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NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION


Objective: Acute pain Within 30 minutes Established To gain trust and Goal met:
guarding related to of nursing rapport by have a nurse patient Within 30 minutes of nursing
behavior on compression of intervention, the talking and relationship intervention, the patient exhibit
the affected the nerve endings patient will exhibit playing with behaviors that indicated his pain was
hand in the affected behaviors or the patient lessen such as playing with his toys
Facial hand movement that by holding it with both hands.
grimace indicates free or
Crying upon lessen his pain Assessed To determine
holding the the area of possibility of
affected pain underlying condition
hand requiring treatment

Instructed To lessen the


patients episodes of pain
mother to
limit
activities that
is not
necessary
for the
patient
To distract attention
Instructed and reduce tension
and
encouraged
the patient
and S.O to
use

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relaxation
technique,
such as
playing with
his toys and
listening to
music music
To evaluate coping
Encouraged abilities and to
verbalization identify areas of
of feelings additional concern
about the
pain
To relieve the pain
Administere the patients
d experiencing
Pain reliever
as
prescribed
by the
physician.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION


Objective: Risk for Within 30min. of Goal met:
Post op extension of nursing Instructed Behaviors Within30 min. of nursing
debridement infection r/t intervention, the the patient necessary to intervention, the patient was
sequestrectomy presence patient will and prevent spread of remains free of infection as
Fever with body incision remains free of significant infection evidence by absence of sign
temperature of infection as other to and symptoms of infection.

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38C evidence by practice
WBC:17.1710g/ absence of sign proper
L in normal range and symptoms disposal of
of 4.50 of infection. tissue and
11.0010g/L waste
product
being used
and perform
hand
hygiene.
To know if the
Monitored
patient had
temperature continued
as indicated presence of
infection by
having febrile

To prevent
Instructed
spread of
patients
infection
S.O to
protect the
integrity of
the skin and
care for
lesion Helps support
Encouraged and strengthen
intake of the immune
protein-rich system.
calorie-rich
foods, fruits

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and
vegetables.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION


Objective: Hyperthermia r/t After 30 min of Established To gain trust and Goal met:
flash skin increase pyrogen nursing rapport have a nurse patient After 30 min of nursing intervention,
skin warm to intervention, the relationship the patients temperature was been
touch patients drop from 38C to 37.5C
irritability temperature will Monitored To establish
temperature drop from 38C to vital signs baseline data of the
: 37.5C patient
38C
Provided To lower patients
TSB temperature

Instructed To release heat and


SO to provide comfort
provide with
loose
clothing
Assessed Warm, dry, flushed
skin skin may indicate a
temperature fever
and color

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Instructed To rehydrate the
patient and body and decrease
S.O to febrile conditions
Increase
fluid intake

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION


Objective: Fear related to After 30 min of Goal met:
Crying upon hospital personel nursing Established To gain trust and After 30 min of nursing intervention,
entering the intervention, the rapport have a nurse patient the patients fear toward us was
room patients fear will relationship decrease and trust was established
Loud cry decrease or the
when patient will Engaged to To gain trust and
touching the established trust conversatio have a nurse patient
patient or n with the relationship
IVF patient
Irritability
with the
presence of Played toys To gain trust and
nurse or with the sees us as his friend
white patient
wearing
personnel Encouraged To assess the
verbalization feelings of the
of feelings patient and gain his
trust

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