Afebrile, T=37.4oc >(-) restlessness / irritability > (-) Irregular pulse rate of 92 bpm > BP = 120 / 70mmHg. Patient was able to verbalize relief of thoracic (surgical) pain from 4 to 2 using Numeric Pain Scale within the shift.
Afebrile, T=37.4oc >(-) restlessness / irritability > (-) Irregular pulse rate of 92 bpm > BP = 120 / 70mmHg. Patient was able to verbalize relief of thoracic (surgical) pain from 4 to 2 using Numeric Pain Scale within the shift.
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Afebrile, T=37.4oc >(-) restlessness / irritability > (-) Irregular pulse rate of 92 bpm > BP = 120 / 70mmHg. Patient was able to verbalize relief of thoracic (surgical) pain from 4 to 2 using Numeric Pain Scale within the shift.
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Download as DOC, PDF, TXT or read online from Scribd
Cues Nursing Long Term Short Intervention Rationale Evaluation/
Diagnosis Goal Term Goal Expected
Outcome S A1 LG1 SG1 PDx E1 > “ Medyo NPI done. To establish humahapdi Acute Pain To recognize The patient rapport with the Goal itong tahi ko related to the will be able patient and Partially sa dibdib at sa tissue physiological to verbalize promote good Met tiyan” trauma responses of relief of communication. The patient and reflex the body to thoracic was able to >Pain of 4 in muscle disease (surgical) Assessed To determine verbalize the thoracic spasm conditions. pain from 4 patient’s deviations from relief of area, and 5 in secondary to 2 using general health normal and thoracic the abd. area to surgery. Numeric condition. obtain (surgical) using 0-10 Pain Scale subjective and pain from 4 Numeric Pain within the objectives cues. to 3 using Scale. shift. Numeric To monitor the Pain Scale > (+) Increase SG1 Assessed pain level of pain within the of pain on using numeric and for shift. abd. area to 7 The patient pain scale. planning the upon will be able intervention E2 ambulation to verbalize that will Goal using 0-10 relief of alleviate pain. Partially Numeric pain abdominal Monitored Met scale. (surgical) vital signs. Provide The patient pain from baseline data was able to O 5-7 to 3 for changes in verbalize >conscious, using patient’s relief of coherent, Numeric condition. abdominal oriented to Pain Scale PRx (surgical) person, time within the Kept rested pain from and place. shift. and Promotes 5-7 to 4 comfortable relaxation. using >afebrile, with head of Allows proper Numeric T=37.4oC bed elevated. ventilation and Pain Scale improves lung within the >(-) expansion. shift. restlessness/ Provided irritability safety by To avoid risks EO1 keeping the of falls that > (-) SOB side rails up. could increase Patient will the pain that the be able to > Irregular patient understand pulse rate of experience. the body’s 92 bpm Provided calm response to restful Promotes disease > BP = surroundings relaxation and conditions. 120/70mmHg and sleep. minimized environmental > (+) activity or tenderness on noise. sternum Administered >(+) guarding analgesic To provide pain behavior on medications relief. chest area as ordered.
> (+) Wound
drsg. on PED abdominal area, (+) Encouraged slight redness verbalization To be aware of and of pain or the client’s (-)purulent discomfort. level of discharge of discomfort. the surgical Advised site. patient to Improves perform deep pulmonary gas breathing exchange and exercises. for pain management. Encouraged diversional To divert activities. attention from pain Cues Nursing Long Term Short Intervention Rationale Evaluation/ Diagnosis Goal Term Goal Expected Outcome S> “Hindi pa A3 LG3 SG3 PDx E3 gaanong NPI done. To establish naghihilom Risk for To maintain Will not rapport with the Goal Met ang sugat ko” infection good manifest patient and “Hindi pa related to a hygiene and signs of promote good Patient did ako naliligo site for physical infection communication. not manifest noon pa ng organism comfort. during the signs of matapos ang invasion shift. Assessed To determine infection operasyon” secondary patient’s deviations from during the to heart condition. normal and shift. O surgery. obtain >afebrile, subjective and >afebrile, T=37.4oC objectives cues. T= 37.1C
>(-) Monitored for To identify any
restlessness/ any developing EO3 irritability complications. infection for early treatment Will be able and referral. to maintain > Poor good hygiene Monitored Provide hygiene and vital signs. baseline data physical >(-) pallor for changes in comfort. patient’s >(-) condition. headache, dizziness Observed skin May predispose for breaks, client to >(-) Cough irritation, or infection. and signs of adventitious infection. breath sounds Monitored Fluctuation >(+) guarding CTT for reflects behavior on fluctuations. differences chest area between inspiration and > good expiration. capillary refill Excessive less than 2 fluctuation may seconds indicate airway obstruction or >S/P TVAP, presence of MVR, PDA large ligation pneumothorax.
> (+) Wound Checked To determine if
drsg. on dressing there is pus abdominal frequently. formation or area, (+) excessive slight redness bleeding. and (-) purulent PRx discharge of the surgical Maintained To prevent site. the wound bacterial clean contamination > (+) CTT of the wounded insertion area
> (+) Patient kept Minimizes
incisional site safe and anxiety and on sternum, comfortable. prevent injury. with slight redness and Provided Promotes (-) purulent adequate rest. recovery from discharge. surgery. Administered May be given antibiotic prophylactically medications for suspected as ordered. infection or contamination.
PED
Advised to Helps avoid
change pulmonary position every stasis of fluid now and then that may lead to respiratory infection
Encouraged Reduces risk of
patient to infection. maintain good hygiene.
Encouraged to To meet the
verbalize needs of the feelings and client. needs.
Health Proper hygiene
teaching about is quite proper necessarily to hygiene. prevent any accumulation of bacteria especially on the open wound.
Subjective Data: Objective Data: - Well Appearing But Independent Nursing Interventions: - Review Intraoperative Desired Outcome. Goal Met. Patient Was Able To