The nursing care plan assessed a patient with acute pain, flushed skin, and tachypnea. The plan was to monitor vital signs, encourage fluid intake, provide a calm environment, and advise rest to reduce pain and normalize vital signs within 4 hours. After intervention, the patient's pain score decreased to 4/10, temperature lowered to 38.5°C, and respiratory rate reduced to 21 breaths per minute, partially meeting the goals.
The nursing care plan assessed a patient with acute pain, flushed skin, and tachypnea. The plan was to monitor vital signs, encourage fluid intake, provide a calm environment, and advise rest to reduce pain and normalize vital signs within 4 hours. After intervention, the patient's pain score decreased to 4/10, temperature lowered to 38.5°C, and respiratory rate reduced to 21 breaths per minute, partially meeting the goals.
The nursing care plan assessed a patient with acute pain, flushed skin, and tachypnea. The plan was to monitor vital signs, encourage fluid intake, provide a calm environment, and advise rest to reduce pain and normalize vital signs within 4 hours. After intervention, the patient's pain score decreased to 4/10, temperature lowered to 38.5°C, and respiratory rate reduced to 21 breaths per minute, partially meeting the goals.
The nursing care plan assessed a patient with acute pain, flushed skin, and tachypnea. The plan was to monitor vital signs, encourage fluid intake, provide a calm environment, and advise rest to reduce pain and normalize vital signs within 4 hours. After intervention, the patient's pain score decreased to 4/10, temperature lowered to 38.5°C, and respiratory rate reduced to 21 breaths per minute, partially meeting the goals.
SUBJECTIVE: Acute pain related to After 4 hours of nursing INDEPENDENT: After 4 hours of nursing -reported diaphoretic restlessness indicated to intervention patient will be intervention the patient was changes in level of able to display reduced -monitor vital signs -for baseline data able to display reduced consciousness tension, relaxed manner ease tension and shows relaxed OBJECTIVE: of movement. -instruct patient to report -to help monitor patients manner. - excessive sweating pain immediately. level of pain and help - restlessness PS of 4/10 decrease pain. -PS of 4/10 - (+) facial grimace -provide quiet and calm -to keep patient relax and ---goal met---- Temp: 39.5 environment. rest properly.
-advice patient for proper bed -to help reduce pain.
rest.
-encourage patient to -to prevent dehydration.
increase fluid intake.
-advice patient for leisure -to help patient not to think
activities. about the pain.
- Prepare TSB (tepid sponge -to assist with measures to
bath) to the patient reduce body temperature COLLEGE OF NURSING Nursing Care Plan
Students Name: Ballesteros, alessandra cherrie l. Year and Section: 1-C
Patient’s Name: X Date of Assessment: May 20, 2020
SUBJECTIVE: Flushed skin related to After 4 hours of nursing INDEPENDENT: After 4 hours of nursing -reported flushed skin dehydration and increase in intervention the patient will intervention: respiratory rate and body be able to maintain body -monitor vital signs -for baseline data temperature. temperature below 39 and Temp-38.5 OBJECTIVE: respiratory rate below 29. -encourage patient to limit -to help decrease flushed of RR- 21 -restlessness movement skin and temperature -red flush cheeks --goal met-- -increase respiratory rate -advice to increase fluid -to help body fluid balance -warm to touch intake
RR: 29 cpm -instruct patient for proper -to help patient prevent Temp: 39.5 bed rest increase of body temperature
- provide quiet -to reduce stress and
environment and limit excess stimulation to visitors promote rest COLLEGE OF NURSING Nursing Care Plan
Students Name: Ballesteros, alessandra cherrie l. Year and Section: 1-C
Patient’s Name: X Date of Assessment: May 20, 2020
SUBJECTIVE: Tachypnea related to After 4 hours of nursing INDEPENDENT: After 4 hours of nursing -reported fast increase blood pressure and intervention patient will be intervention: breathing/breathing hardly respiratory rate able to breathe normally. -monitor vital signs -for baseline data BP: 140/90 bpm Bp: 130/90 -instruct patient for proper -for effective airway RR: 21 cpm OBJECTIVE: RR:20 positioning PS: 5/10 -tachypnea PS: 4/10 -anxiety -advice patient to increase -to help body regulate well --goal partially met-- -loss of consciousness fluid intake -PS of 8/10 -encourage patient for proper -to help decrease pain Bp: 190/120 bpm bed rest PR: 115 RR:29 cpm -put side rails up -to provide safety spO2: 96% -provide quiet and clean -to help prevent any increase environment in vital signs
