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DVT Diagnosis: Leptospirosis Weils Syndrome Assessment Subjective: “Nagad-adu met ti pantal pantal kon”, as verbalizes by the patient Objective: Nursing Diagnosis Impaired integrity presence of rashes Planning Intervention Rationale Evaluation
Independent Assess skin After 1-2 days thoroughly due to of nursing
intervention, Maintain the patient by absence hygiene will have To maintain skin of rashes improved skin integrity at optimal integrity as Monitor laboratory level evidenced by results pertinent to reduction of causative factors Clotting factors may show abnormal rashes
Promote comfort patient’s result that may increase the patient risk cause
patient To determine if The goal rashes developed in was met as other parts of the evidenced strict body
Rashes may itchiness Collaborative Give medications To relieve as prescribed discomfort
other methods to promote comfort and to relieve pain Intervention Rationale To provide base line imformation Pain is unique to each patient. One may encounter varying descriptions because of individualized perceptions. the patient will demonstrate use of relaxation skils. the patient was able to demonstrat e use of relaxation skills. breathing technique and guided imagery. Carefully position affected area Apply local massage gently to affected areas Encourage range . Non verbal cues may aid in evaluation of pain and effectiveness of therapy Cognitive behavioral interventions may reduce reliance on pharmacological therapy and enhance patient’s Evaluation After 8 hours of nursing interventio ns. other methods to promote comfort and relieve pain - - Independent: Assess reports of pain.Patient Name: Mr. including location and intensity (scale of 0-10) Observe non verbal cues Explore alternative pain relief measure like relaxation technique. DVT Diagnosis: Leptospirosis Weils Syndrome Assessment Subjective: “Sobra met sakit ulo kun pati bagbagik”.3 P: 89 R:22 BP: 110/70 Nursing Diagnosis Acute pain related to bacterial infections in the body Planning After 8 hours of nursing interventions. as verbalized by the patient Objective: -facial grimacing -irritability -gurading of the affected area -V/S taken as follows: T: 37.
Review disease process and future Provides knowledge expectations base from which .- of exercises Maintain adequate intake motion fluid - Collaborative Administer medication as indicated like antibiotics and analgesics sense of control Reduces discomfort.Review individual patient can informed . and risk for injury Help reduce muscle tension Prevents joint stiffness and possible contracture fromation Dehydration increases sickling and corresponding pain Analgesics reduces pain and promotes rest and comfort. while antibiotic inhibits further bacterial infection Patient Name: Mr. DVT Diagnosis: Leptospirosis Weils Syndrome Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation After 2 days of nursing interventio Subjective: Knowledge “Han ko met evidenced gamen ammo statement After 2 days deficit of nursing by intervention of client initiate Independent .
skin breakage.) To know what different method can he use to protect his self to the organism thus preventing the disease process Promotes understanding of and enhances cooperation in treatment and reduces risk of recurrence and complications Necessary for optimal healing and general well being Prevents fatigue. client initiated necessary lifestyle changes . side effects and importance of adherence to regimen Discuss need for good nutritional intake/balanced diet Encourage adequate rest periods with scheduled activities Review necessarily of personal hygiene and environmental cleanliness. waterlogged skin. and promotes healing Helps control environmental exposure by diminishing the number of pathogens n . isu hanak nagpapacheckup edin.” As verbalizes by the patient Objective: - - - - - risk factors and mode of transmission/porta l of entry of infections Promote health teaching about prevention of transmission Provide information about drug therapy. conserves energy. proper cooking techniques/food storage choices Job that may include animals. exposure to pathogens.nga misconception and necessary leptospirosis development of lifestyle met gayam preventable disease changes daytuyen. Interactions. contaminated flood. contaminated drinking water.
rhythmic breathing) Rationale Serves as baseline date and reference To reduce the intensity of pain To initiate comfort To decrease the pain felt by the patient Evaluation After 2 hours of continuous nursing interventio ns. the patient relates of lessened pain.g. the significant others significant others can easily remind him. Significant others may also convince him to participate in the prevention and health promotion regimen Patient Name: Mr.Monitor vital signs .present Dependent: So if ever the client .Discuss it with forgives. Pain scale becomes .Instruct patient on techniques to reduce muscle tension . DVT Diagnosis: Leptospirosis Weils Syndrome Assessment Subjective: “ Nagsakit met toy limteg nga saka kun” as verbalized by the patient Objective: Grimaci ng of Nursing Diagnosis Impaired comfort related to acute pain secondary to disease process as manifested by edema Planning After 2 hours of nursing interventions the patient will relate lessened pain Intervention Independent . slow.Teach specific relxation strategy (e. goal met.
3 Dependent: .Give pain medication as ordered by the physician 2/10 Patient Name: Mr. DVT Diagnosis: Leptospirosis Weils Syndrome Assessment Nursing Diagnosis Planning Objective: - Intervention - Rationale Evaluation After nursing interventio n the patient performed measures in decreasing risk of Risk for bleeding After nursing Yellow related to intervention sclera decreased platelet the patient count perform Pale measures to Plt count reduce risk of of 41 from bleeding the normal value of 150-400 - - To prevent fatigue Encourage and lessen oxygen consumption adequate rest To maintain fluid periods volume and Instructed to hydration increase fluid To maintain fluid intake volume Maintained To avoid alteration in result of possible intravenous fluid stool exam Instructed to avoid To prevent bleeding . face noted Pain scale of 6/10 wherein 110 as severe pain and 0 as no pain V/S BP: 110/80 PR: 78 RR: 23 T: 37.
4 - - eating dark colored foods Instructed to avoid using hard toothbrush and blade in shaving mustache Encourage to assume comfortable position bleeding Patient Name: Mr. sa sobrang sakit na jay sakak” Nursing Diagnosis Activity intolerance related to immobility secondary to pain Planning After 8 hours of nursing intervention the client will understand the importance of - Intervention Turn and reposition the patient at least every 2 hours Teach isometric exercise Provide emotional - Rationale Turning and repositioning prevents skin breakdown and atelectasis and improve lung expansion This will help client Evaluation After 8 hours of nursing interventio n.- V/S BP: 100/70 PR: 78bpm RR:24 bpm T: 36. DVT Diagnosis: Leptospirosis Weils Syndrome Assessment Subjective: “Hanak pay makatugaw tugaw met. the client enumerates - - .
Objective: Limited ROM on lower extremiti es Patient appears weak Facial grimace noted when the leg was ask to raise Pain scale 9/10 maximum activity level - - support and encouragement Encourage verbalize pain and discomfort and observe nonverbal cues for pain Implement ROM exercise. progress from passive to active ROM - - - to increase muscle tone and prevent contracture This will improve client’s self.concept and motivate to form ADL This will help to assess the location. quality and intensity of pain This will help client to increase muscle tone and prevent contracture and maintain joint mobility techniques that enable resumption of activities such as isometric exercise and he was able to express willing to participate in care .
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