N O 1
Nursing Diagnosis
Nursing Goals
Nursing Intervention
Acute pa p ain related After doing the nursing to
the the
phy physica sicall care, re,
injury agents
cli client
comfort
•
level level increas increasee with with the
compre comprehen hensive sively ly about about the
criteria :
pain include the Provocative,
Client reporting
•
•
that the pain was
•
been decrease
•
calm# could have
•
a rest $ital $ital sign in a
•
12'()' mm*g, P :
to handle the pain Colaboration with the doctor to
-is of infection After doing the nursing
with
!ree
the
•
the aseptic aseptic technic technic during during the from
the
infection •
normal limit %9 11'''. $ital sign
in
normal limits
a
installation of the euipment ;o the the woun wound d care, care, ;ress ;ressin ing g the the infu infuse se and and also also the the ;C
symptom he leuosit •
everyday /ncrease the nutrition intae and
•
the adeuate fluid each the client family and or
numbe umberr is in a
•
to
systemic and local infection Preserve the environment with
•
procedures
analgetic
3bser 3bserva vati tion on the the symp sympto tom m of
decreased decreased imunity imunity,, criteria : •
an
•
post cares, there8s no ris of woun wound, d, infection
give
decrease the pain
2'"(minutes.
invasive
past e"periences of pain 6ive the restful environment 7ducate the client about the
% rela"ation, distraction, etc.
- : 1+
opera operati tive ve
teurapeutic
normal limit % &P :
+'1''"(minutes
to
uncomfortable 4se the
the
nonpharmacologi
•
related
of
comunication to nowing the
from 5 to 2 !ace e"pression
•
0uality, -egion, cale, ime 3bse 3bserv rvati ation on the the nonv nonver erba ball responses
decrease Pain scale has
•
2
/nterviewing
the client about the symptom of an infection and reported if the infection happened
•
Colaboration with the doctor to give an antibiotic accordingly to the programs
/$
$ /=P>7=7<A/3< A<; 7$A>4A/3< Nursing Diagnosi
Date
Implementation
Evaluation
s
1)(11(2'1+
1
'2'' pm
')'' am
1''' am
patient Chec the vital of signs
1'?' am
11?' am
;o assement pain to the
patient each of the techniue
rela"ation to thre patient 6ive etorolac inj ?'mg(iv
: Patient said the pain lie a punctured 3 : cale of pain 5, : ?+,@ '
C, - : 1)"(m, P : )2"(m,
&P : 11'()' mm*g A : Acute pain resolved in part
Mona
P : continue intervention Mona
1)(11(1+ ')?' am
'2'' pm
;o dressing iv line and
: 3 : area around insertion, iv
urinary catheter Assess the sign and
symptom of infection 6ive ceftria"one inj
1''' am 11'' am 2
line and urinary catheter have no sign of infection : ?+,@ 'C, - : 1)"(m, P :
1g(iv Ovi
)2"(m, &P : 11'()' mm*g A : the problem is solved P :continue intervention Ovi
1
1(1'(1+ 1''' am
1'?' am
Puul '2''pm
Chec the vital of signs
patient 7ncourage patient to do
: patient say the pain is reduced 3 : cale of pain ?, : ?+,@
11?' am
deep breathing rela"ation
'
techniue 6ive etorolac inj
&P : 11'(@' mm*g
C, - : 1)"(m, P : @)"(m,
A : Acute pain resolved in
?'mg(iv
part Tiara
P : continue intervention Tiara
1(11(1+ ')?' am
2
'2'' pm
;o dressing iv line and
: 3 : area around insertion, iv
urinary catheter ;o the wound care with
aseptic technicue Assess the sign and
symptom of infection 6ive ceftria"one inj
1''' am
11'' am
line and urinary catheter have no sign of infection
1g(iv
: ?+,+ 'C, - : 1)"(m, P : @)"(m, &P : 11'(@' mm*g A : the problem is solved
Sufi
P :continue intervention Sufi
2'(11(1+ 1''' am
1'?' am
'2''pm
Chec the vital of signs
patient 7ncourage patient to do deep breathing rela"ation
1 11?' am
techniue 6ive etorolac inj
: patient say the pain is reduced 3 : cale of pain 2, : ?+,5 '
C, - : 1)"(m, P : ))"(m,
&P : 11'()' mm*g A : Acute pain is solved
?'mg(iv Ilham
P : stop intervention Ilham
2
2'(11(1+ ')?' am
1''' am
'2'' pm
;o the wound care with
: 3 : area around insertion, iv
aseptic technicue Assess the sign and
symptom of infection 6ive ceftria"one inj
11'' am
1g(iv each patient to do
line and urinary catheter have no sign of infection : ?+,5 'C, - : 1)"(m, P : ))"(m, &P : 11'(@' mm*g
preventive infection after A : the problem is solved
treatment
P :continue intervention Sufi
Sufi