NURSING CARE PLAN

ASSESSMENT PLANNlNG lNTERVENTlON RATlONALE EXPECTED

OUTCOME
S masakit ang tiyan
ko
O Pain scale: 8/l0
- facial grimace
-irritable
-guarding behavior
-PR: l06cpm
-RR: 23bpm
-Temp: 38.8
Celsius
DlAGNOSlS
Acute Pain related to
inflammation of the
small intestine
SClENTlFlC
EXPLANATlON
From the ingestion of
contaminated food,
Salmonella typhi were
multiplied at Peyer's
patches which causes
an inflammation at the
small intestine.
Within 3 hours of
nursing intervention
the patient will be
able to rate pain on a
scale of 2/l0 from
8/l0.
>Perform comfort
measures to promote
relaxation such as
massage, bathing,
repositioning and
relaxation techniques.
>Plan activities with
patient to provide
distraction, such as
reading, crafts,
television and visits.
>Manipulate the
environment to
promote uninterrupted
rest.
>Help patient to a
comfortable position
and use pillows to
splint or support
painful areas
>Apply heat or cold
compress.
> Collaborate with
patient in
>These measures
reduce muscle tension
or spasm redistribute
pressure on body parts
and help patient focus
on non-pain related
subjects.
>to help patient focus
on non-pain related
matters.
>This promotes health,
well being, and
increase energy level
important to pain relief.
>to reduce muscle
tension ort spasm and
redistribute pressure
on body parts.
>to minimize or relive
pain.
> Gaining patients trust
and involvement helps
After 3 hours of
nursing intervention
the patient's pain
scale was 2/l0 from
8/l0.
administering
prescribed analgesics
when alternative
methods of pain
control are
inadequate.
ensure compliance and
may reduce medication
intake.
ASSESSMENT PLANNlNG lNTERVENTlON RATlONALE EXPECTED
OUTCOME
S
O 38.8 Celsius
-flush face
-warm skin
-PR: l06cpm
-RR: 23bpm
DlAGNOSlS
lncrease body
temperature related to
infection
SClENTlFlC
EXPLANATlON
Due to bacterial
invasion, there is
positive lgM which
indicates acute phase
of infection which is
part of the
inflammatory reaction
process.
Within l hour of
nursing intervention
the patient body
temperature will
decrease from 38.8
Celsius to 37.5
Celsius.
>Monitor Vital signs
especially
temperature every l
t0 4 hours
> Use non
pharmacologic
measures to reduce
excessive fever such
as removing sheets,
blankets, and most
clothing; placing ice
bags on axillae and
groin; sponging tepid
water.
>Provide proper
ventilation
>Monitor heart rate
and rhythm, blood
pressure, respiratory
rate, LOC and level of
responsiveness and
capillary refill time
every l to 4 hours
> to obtain an accurate
core temperature.
> Non pharmacologic
measures lower body
temperature and
provide comfort.
Sponging reduces
body temperature by
increasing evaporation
from skin. Tepid water
is used because cold
water increases
shivering, thereby
increasing metabolic
rate and causing
temperature to rise.
> Patients need
enough oxygen supply
that help to normalize
body temperature.
>to evaluate
effectiveness of
interventions and
monitor for
complications.
After l hour of
nursing intervention
the patient body
temperature was
decrease from 38.8
Celsius to 37.5
Celsius.
>Maintain bed rest.
>Administer
antipyretics, as
prescribed and record
effectiveness.
>to reduce metabolic
demands and oxygen
consumption.
>Antipyretics act on
hypothalamus to
regulate temperature.
ASSESSMENT PLANNlNG lNTERVENTlON RATlONALE EXPECTED
OUTCOME
S Paputul-putol ang
tulog ko, nahihirapan
akong matulog
O irritable
-inability to
concentrate
-yawning
-presence of eye
bags
DlAGNOSlS
Sleep pattern
disturbance related to
environmental status
SClENTlFlC
EXPLANATlON
The presence of
environmental
problems, the patient
finds hard time in
sleeping.
Within 3 hours of
nursing intervention
the patient will
express feeling well
rested.
>Encourage patient to
identify factors in the
environment that
make sleeping
difficult.
>Perform
interventions to
promote sleep, such
as giving patient a
bath or back rub
ensuring that patient
is positioned properly
or providing pillows,
food or drink.
>Teach patient
relaxation techniques,
such as guided
imagery, meditation,
and progressive
muscle relaxation.
Practice them with
patient at bedtime.
>lnstruct patient to
limit alcohol and
caffeine intake and
avoid foods that
interfere with sleep
> A strange or new
environment may
affect rapid-eye-
movement (REM) and
non-rapid-eye
movement (NREM)
sleep.
>Personal hygiene
routine precedes sleep
for many individuals.
Milk and some high
protein snacks such as
cheese or nuts, contain
L-trytophan, a sleep
promoter.
>Purposeful relaxation
efforts commonly
promote sleep.
>Dietary changes may
help to promote restful
sleep.
After 3 hours of
nursing intervention
the patient was able
to express feeling
well rested.
such as spicy foods.
Foods and beverages
with caffeine should
be avoided for 4 to 5
hours before bedtime.
>Make immediate
changes to
accommodate patient-
for example, reduce
noise; change
catheterization,
medication or
treatment schedule;
change lighting.
>Advise patient to
avoid daytime naps
>Tell patient to avoid
spending long periods
in bed without sleep.
>These measures
promote rest and
sleep.
>to promote restful
nocturnal sleep.
>Activity produces
healthy fatigue, which
promotes restful sleep.