Nursing Care Plan for alteration in Comfort

Problem: Headache / Pain

Diagnosis: Alteration in comfort related to headache at the frontal part 2* to her illness

Assessment Goal Intervention Implementation Evaluation

Objective: At the end of Independent:

2* of rendering Goal Met:
 Restless nsg. care, pt. 1. Note for the location, scale, intensity and  Pain noted at the
 Facial Grimace will be able to onset of pain frontal part with the After 2 hours
verbalize relief  To determine the nsg. care to be given to scale of 5/10 from 0- of rendering
 Vital signs of pain with the pt. 10 scale. care, pt.
T- 39 * C the scale of verbalized
P- 88 bpm 0/10. 2. Maintain a calm and quite environment.  Calm and quite relieve of pain.
R- 24 cpm  To minimize stimulus that could environment was
BP- 110/ 70 aggravate the condition of the pt. provided
mmHg

3. Use relaxation technique such as: heat and  Explained to the pt.
cold application an deep breathing exercise the need for heat and
Subjective:  To promote comfort and relaxation. cold application; and
taught the pt. to take a
Pt. verbalized of deep breathe
moderate pain with 4. Provide a dim and light but providing good whenever pain
the scale of 5/10: ventilation. occurs.
 To add comfort to the pt.
0-3 = less pain  Suggested to the pt.
4-7 = moderate that dim light provides
pain Dependent: comfort.
8-10 = severe pain
5. Administer Ponstan 250 mg. 1 tab every 6  Ponstan 250 mg. 1
hours tab was given
 To help relieve of pain.
Nursing Care Plan for Fever

Problem: Elevated body temperature

Diagnosis: Related to on going infection

Assessment Goal Intervention Implementation Evaluation

Objective: At the end of 2 Independent:

hours, pt’s. body Goal Met:
 Weak temp. will be 6. Monitor the core temperature of  Temp. was
 Warm to touch lowered down the patient. monitored for fever. Pt’s body temp.
 Temp. = 39 * C within normal  Necessary to assess  Temp. 39 * C was reduce to
range, 36.5 * C – changes of temp. 37.4 * C.
37.5 * C
7. Wear loose clothing.  Encouraged and
 To help reduce fever. explained the help
Subjective: of wearing loose
fitting
“ Lain akong 8. Provide TSB; avoid use of
paminaw, init alcohol.  TSB done.
kaayo ko” as  It helps reduce fever.
verbalized by the
patient. 9. Encourage to increase fluid
intake.  Encouraged pt. To
 Helps to reduce fever. increase fluid intake.

Dependent:

10. Administer paracetamol 500  Administered

mg. 1 tab., q 4 hours PRN for paracetamol 500
fever. mg. 1 tab.
 Helps to reduce fever.