Assessment Nursing Scientific Planning Implementation Rationale Evaluation

Diagnosis Background
Subjective: Acute Infection/ Short Term Independent The patient’s self- After 1 hour of
Patient reports abdominal obstruction After 1-2 hours of  Determine the report on pain is nursing
abdominal pain pain related to nursing intervention, location, the gold standard intervention the
and pain of 9 infection as Irritation of the patient will be characteristics, in pain assessment was able to
from pain scale of evidenced by parietal able to onset, duration, as they can verbalize a
1/10 weakness, peritoneum  improved vitals frequency, describe the satisfactory
fever, such as baseline quality, and location, intensity, pain level
Objective: lethargy and levels for BP, severity of pain and duration. using the
V/S as follows: patient Distention of the and respirations via assessment. Thus, assessment numeric pain
Temp: 38.9 reporting stomach  A pain of pain by scale,
degrees Celsius abdominal reduction to conducting an maintains
BP: 140/80 pain and pain Pain transmission 3 to 4 on a interview helps the baseline vitals,
RR: 22 cpm of 9 from in nociceptors standardize nurse in planning uses non-
PR: 80 bpm 1/10 pain d pain scale optimal pain pharmaceutical
Spo2: 97% scale and Acute abdominal after management and
 Afebrile abdominal pain receiving strategies. pharmaceutical
 Weak pain. analgesics.  Determine the Some patients may pain relief
 Abdominal  Demonstrate pain patient’s be satisfied when strategies
pain relief by anticipation for pain is no longer effectively.
 Lethargic maintaining stable pain relief. intense; others will After 1 day of
vital signs, no demand complete nursing
signs of weakness, elimination of intervention,
abdominal pain pain. This the patient was
and lethargy influences the able to
perceptions of the demonstrate
effectiveness of non
Long Term the treatment pharmacologic
After 1 day of modality and their pain
nursing eagerness to management as
interventions, the engage in further needed. Goal is
patient will be able  Provide treatments. met.
to nonpharmacologic Nonpharmacologic
 Demonstrate non pain management. methods in pain
pharmacologic management may
pain include physical,
management cognitive-
strategies
 including behavioral
relaxation skills strategies, and
and diversional Dependent lifestyle pain
activities for Provide management.
individual pharmacologic pain
situation management as Pain management
ordered. using
pharmacologic
methods involves
using opioids
(narcotics),
nonopioids
(NSAIDs), and co
Collaborative: analgesic drugs.
Evaluation of lab
results with medical To check for any
laboratory imbalances
technologists
Subjective: Hyperthermia Bacterial/ viral After 2-3 hours of Independent After 2-3 hours
Patient’s daughter related to infection nursing intervention Loosen or remove Exposing skin to nursing
reported 4 times infection as the patient is able to excess clothing and room air decreases intervention,
of vomiting and evidenced by Release of  Maintain body covers. heat and increases patient was
rate pain of 9 in 3 times of pyrogens temperature evaporative able to
pain scale 1/10. vomiting, below 38.9 cooling. Maintain body
Objective: passed Activates on degree Celsius Provide hypothermia Use cooling temperature
 Vomited 3 approximately anterior  maintains BP blankets or cooling blankets that below 38.9
times of 200 ml of hypothalamus and HR within blankets when circulate water degree Celsius
around 100 urine in the normal limits. necessary. when the body maintains BP
ml of greenish urinal, Increased body temperature is and HR within
fluid afebrile, temperature needed to be normal limits.
 Passed weakness, cooled quickly Goal is met.
approximately lethargy, Provide a tepid bath A tepid sponge
200 ml of respiration of or sponge bath. bath is a non-
urine in the 22, BP: pharmacological
urinal 140/80 and measure to allow
 Weakness reports pain evaporative
 Lethargy of 9 in pain cooling.
 V/S as scale 1/10 Dependent
follows: Start intravenous Intravenous
Temp: 38.9 normal saline normal saline
degrees Celsius solutions or as solution
BP: 140/80 indicated. replenishes fluid
RR: 22 cpm losses during
PR: 80 bpm shivering chills.
Spo2: 97% Provide antipyretic To reduce fever
drugs as ordered
Collaborative
Evaluation of lab To identify cause
results of fever
Subjective: Risk for fluid Depletion of fluids Short term: Independent After 3 hours
Patient’s daughter volume available After 1 -3 hours of Encourage/remind As individuals age of nursing
reported 4 times deficit related nursing intervention patient of the need for sometimes there is intervention the
of vomiting and to vomiting as Cells become the patient’s vital oral intake. a loss of thirst, patient vital
abdominal pain. evidenced by unable to replace signs will remain reminding and signs returned
Objective: 3x of ECF losses stable and/or return encouraging to normal,
V/S as follows: vomiting, to patient’s baseline. individuals may intake and
 Temp 38.9 C, passed Electrolyte  Patient’s intake help them to output
 PR 80 bpm, approximately imbalance and output will remember the need stabilized and
 22 cpm, 200 ml of stabilize. to continue verbalized
 BP 140/80, urine in the Risk for fluid  Verbalize drinking fluids understanding
 Spo2 97%. urinal, volume deficit understanding of even if they do not of the
 Vomited 3x; afebrile, the condition and feel they are condition.
100 ml of weakness, its causes thirsty. After 2 days of
greenish fluid lethargy, poor Educate patient and Education will nursing
 Passed appetite Long term family on possible help allow the intervention,
approximately anxious and After 2 days of causes of patient and family the patient was
200 ml of patient’s nursing intervention dehydration. to have a better able to
urine in the daughter the patient will be understanding of verbalize and
urinal report 4 times able to verbalize the diagnosis and demonstrate
 Afebrile of vomiting measures to preventative take home
 Weakness and take at home to measures they can measures to
 Lethargy abdominal maintain take in the future maintain
 Poor appetite pain. hydration/preve to avoid hydration. Goal
 Anxious nt dehydration dehydration. is met.
Dependent
Administer Severely
intravenous hydration dehydrated
as ordered patients or patients
 unable to take oral
hydration may
require IV
hydration to
maintain
appropriate
hydration level.
Administer Dehydration can
electrolyte lead to electrolyte
replacements as abnormalities; it is
needed/as ordered. important the
nurse monitors for
this and provides
supplemental
replacements
when needed.
Collaborative:
Evaluation of lab To check any
results with medical imbalances to
laboratory identify the
technologists condition further