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NURSING CARE PLAN

ASSESSMENT

O> Received on
semi-fowlers position, conscious, coherent, afebrile, oriented; conversant; obeys command; with GCS score of 15/15; 2mm size of pupils; PERRLA; able to follow six cardinal gazes; intact hearing and gag reflex; muscle strength of 5/5 in BUE; 1/5 on BLE; can turn sideways with assistance; with IVF # 6 infusing well @ right hand; with Foley catheter intact and patent

DIAGNOSIS Acute pain r/t perianal irritation with pain scale of 7/10 as manifested by crying and moaning

PLANNING SHORT TERM: After 8 hours of nursing intervention, the client will be able to report pain is relieved LONG TERM: After 3 days of nursing intervention, the client will be able to demonstrate use of relaxation skills and diversional activities, as indicated, for individual situation

INTERVENTION INDEPENDENT Assessed general condition; monitored V/S Provided safety by raising the side rails and placing pillows under bony prominences Used pain rating scale; observed nonverbal cues and pain behaviours Provided comfort measures Provided perineal care and diaper changing

RATIONALE To obtain baseline data Prevent client from any injuries and pressure sores

EVALUATION SHORT TERM: After 8 hours of nursing intervention, the client was able to report pain is relieved at pain scale of 3/10 LONG TERM: After 3 days of nursing intervention, the client was able to demonstrated use of relaxation skills and diversional activities, as indicated, for individual situation

Indicator present when client is unable to verbalize

To relieved pain

To promote comfort and prevent further infection

Provided comfort

To promote nonpharmacolo

measures and calm activities

gical pain management

Instructed in and encouraged use of relaxation techniques Encouraged adequate rest periods DEPENDENT Administer analgesics, as indicated and notify the physician if regimen is inadequate COLLABORATIVE Evaluated laboratory results

To distract attention and reduce tension

To prevent fatigue

To maintain acceptable level of pain

To check for any imbalances

NURSING CARE PLAN


ASSESSMENT

O> Received on
semi-fowlers position, conscious, coherent, afebrile, oriented; conversant; obeys command; with GCS score of 15/15; 2mm size of pupils; PERRLA; able to follow six cardinal gazes; intact hearing and gag reflex; with hyperactive bowel sounds heard upon auscultation 5 sec/min; muscle strength of 5/5 in BUE; 1/5 on BLE; can turn sideways with assistance; with IVF # 6 infusing well @ right hand; with Foley catheter intact and patent

DIAGNOSIS Bowel incontinence r/t loss of rectal sphincter control

PLANNING SHORT TERM: After 8 hours of nursing intervention, the client will be able to feel comfortable and clean LONG TERM: After 3 days of nursing intervention, the client will be able to identify individually appropriate interventions

INTERVENTION INDEPENDENT Assessed general condition; monitored V/S Provided safety by raising the side rails and placing pillows under bony prominences Auscultated abdomen

RATIONALE To obtain baseline data Prevent client from any injuries and pressure sores

EVALUATION SHORT TERM: After 8 hours of nursing intervention, the client was able to felt comfortable and cleaned LONG TERM: After 3 days of nursing intervention, the client was able to identify individually appropriate interventions

For presence, location and characteristics of bowel sounds

Provided comfort measures Provided perineal care and diaper changing

To relieved pain

To promote comfort and prevent further infection To promote nonpharmacolo gical pain

Provided comfort

measures and calm activities

management

Instructed in and encouraged use of relaxation techniques Encouraged adequate rest periods COLLABORATIVE Evaluated laboratory results

To distract attention and reduce tension

To prevent fatigue

To check for any imbalances

NURSING CARE PLAN


ASSESSMENT

O> Received on
semi-fowlers position, conscious, coherent, afebrile, oriented; conversant; obeys command; with GCS score of 15/15; 2mm size of pupils; PERRLA;

DIAGNOSIS Risk for injury r/t decreased muscle strength in lower extremities

PLANNING SHORT TERM: After 8 hours of nursing intervention, the client will remain free from injury LONG TERM: After 3 days of nursing intervention, the client will be able to modify environment as

INTERVENTION INDEPENDENT Assessed general condition; monitored V/S Assessed muscle strength Provided safety by raising the

RATIONALE To obtain baseline data

EVALUATION SHORT TERM: After 8 hours of nursing intervention, the client remained free from injury LONG TERM: After 3 days of nursing intervention, the client was able to modify environment as

To identify risk for falls

Prevent client from any

able to follow six cardinal gazes; intact hearing and gag reflex; muscle strength of 5/5 in BUE; 1/5 on BLE; can turn sideways with assistance; with IVF # 6 infusing well @ right hand; with Foley catheter intact and patent

indicated to enhance safety

side rails and placing pillows under bony prominences Provided comfort measures Provided perineal care and diaper changing

injuries and pressure sores

indicated to enhance safety

To relieved pain

To promote comfort and prevent further infection To promote nonpharmacolo gical pain management

Provided comfort measures and calm activities Encouraged adequate rest periods COLLABORATIVE Evaluated laboratory results

To prevent fatigue

To check for any imbalances