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Published by kreny10

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Published by: kreny10 on Dec 12, 2009
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Sakamoto, Karen S.July 28, 2009BSN 4BRot 3 PCMC
I.Mr. AA, 3yoDx: Acute symptomatic seizure 2 to metabolic
encep. 2 to AGE
Assessment N.Diagnosis Inference Planning Intervention Rationale Evaluation
O:>The patientconsume his bottle whilelying downRisk for aspirationrelated to body positioningwhile bottlefed.Ingestion of milk formula passing tothe normalingestion pathwaythat has a possibilityto obstructor block the pathway because of  poor body positioningthat resultto risk of aspiration.
Short termgoal:
After 5hours of nursinginterventions, the patientwill be abletodemonstratetechniques to preventaspiration.>assess thecondition of the patient.>identify at-risk clientaccording tocondition.>educate the patient andrelative toelevate clientto highest or  best possible position(e.g., sittingupright inchair)>educate the patient andrelative toavoidwashingsolids downwith liquids>advice the patient andrelative notto jump>to obtain baselinedata>to managedifferentintervention>normalgravityhelps thefood godown toyour digestivetractsmoothlythus preventingaspiration>it may justadd up toaspiration if  present>to let thefood beabsorbedAfter 5 hoursof nursinginterventions, the goalwas met asevidenced by patient ableto consumehis milk formula properly andthe absenceof the risk for the patient toexperienceaspiration.
around whenthe stomachis full.>Refer to physiciananddigested. Itwill alsohelp the patient notto vomit.II.Mr. LA, 7yoWorking dx: Myositis
Assessment N.Diagnosis Inference Planning Intervention Rationale Evaluation
S: “di komagalaw e.Masakit padin (pointinghis L leg)” asverbalized bythe patient.O:>Observedevidence of  pain>Guarding behavior >Expressive behavior Acute painrelated tounderlying physicalagents of the musclePain is caused by underlyingrare conditionof the musclethat makes the personuncomfortable because of the discomfortthat it gives.After 8 hours of nursinginterventions,the patient will be able tofollow prescribed pharmacological regimen andlevel of pain bedecrease to6/10.>assess thecondition of the patient>determine anddocument presence of  possible pathophysiological/ psychologicalcauses of pain(e.g.inflammation,infections, etc)>Observenonverbal cues behaviors (e.g.how client walks,sits, etc)>to obtain baselinedata>to lessenand avoidthe pain by proper management>toAfter 8 hoursof nursinginterventions, the goalwas met asevidenced bythe patientwas able tofollow the prescribedtherapeuticmanagementto his caseand level of  paindecreased to6/10.
(Restlessness)>Diaphoresis>Pain scaleof 7/10>Ascertain client’sknowledge of andexpectations about pain management>Determineclient’s acceptablelevel of pain>Provide comfortmeasures such astouch,repositioning, etc.>Encourage use of relaxationtechniques such as breathing,imaging, etc.>refer to physiciananticipate pain and provide proper care>to be ableto respondtotherapeuticmanagement>to be ableto establish patient’strust in youand not togive further  pain to the patient>to lessenthe pain>to divertattention of  painIII.Ms. RAM, 2yoAdm dx: hepatic abscess
Assessment N.Diagnosis Inference Planning Intervention Rationale Evaluation

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