Assessment •
65 years of Age
Subjective: From Patient: • Fatigue • Malaise, sore and stiff joints. Objective: • Fatigue, Malaise, sore and stiff joints are symptoms for possible arthritis. Subjective: From Wife: • Low grade-fever • Losing of weight Objective: Fever is a possible sign for infection. *DIAGNOSED with possible Arthritis*
Diagnosis Impaired physical Mobility as evidence by joint stiffness and pain risk for Arthritis.
Planning Short Term: Within 8 hours: •
Pain scaled from 1-10. 10 as maximum.
Long Term: Within 2 days: • •
• •
Patient verbalizes no presence of pain. Patient displays no signs of stiff joints and sore joints. Patient’s temperature will have 36-37 C. Patient’s Pain will be alleviated to a pain scale of 0.
Intervention Independent: 1. Palpate the area of Pain.
To determine the area’s diameter of infection.
2. Ask the Patient to scale the Pain from 110.
To determine the
patient’s level of pain endured.
3. Put ice-pack on affected area.
To numb the pain. 4. Perform physical assessment on vital signs.
To determine the level of fever.
5. Ask the patient to stand and record the findings
To document the patient’s weight and compare it to any old record to determine if the patient has indeed lost weight.
Evaluation Goals are met. Patient’s pain is Alleviated. Patient’s joints display a normal ROM and are functioning well. Patient’s temperature displays as 36 C. Patient verbalizes no presence of pain.
Collaborative: Dietary management: 1. Educate patient to drink plenty of Milk.
Calcium helps fortify the patients bones and risk for osteoporosis.
2. Increase Fluid intake.
Fluids can help the
patient’s fluid balance.
Independent: 6. Administer medications for Pain relief and Fever control.
To control the patient’s fever and pain endured.