will be at ease and level of anxiety decreased
9.1.1.1.1. Patient will posses clear urine
10. Increased Blood Volume/Increased Systematic Blood Pressure
11. Goals
11.1. Patient presents bloody urine & flank pain for the past 48 hours
11.1.1. Oliguric Stage: (last 5 days to over 15 days)
11.1.1.1. Renal changes occur: decrease tubular transport, decrease urine formation, low GFR. (note pt. presents decreased urine output upon admission.) During this stage, bleeding+ infection is common.
11.2. Patient's vital signs will be within normal range
11.2.1. Patient will have a urine output within normal range (400-500mL)
11.2.1.1. If patient’s kidneys do not improve, patient may need to undergo dialysis