INTERVENTION

DAY/DATE Friday/May 13th 2011 DX I GOAL Status respiration: Airway Potency, with indicator: a. Capable to identificate and prevent factor that resist the airway. b. Demonstrate an effective cough, clear breath sound, no cyanosis and dispneu. c. Show the airway potency. Saturday/May 14th 2011 II Pain control with indicator: a. Identifying the causes factor of pain. b. Use non analgetics method to reduce the pain. NURSING ACTION Airway Management
a. Order the patient to

RATIONALE a. To maximize the ventilation. b. To record the additional sounds c. To eliminate the airway secretion.
d. To record the

SIGNATURE

sit in semi fowlers position.

b. Auscultate breath

sound. c. Do the chest physioteraphy if needed.

d. Monitor the

respiration. Pain Management.

a. Assess about the

status of respiration. a. To assess about the pain characteristic. b. To reduce the pain.

pain include place, durations, quality and frequency. b. Teach to use nonPharmacologic therapy, includes relaxation, distractions, guide

c. Use analgetics according to the need.

imaginary. c. Administrating the analgesics teraphy according to the indication d. Increase an enough rest Fever Treatment
a. Monitor

c. To reduce the pain.

d. To comfort the

patient and support the cure process.

Sunday/May 15th 2011

Thermoregulation: The body temperature is decreasing with indicator: a. The body temperature is in normal range.

the temperature as frequent as possible. b. Collaborate the administrating antipyretic. c. Monitor the blood pressure, pulse and RR.

a. To control the

body temperature is in normal range. b. To decrease the body temperature. c. To control the blood pressure, pulse, and RR are in normal range. d. To prevent dehydration.

b. Pulse and

respiration are in normal range.

d. Monitor intake and c. There is no skin

colour range and headache.

output of body liquid. e. Monitor skin colour and temperature.