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care-plan

care-plan

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Published by Haijan Othman

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Published by: Haijan Othman on Apr 24, 2012
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04/24/2012

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Nursing Care Plan

Student Name/Date: Alyson L. Conway, 11/14/07

Nursing Diagnosis
(Dx, related to, & as evidenced by)

Expected Outcomes
(Short term (8-48 hr.) reasonable expectations stated in measurable, behavioral terms, i.e., action verbs)

Nursing Interventions/Rationale
List all interventions for each nsg. dx (include patient/family teaching)

Outcome Evaluation
(Patient outcome noted as met or unmet/responses described)

Acute pain related to infectious process and inflamation as demonstrated by patient complaints of pain.

Patient’s pain rating will be under 3 on a scale of 1-10 at all times.

Asses pain every 2 hours using a 110 scale, pain scales provide a measure of pain which is consistent (Ackley & Ladwig, 2008) Teach patient adverse complication of uncontrolled pain, it is important the patient understand why pain is treated so they will report discomfort (Ackley & Ladwig, 2008). Teach patient deep breathing and visulization, these methods can reduce pain preception and return to the patient a feeling of control (Ackely & Ladwig, 2008). Teach patient that addiction to pain meds is not formed when medication is needed due to acute pain (S. Roberts, Analgesics, November 2007) Work with physical therapy to develop a exercise routine as tolerated by patient. Exercise can relieve pain and limit other complications such as constipation related to opiod use (Lewis, 2007) Plan patients day so that aggrevating activities coincide with peak of analgesic. Patients should be medicated before procedures and activities that incite pain to prevent spikes in pain (Lewis, 2007) Provide patient with distractions of choice such as TV, music or reading. Distraction can help to relieve pain (Lewis, 2007)

Outome partially met, the patient stated pain relating below 3 for some of the day.

. shortness of breath while standing and patients statements. Impaired Mobility related to excess weight and pain as demonstrated inability to rise easily from bed and move about. Impaired skin integrity related to skin infection and wound. Chronic low self esteem related to exess weight as demonstrated by patient’s statements of being a “monster”. Disturbed body image related to exess weight as demonstrated by patient’s statements of being a “monster”. increased blood pressure. Anxiety related to hospitalization as demonstrated by patients statemest of discomfort.Other Diagnosis: • • • • • • • • Activity Intolerance related to excess weight as demonstrated by inability to rise easily. Disturbed sensory preception related to ineffective tissue prefusion and demonstrated by patient’s staments of not “feeling” anything on mons pubis. Functional Urinary Incontience related to decreased mobility as demonstrated by inability to get to the toliet.

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