This nursing care plan addresses three problems: acute pain, unstable blood glucose levels, and hyperthermia. For acute pain, the goals are to relieve pain within 1-2 hours through interventions like medication, positioning, and distraction. For unstable blood glucose, the goals are stable levels within normal range in 2-3 weeks through strict diet, medication, and education. For hyperthermia, the short term goal is to lower temperature within 1-2 hours through interventions like loose clothing and monitoring.
This nursing care plan addresses three problems: acute pain, unstable blood glucose levels, and hyperthermia. For acute pain, the goals are to relieve pain within 1-2 hours through interventions like medication, positioning, and distraction. For unstable blood glucose, the goals are stable levels within normal range in 2-3 weeks through strict diet, medication, and education. For hyperthermia, the short term goal is to lower temperature within 1-2 hours through interventions like loose clothing and monitoring.
This nursing care plan addresses three problems: acute pain, unstable blood glucose levels, and hyperthermia. For acute pain, the goals are to relieve pain within 1-2 hours through interventions like medication, positioning, and distraction. For unstable blood glucose, the goals are stable levels within normal range in 2-3 weeks through strict diet, medication, and education. For hyperthermia, the short term goal is to lower temperature within 1-2 hours through interventions like loose clothing and monitoring.
This nursing care plan addresses three problems: acute pain, unstable blood glucose levels, and hyperthermia. For acute pain, the goals are to relieve pain within 1-2 hours through interventions like medication, positioning, and distraction. For unstable blood glucose, the goals are stable levels within normal range in 2-3 weeks through strict diet, medication, and education. For hyperthermia, the short term goal is to lower temperature within 1-2 hours through interventions like loose clothing and monitoring.
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7.
NURSING CARE PLAN
1. ACTUAL PROBLEM: Acute Pain
Problem Goals Interventions Evaluation
Subjective Data: Short Term: Nursing Interventions:
Patient After 1-2 Instructed Patient verbalize hours of patient to reported d pain at rendering assume minimal relief the Right appropriate comfortable from pain Upper nursing position Quadrant interventions Provided quiet with a , the patient and calm scale will report environment ranging relief from Advised patient from pain with a to divert 6/10 to scale of 1/10 attention by 8/10 to 3/10 conversing with relatives or do Objective Data: meditation Guarding behavior Pharmacological at the Interventions: RUQ Administered Verbalization PRN medications of relief from as ordered: pain 1. Paracetam ol 500 mg/tab 1 tab per orem 2. Dolcet tab Long Term Goal: 1 tab per Treatment of orem underlying etiology: Medical-Surgical Hepatic Management: Abscess UTZ guided Drained drainage of 300cc grayish hepatic abscess pasty (02-23-19) material Insertion of Output drainage ranging from catheter (pigtail) 10-150cc Flushing of pigtail Mass as ordered decreased in size from 7.6x7.9x7.5c m to 4.4x6.2x5.3c m (03-02-19) Pharmacological Management: Administered antibiotics as ordered: 1. Piperacillin- Tazobactam 4.5 g intravenousl y every 8 hours (02-16- 19) 2.Metronidazol e 500mg intravenously every 8 hours 3. Meropenem 1g intravenously every 8 hours GOAL IS MET
2. ACTUAL PROBLEM: Unstable Blood Glucose Level
Problem Goals Interventions Evaluation
Subjective Data: After 2-3 weeks of Nursing Interventions:
Hba1c rendering Instructed Patient result: 6.90% appropriate nursing patient to became CBG levels interventions, the report signs of more ranging from patient will manifest rebound compliant to 131 mg/dL a stable blood sugar hypoglycemia treatments to 528 level within normal such as: mg/dL range 60-120 mg/dL weakness, dizziness, blurred vision Discuss to patient the action of antidiabetic medications and it’s importance
Medical- Pharmacological Interventions: Capillary Blood CBG level: Glucose 131-528 monitoring three times a day as ordered (2-13-19) Strict adherence to diet: on 1200 kcal renal diet, 1.2 g Na, 1.2 g K, 800 mg Phosphorous, 1.5g/kg/day CHON divided in 3 meals and 2 snacks + 6500 mg Ensure in 1 glass H2O Administered Insulin as ordered: 1. Lantus 14 FBS: 97 units once mg/dL (03- a day 04-19) 2. Apidra 6 FBS: 106 units SC mg/dL (03- defer for 08-19) CBG <100 CBG: 85-115 mg/dL mg/dL three times a day antecebum 3. Linagliptin (Trajenta) 5 mg/tab once a day
GOAL IS MET
3. ACTUAL PROBLEM: Hyperthermia
Problem Goals Intervention Evaluation
Objective Data: Short Term: Nursing Interventions:
Body After 1-2 Have the patient Patient temperatur hours of wear lose reported e ranging rendering clothing feeling of from 37.7 appropriate relief degree nursing Performed Tepid Celsius to intervention Sponge Bath 38.6 degree s, patient Celsius will have a Advised patient Skin warm body to increase fluid to touch temperature intake within normal range 36.5- Pharmacologic 37.5 degree Interventions: Celsius Administered Body Paracetamol 300 Temperature mg intravenously of 36.0 as ordered degree Celsius IV Fluid regulation increased as ordered
Long Term: Medical-Surgical
Treat Management: underlying UTZ guided Drained etiology: drainage of 300cc grayish Hepatic hepatic abscess pasty Abscess (02-23-19) material Insertion of Output drainage catheter ranging from (pigtail) 10-150cc Flushing of pigtail Mass as ordered decreased in size from 7.6x7.9x7.5c m to 4.4x6.2x5.3c m (03-02-19)
Pharmacological Management: Administered No antibiotics as episodes ordered: of fever 1. Piperacillin- Tazobactam 4.5 g intravenously every 8 hours (02-16-19) 2. Metronidazol e 500mg intravenously every 8 hours 3. Meropenem 1g intravenously every 8 hours GOAL IS MET
4. ACTUAL PROBLEM: Acute Pain
Problem Goals Intervention Evaluation
Subjective Data: After 2-3 days of Nursing
Verbalized rendering Interventions: pain in the appropriate nursing Instructed to abdomen interventions, patient increase with a scale will be able to: mobility at ranging 5- (1) verbalize least turning 8/10 relief of from side to abdominal side or pain and ambulating (-) Bowel (2) reports (+) Advised to movement Bowel increase fluid for 5 days movement intake Instructed to add and consume fiber rich foods
Pharmacological Interventions: Administered Reports 3 Lactulose Bowel 30cc once a movement day at hours (02-26-19) of sleep as No ordered occurrence of abdominal pain
