Emilio Aguinaldo College College of Nursing and Midwifery Jacob, Jasmin A. 06-1-41720 Objective - The patient identified severity of pain as 7 from pain scale of 0 – 10. - Guarding behavior - (+) Facial Grimace - Diaphoresis
Sec. 22 3rd year Nursing Diagnosis - Alteration of comfort, related to inflammation, edema, secondary to pelvic inflammatory disease.
Planning - At the end of the shift the patient will be able to report a decrease of pain from 7 to 4.
Intervention
Evaluation
- Determine / document presence of possible patophysiological causes of pain. - Encourage adequate rest periods to prevent fatigue. - Discuss impact of pain on lifestyle / independence and ways to maximize level of functioning. - Identify specific signs / symptoms and changes in pain characteristics requiring medical follow up.
- Goal Met, after 4 hours of nursing intervention the pain is decreased from 7 to 4.
Emilio Aguinaldo College College of Nursing and Midwifery Jacob, Jasmin A. 06-1-41720
Sec. 22 3rd year
Objectives
Nursing Diagnosis
Planning
Nursing Intervention
Evaluation
- Increase in body temperature above normal range = T – 38.1 ° C. - Flushed skin; warm to touch. - Tachypnea; Tachycardia; (unstable BP)
- Increase in temperature, related to inflammatory process, manifested by warm and flushed skin and tachycardia.
- At the end of the shift the patient’s temperature will decrease from 38.1°C to 36°C.
- Administer anti pyretic, orally / rectally as ordered. - Refrain from use of aspirin products in children. - Promote surface cooling by means of TSB. - Provide high calorie diet, tube feedings or parenteral nutrition.
- Goal Met, after 4 hours of nursing intervention the patient’s temperature has been decreased from 38.1°C to 36°C.