Diagnosis: Acute Pain
Desired Outcome 1: Patients will have reduced pain from 8/10 rate to 4/10 for the duration of this shift.
Desired Outcome 2: Patient will have no signs and symptoms of pain as evidenced by apical pulse between 60-100 beats/min, respiration rate between 12-20 breath/min, and temperature 97-100.4 F for the duration of this shift.
Interventions: Response:
1. Assess patient’s vital sign and ask patient’s response to pain
2. Reposition patient every 1-2 hours to provide comfort
3. Whenever patient felt pain offer PRN pain medication and instruct the patient to do deep breathing
4. Encourage patient to use pain distraction activities such as reading books, listening to music, and back massage. 1. Patient’s vitals are at the …show more content…
Desired Outcome 2: Patient will take 10 steps after eight hours of nursing intervention (i.e., medicate before 30 minutes before exercise) for the duration of this shift.
Interventions: Response:
1. Assist the patient to do an active or passive range of motion exercise on both affected and unaffected extremities.
2. Encourage the patient to involve in self-care activities (i.e., eating, bathing, dressing, reposition, and transfer).
3. Monitor patient vital signs (B/P, P, R, T, & SaO2)
4. Teach patient how to use mobility aid (i.e., walker, cane, & crutch)
1. patient states "I able to bare lightweight in the affected extremities."
2. The patient states "I am able to complete self-bathing activities with a minimal assistant."
3. Patient’s vitals are at the baseline data which is B/P-114/67, P-79, R-20, T-98.2 and SaO2-94%@1L
4. The patient maintained mobility at highest level
Evaluation: Patient was able to maintain strength and take 10 steps in a slow manner for the duration of this …show more content…
Desired Outcome 2: Patient will demonstrate postoperative care after discharge for the duration of this shift.
Interventions: Response:
1. Teach the patient proper techniques of wound care and involve the patient in the procedures
2. Assess the patient understanding of the treatment plan and follow-up care
3. Identify the patient’s support groups (i.e., family, friends, & church members)
4. Teach how to obtain proper nutrition and hydration 1. The patient expressed a desire to increase learning wound care dressing change procedure and techniques
2. The patient states “I prefer written handouts in large fonts”
3. The patient responds “I live with my wife and granddaughter”
4. The patient states “I will increase protein intake, decrease fat intake by 10%, and drink 2-3L of fluid per day
Evaluation: Patient describes and demonstrates postoperative care after discharge for the duration of this
Desired Outcome 1: Patients will have reduced pain from 8/10 rate to 4/10 for the duration of this shift.
Desired Outcome 2: Patient will have no signs and symptoms of pain as evidenced by apical pulse between 60-100 beats/min, respiration rate between 12-20 breath/min, and temperature 97-100.4 F for the duration of this shift.
Interventions: Response:
1. Assess patient’s vital sign and ask patient’s response to pain
2. Reposition patient every 1-2 hours to provide comfort
3. Whenever patient felt pain offer PRN pain medication and instruct the patient to do deep breathing
4. Encourage patient to use pain distraction activities such as reading books, listening to music, and back massage. 1. Patient’s vitals are at the …show more content…
Desired Outcome 2: Patient will take 10 steps after eight hours of nursing intervention (i.e., medicate before 30 minutes before exercise) for the duration of this shift.
Interventions: Response:
1. Assist the patient to do an active or passive range of motion exercise on both affected and unaffected extremities.
2. Encourage the patient to involve in self-care activities (i.e., eating, bathing, dressing, reposition, and transfer).
3. Monitor patient vital signs (B/P, P, R, T, & SaO2)
4. Teach patient how to use mobility aid (i.e., walker, cane, & crutch)
1. patient states "I able to bare lightweight in the affected extremities."
2. The patient states "I am able to complete self-bathing activities with a minimal assistant."
3. Patient’s vitals are at the baseline data which is B/P-114/67, P-79, R-20, T-98.2 and SaO2-94%@1L
4. The patient maintained mobility at highest level
Evaluation: Patient was able to maintain strength and take 10 steps in a slow manner for the duration of this …show more content…
Desired Outcome 2: Patient will demonstrate postoperative care after discharge for the duration of this shift.
Interventions: Response:
1. Teach the patient proper techniques of wound care and involve the patient in the procedures
2. Assess the patient understanding of the treatment plan and follow-up care
3. Identify the patient’s support groups (i.e., family, friends, & church members)
4. Teach how to obtain proper nutrition and hydration 1. The patient expressed a desire to increase learning wound care dressing change procedure and techniques
2. The patient states “I prefer written handouts in large fonts”
3. The patient responds “I live with my wife and granddaughter”
4. The patient states “I will increase protein intake, decrease fat intake by 10%, and drink 2-3L of fluid per day
Evaluation: Patient describes and demonstrates postoperative care after discharge for the duration of this