A.

Nursing Interventions
Client Name: An. S Day / Date: Thursday, July 12, 2018
No. RM: 48 05 36 Treatment room: Lambu Barakati Children

Nursing Interventions
Nursing Action Plan
Day / Date Nursing diagnoses Goal / Criteria Results Action
(NOC) (NIC)
Thursday Acute pain NOC: NIC:
7/12/2018 associated with Pain Control Pain Management
biological injury 1. The client reports 1. Perform a
agents reduced pain comprehensive pain
2. Clients can assessment including
recognize the duration location,
(onset) of pain characteristics,
3. The client can frequency duration,
describe the causative quality and
factor precipitation factors.
4. Clients can use non- 2. Observe for
pharmacological nonverbal
techniques instructions regarding
5. Clients use discomfort
analgesics accordingly 3. Control the
instructions environmental factors
Pain Level that can affect the
1. The client reports patient's response to
reduced pain discomfort (for
2. Clients do not appear example, room
to complain and cry temperature, lighting,
3. The client's facial noise)
expression does not 4. Teach about non-
indicate pain pharmacological
techniques (deep
 4. The client is not breath relaxation
agitated techniques)
5. Support adequate
rest / sleep to help
reduce pain
Provision of
analgesics
6. Check for a history
of drug allergy.
7. Check the
medication orders
including medication,
dosage, and
frequency
Monitor vital signs
Monitor blood
pressure, pulse,
temperature and
respiratory status
accurately
Thursday Hippertermia is NOC: NIC:
7/12/2018 related to the Thermoregulation Fever Treatment
process of infection Results Criteria: 1. Monitor
(disease) 1. Body temperature in temperature and other
the normal range vital signs (blood
2. The pulse and RR pressure, pulse and
are in the range normal breathing) Monitor
3. There is no change skin color and
in skin color and no temperature
complaints dizzy 3. Cover the patient
with blankets or light
clothing depending
on the fever phase
 4. Compress the
patient on the groin
and axilla
5. Give intravenous
fluids
6. Collaborative
administration of
antipyretic therapy,
antibiotics or anti-
chills agents
Thursday Nutrition is less NOC: NIC:
7/12/2018 than the body's Nutritional Status: food Nutrition Monitoring
needs related to and Fluid Intake 1. Monitor for weight
decreased appetite Results Criteria loss
1. There are no signs of 2. Monitor child or
malnutrition parent interactions
2. Demonstrates an during meals
increase in taste and 3. Monitor skin
swallowing functions turgor
3. No significant weight 4. Monitor dryness,
loss occurs dull hair, and break
4. Able to identify easily
nutritional needs 5. Monitor nausea
and vomiting
6. Monitor albumin
levels, total protein,
hemoglobin, and
levels