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Outcomes
SUBJECTIVE
The patient will
report absence of
The patient
pain or a decrease
verbalize I
felt sickly hot The patient will
and weak.
participate in ADLs
The patient
and therapeutic
activities without
verbalize
limitation by pain.
slight
tingling
sensation The patients will
when peeing. report less
Throat pain
respiratory distress
and will participate
in ADLs with
diminishing
OBJECTIVE
dyspnea or
fatigue.
Elevated
temperature( The patients
38.9 degree
weight will be
Celsius)
maintained or
Blood in
weight loss
urine
minimized.
Weak in
a. The patient will
appearance
not develop a
Oxygen
pressure sore.
saturation:
88%
The patient will be
Dyspnea
independent in
60 kls.-55 kls.
Assessment
Nursing Interventions
PAIN
assessment for the presence and characteristics of pain (location, quality, and
intensity on a 0-to-10 scale, and its aggravating and relieving factors)
administering analgesics and adjuvant agents and evaluating their efficacy
advocating for around-the-clock dosing (versus as-needed dosing) of
analgesics for chronic pain, preferably by the oral route
evaluating and preventing untoward side effects (e.g., constipation from
chronic opiate or tricyclic antidepressant use);
using nonpharmacologic techniques as appropriate, such as assuring
adequate periods of undisturbed rest, positioning, heat and cold applications,
warm baths, massage, and other relaxation techniques
educating the patient and family regarding (a) reporting pain at its onset and
before it becomes disabling, (b) how to use the 0-to-10 scale to rate pain
intensity, (c) reporting uncontrolled or inadequately controlled pain, (d) the
medications used to control pain and for side effect management, and (e)
Symptom Management
FEVER
Drink plenty of fluids (water, juice, noncaffeinated beverages) at least 6-8
glasses per day. Get plenty of rest to conserve
energy and avoid fatigue.
Take tablets or other medicine as directed by
your doctor or nurse to lower your fever or
high temperature.
If you are taking antibiotics, be sure to take
all of the medication (complete the
course).
Take your temperature when you feel sick. If
it is more than 99F (3 8C), take it
again in 3 to 4 hours.
Avoid sponge baths while using fans as these
may cause you to have chills and
shivering. Shivering causes the temperature
IMPAIRED GAS EXCHANGE
to rise even higher and should be avoided
respiratory assessment (e.g., reporting any increased shortness of breath,
when possible.
cough, or chest pain) and pulse oximetry
administering and titrating oxygen to a physician-prescribed oxygen saturation Keep the skin dry and covered.
level
FATIGUE
administering antibiotics and monitoring for side effects
Do small tasks to avoid fatigue.
administering opioids (e.g., morphine) for palliation
Drink energy drinks (cg. Gatorade. Lucozade)
assisting with ADLs
and take oral rehydration solution.
organizing care to provide maximal periods of rest
Rise slowly when waking up sit up first.
repositioning the patient as necessary to facilitate excursion and promote
Drink solution from boiled beetroot.
postural drainage
educating the patient regarding purse-lipped breathing to decrease tachypnea Chew 2 to 3 cloves of garlic three times a day.
When cooking vegetables ensure that they
and anxiety
are not overcooked as vitamins get
preparation for a pulmonary diagnostic work-up.
Spiritual Care
Co Morbid Management
Evaluation
PNEMUCCOCAL INFECTION
Diagnostic: the sputum Gram's stain-
out of bed,
feeding the patient and encouraging oral intake
transfer, or
administering intravenous hydration, appetite stimulants, antidiarrheals, and
ambulate.
antiemetics as ordered
advising the physician of uncontrolled symptoms that interfere with intake and
destroyed.
Try relaxing or stress-reducing activities such
as deep-breathing exercises, meditation,
personal quiet time, massage. listening to
music or relaxation tapes, getting involved in
activities (e.g. volunteer work) taking walks
Eat more of the following foods: oatmeal and
other whole grain cereals, fruit and raw
vegetables, whole grain baked goods
yoghurt and low or non-dairy products.
Limit the following foods: sugary & fast foods
and other high fat foods. Reduce alcohol
and caffeine intake, as these tend to make
you sluggish later.
Develop a routine of going to bed in the
evening and getting up each morning at the
same time. A good night s sleep can help
you think more clearly. Naps are okay. But
keep them short and early in the day.
Avoid or reduce your use of alcohol and other
mood-altering non-prescription drugs (eg..
cocaine, speed. dagga. glue)
NIGHT SWEATS
Keep your skin warm and dry.
Wear light cotton clothing and use fewer
blankets.
open windows to allow ventilation and fresh
air.
Drink plenty of fluids (water. juice. noncaffeinated beverages) at least six to
eight glasses per day.
Drink cold water.
for dying;
(e.) discussing the patients
wishes regarding their death
bible.
The patient will
thought that reading
Holy Scriptures
promoted hope and
peace
.
Pastor Consultation
Organizing a visit from
a pastor (or priest)
so that the patient
will be blessed.
Encouraging Patients
to Trust
God/Supreme
Being/Creator.
The nurse may give
an advice to the
patient about having
a strong faith for the
patient's healing.
Demonstration of
Love, Compassion,
and Forgiveness
educating the patient or in-home caregiver regarding the skin and wound care
regimen
advocating for rehabilitation consultation, if appropriate, to increase the
patient's mobility
consulting with the social worker or discharge planner regarding the patient's
continuing wound care needs after discharge.
forgiveness to the
patient.
Taking interest and
listening actively
and being present
were important
aspects of a
human interaction.
Demonstrating
empathy and
sympathy helps
patients cope with
illness.
orthostatic hypotension)
informing all other caregivers about patients at risk for fall
instructing the patient and family to request assistance when the patient is
WEIGHT LOSS
Eat and drink a lot.
Eat frequent, small meals.
Take multivitamins.
Add garlic to your food.
The signing of advance
Keep track of your weight by weighing
directives must be
yourself or by looking for changes in the way
witnessed by two
your clothes fit.
individuals who are not
Cook and eat with friends or family to make
related to the patient or
meals enjoyable.
involved in the patients
Eat high-protein high-calorie foods and
treatment.
snacks such as peanut butter and jelly,
sandwiches, crackers and cheese, pudding Individuals who are mentally
and yoghurt.
competent can revoke at
Add instant breakfast drinks, milk shakes or
any lime their advance
other supplements to your diet and drink
directives. If a patient is
them any time of the day.
deemed mentally
Take a multivitamin with at least 100%
incompetent, state statutes
Recommended Daily Allowance (RDA)
may allow the court to
every day.
designate a surrogate
Keep foods that are easy to prepare on hand
decision-maker for the
patient.