Julio Martinez; a 20-year-old, Male, Hispanic comes into the ED with signs of nausea, vomiting, abdominal pain.

Patient’s Initials: _J.M____

 Student’s Name: Rosana Olivera, Brittany Arellana, Vanessa Cano _______
Date: __July 9, 2020__

Assessment Nursing Diagnosis Planning Implementation Rationale Behind Intervention Evaluation

- Julio Psychosocial ND: By the end of the shift: Independent: - Isolation may be Goals met:
Martinez - Identify support partly self-imposed
- 20-year-old systems available because the patient - Understanding the
- Male to patients. (SO, fears rejection/reaction social acceptance
Social Isolation - Ascertain family, friends) of others.  of the condition. 
- Hispanic patient’s
related to - Teach techniques - Involving patients in a - Trust between
perceptions of perception of the such as deep community group nurse and patient
situation.  breathing, and setting/family/relatives was met to ensure
unacceptable
Subjective: - Explain relaxation reduces sense of proper care. 
social or sexual significance of
behavior/values techniques isolation and promotes - Began
- Extremely transmission - Encourage socialization.  communicating
tired “I’ve as evidenced by precautions to patients to - Understanding the with peers and
been feeling expressed feelings patients.  significance of social groups 
request
very lazy and of aloneness - Educate on safe transmission and - Looking into
medication as
weak lately”  imposed by sex practices. precautions may help participating in
early as possible.
- “I’ve lost so others, feelings of - Make the patient the patient cope with activities/programs
much weight feel comfortable, and adhere to them at level of
rejection.
in the last enough for them better and develop ability/desire. 
Collaborative:
couple of to trust you.  new approaches to life - Repeated to me
- Spend time
weeks, idk - Educate patient with HIV infection.  the transmission
talking with
what’s wrong Psychological ND: on how to - Patients may precautions he
patients during
with me”  manage experience physical needs to adhere to.
and between care
- “I’ve been condition, isolation as a result of - The patient was
activities.
having lifestyle changes. current medical status. able to have a
- Be supportive,
unprotected Acute Pain - The patient’s - Building a relationship
allowing for decreased
sex for the related to subjective with the patient may
verbalization of perception of pain.
last couple of abdominal perception of enhance self-esteem
patient by active- - The patient
months, cramping as pain decreases as and decrease negative
listening. stated  a pain rate
should I be documented by behaviors.
evidenced by - Treat with of 0 on a 0-10
scared?” the pain scale. - Competent pain
abdominal dignity and scale. Non verbal
 distention and - Nonverbal regard for management requires indicators of
guarding. indicators of patients feelings. frequent and thorough discomfort such as
discomfort such - Explain isolation assessment of these grimacing and
Objective: as grimacing will precautions and factors. Using a pain guarding were also
be absent or procedures to scale provides an diminished
- Pain level 7 diminished patient  objective
from scale 1- - Look at available measurement that - Patients had
10 resources; enables assessment of adequate nutrition
- High fever In 24-48 hours: support healthy pain management with evidence of
Imbalanced
- Shortness of behaviors.  strategies  stable weight,
breath
Nutrition: Less - Involve patients - Go over - Pain that is allowed to retinol- binding
- ELISA than Body with community precautions when become severe is more protein 4-5 mg/dl,
diagnostic test Requirements support services. having sex in the difficult to control. serum albumin
came back related to future. For Prolonged stimulation 3.5-5.5 g/dl and a
- Patients will example, the of pain receptors
positive increased positive N state.
have adequate proper  use of results in increased
- CD4+ T Cell metabolic nutrition with condoms and to sensitivity to painful
count of less rate/nutritional evidence of always inform stimuli and will
than 200 needs as stable weight, sexual partners increase the amount of
- Body weight evidenced by lack retinol- binding about their drug required to
decreased of interest in protein 4-5 condition. relieve pain 
5lbs in 1 food, aversion to mg/dl, serum - Assess and - Heat and cold
week. albumin 3.5-5.5 record the application are
eating, altered g/dl and a following: effective
- Retinol- taste sensation. positive N state. location, onset, nonpharmacologic
binding duration and measures that reduce
protein (RBP) factors that pain as well as
is greater than precipitate and augment effects of
5.  alleviate the analgesics 
- Serum patients pain. - The deep breathing
Albumin is With the patient techniques reduce pain
less than 3.5 establish a pain intensity by decreasing
g/dl scale, rating from skeletal tension 
- Nitrogen (N) 0 (no pain) to 10 - By administering back
test is ( worst pain)  rubs and massages
Negative. - Administer they will promote
V/S: analgesics as relaxation and comfort
prescribed. - Progressive weight
T:103F - Provide heat or loss, wasting of
HR: 65  cold application muscle tone, loss of
BP: 134/82 mmHg to affected areas snake turgor, and
(apply cold packs decrease in total
RR: 22 bpm
to reduce protein can decrease
swelling the patient’s ability to
associated with withhold the
infections) infection. 
- Assess - Smaller, more
nutritional status frequent meals may be
daily, Noting the easier to tolerate than
weight, caloric 3 large big meals a
output, and day.
protein values.  - The measures of deep
- Provide frequent, breathing and
high caloric, high voluntary swallowing
protein meals, help the sensation of
allowing enough vomiting. 
time for the - Nausea and vomiting
patient to eat, is easier to control
offer when it's treated
supplements in before it gets too
between eating.  severe or is prolonged.
- Provide
instructions for
deep breathing
and voluntary
swallowing.