PAIN

NURSING CARE PLAN

Assessment Diagnosis
Acute pain related to myocardial ischemia as evidenced by Facial grimace, Restlessness ,Positioning to avoid pain and a Pain scale 7 / 10 STG : After 1 hour of nursing intervention the client will able to reduce pain from 7 to 3.

Planning

Intervention
Independent : Monitored vital sign. Provided comfort measures quite environment and calm. Encouraged adequate rest. Monitored surgical for dehiscence and evisceration.

Rationale

Evaluation
Goal met.

Subjective : Masaki tang aking dibdib as verbalized by the patient. Objective : Facial grimace Restlessness Positioning to avoid pain. Pain scale 7 / 10

To served as base line data. To promote nonpharmacological pain management.

LTG : Inference: Acute pain is an unpleasant sensory And emotional experience arising from actual or potential tissue damage. Sudden or slow onset of any intensity from mild to severe. Upon discharge of the patient , He will be able to go back to his ADL without due pain and discomfort.

To prevent fatigue. Careful monitoring enables early detection.

After an effective nursing intervention the patient verbalized a relief of pain and pain scale was reduced from 7 to 3.

Vital signs : BP : 140/100 mmHg RR : 23 cpm PR: 110 bpm T: 38.5 celcius

Dependent : Administered Analgesics as prescribed by the physician. Collaborative : Collaborate with Cardiologist To maintain acceptable level of pain.

For the treatment of causes that distribute to pain.

Assessment
Subjective : Nurse mainit ang pakiramdam ko pa punasan naman ako wala yung nagbabantay sa akin eh as verbalized by the patient. Objective :

Diagnosis
Hyperthermia related to infection as evidenced by Flushed skin, Restlessnes ,Skin warm to touch and temperature of 38.5 celcius STG :

Planning

Intervention
Independent : Monitored vital signs. Provided Tepid sponged bath.

Rationale

Evaluation
Goal met

After 30 minutes of effective nursing intervention the patient s temperature will decreased from 38.5 to 37.5 celcius. LTG :

Flushed skin Restlessness Skin warm to touch. Weakness

Vital signs: BP : 140/100 mmHg RR : 23 cpm PR: 110 bpm T: 38.5 celcius Laboratory: Neutrophils : 75.9 = 55 - 70 its normal range

Upon discharged of the patient he will be able to maintain normal body temperature and can perform his activities of daily living.

To served as a baseline data. To decrease body temperature of the patient, & to Increase heat loss through conduction. To decreases warmth and increases evaporative cooling. To meet the increase metabolic demands and prevent dehydration.

The patients body temperature decreased from 38.5 to 37.5 celcius.

Removed excess clothing and covers.

Provide adequate of nutrition and fluids.

Dependent : Administer anti pyretics as ordered by the physician. To reduced the clients fever.

Collaborative