Patient Name /biographical data F.

J - sex -male Age 22 African American , Single Student, Christian

Assessment Subjective: "My head is hurting me ", Patient reported vomiting and drowsiness fever when pain started and left ear pain. Patient took 2 Advil to help with headache and left ear pain. Patient reported temporary relief with analgesics.

Diagnosis Acute Pain related to left ear infection (as evidenced by erythema and swelled ear; elevated pulse, respirations, and report of 8/10 ear pain )

Objective: FJ pain is 8/10 on the scale patient is a confused state of mind. Left Ear is warm to touch and show some swelling Bp 120/70 , temp 100.4 Pulse 70, Respiratory Rate 24 bpm

Planning Goal setting Short Term: Teach patient to use analgesics correctly, this will decrease unwanted effects of analgesics. Have patient use non analgesics relief measure. (warm Compress) Decrease temperature to normal levels Long Term: Teach patient to recognize and reduce factors that may precipitate pain in the future.

Implementation/ Intervention Perform a comprehensive assessment of pain to include location, onset, frequency, quality and severity. Consider culture influences on pain response. Personal factors and believes can influence pain tolerance. Implement use warm compress and create a quiet environment with dim lighting this aid in comfort in turn, decreasing pain.

Evaluation Partial outcomes met. The client verbalizes pain and discomfort. Patient is willing to try nonanalgesics techniques. Patient verbalized full understand of how to appropriately take medication.

Lisa Rae L. R Female Age 78 Race: Caucasian

Assessment subjective : Patient reported she took 50 mg of hydrochlorothiazide , 10 mg alendronate and 600mg calcium carbonate at home this morning. Ms. R also report she may have taken 2 tabs of hydrochlorothiazide. Reports falls and pain in right hip.

Diagnosis At Risk for injury from fall due to impaired mobility. ( As evidence by injury to right hip after fall and patient using a walking assistant device)

Objective: Pt. has right hip hematoma , skin is intact , warm and tender to palpate. Patient Is mobile with moderate assistance. Pt. is alert and orientated to person and place but disoriented to day and time. Lungs are clear throughout and cardiac regular rate Temp 98.8 , BP 94/70, Respiratory Rate 18 pain is 5/10

Planning Goal Setting Short term : prevent fall, orient pt. to current environment (hospital ) teach pt. to ambulate slowly to prevent orthostatic hypotension and use walker properly as well as demonstrate to patient techniques to strengthen lower extremity. Educate her daughter on proper helping techniques of ambulation Long term : prevent future falls at home. Educate patient on preventing orthostatic hypotension when rising out of bed .

Implementation /Intervention Orient client to environment. Assess ability to use call bell, side rails, and bed controls. Demonstrate safety technique for ambulation to family member.

Evaluation Patient 's goals have been met client is able to verbalize an understanding the risks factors for falls, properly use walker and Patient vital signs remain within normal limits

Make changes in client s environment that may cause or contribute to injury to increase client's awareness.

Client did not experience any falls during hospital stay. Client understands and verbalized the plan to make changes at home to ensure safety