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    NCP CP

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    xacharowee
    The document contains notes from a nurse regarding a patient with hyperthermia, acute pain, and deficient knowledge about his chronic osteomyelitis. It includes the patient's subjective complaints, objective assessments, nursing diagnoses, goals of care, and interventions to be provided over multiple shifts to address the patient's temperature, pain, and lack of understanding about his illness. The notes document the patient's responses and whether the goals of care were met at the end of each shift.

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    NCP CP

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    xacharowee
    412 views8 pages
    The document contains notes from a nurse regarding a patient with hyperthermia, acute pain, and deficient knowledge about his chronic osteomyelitis. It includes the patient's subjective complaints, objective assessments, nursing diagnoses, goals of care, and interventions to be provided over multiple shifts to address the patient's temperature, pain, and lack of understanding about his illness. The notes document the patient's responses and whether the goals of care were met at the end of each shift.

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    The document contains notes from a nurse regarding a patient with hyperthermia, acute pain, and deficient knowledge about his chronic osteomyelitis. It includes the patient's subjective complaints, objective assessments, nursing diagnoses, goals of care, and interventions to be provided over multiple shifts to address the patient's temperature, pain, and lack of understanding about his illness. The notes document the patient's responses and whether the goals of care were met at the end of each shift.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    412 views8 pages

    NCP CP

    Uploaded by

    xacharowee
    The document contains notes from a nurse regarding a patient with hyperthermia, acute pain, and deficient knowledge about his chronic osteomyelitis. It includes the patient's subjective complaints, objective assessments, nursing diagnoses, goals of care, and interventions to be provided over multiple shifts to address the patient's temperature, pain, and lack of understanding about his illness. The notes document the patient's responses and whether the goals of care were met at the end of each shift.

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    Attribution Non-Commercial (BY-NC)
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    Download as doc, pdf, or txt
    of 8

    Hyperthermia Date/ Time M A Y Subjective : init akoang paminaw, 2 as verbalized by the 2 0 1 1 @ 4:30 patient.

    . Objective: -flushed skin -warm to touch -temp of 37.9C R: Hyperthermia is the elevation of body temperature above normal range. Most often, it results from infection somewhere in the body, but it may be caused R: to promote core cooling. Administer medications as prescribed. R: To avoid heat loss by radiation and conduction.
    Conduct tepid sponge bath.

    Cues

    Nursing Needs Nutritiona lMetabolic Pattern

    Nursing Diagnosis Hyperthermia R/t bacterial Infection 2 to chronic osteomyelitis

    Objectives of Care Within the 8 hours duty, the patients temperature will decrease within the range of 0.11.0C.

    Intervention

    Evaluation

    Establish rapport R: to gain trust and cooperation. Monitor Vital Signs R:To have a baseline data Monitor Input and Output R: to Replace fluids and electrolytes loss. Promote use of light clothing.

    May 2, 2011 @ 7:00pm GOAL MET Within the 8 hours duty, the patients temperature decreased from 37.9C to 37.5C.

    pm

    -dry and dehydrate d skin.

    by other conditions. Macrophages, white blood cells, and injured cells release chemical substances called pyrogens that act directly

    R: to treat underlying cause. Provide high-calorie diet. R: to meet increased metabolic demands. Promote bed rest. R: to reduce metabolic demand/oxygen consumption. Assist with internal cooling methods R: to promote core cooling. Provide supplemental oxygen

    on the hypothalamus, causing its themostat to be set to a higher temperature. Source: R: To offset increased oxygen demands and consumption.

    Essentials of Anatomy and Physiology by Elaine Marieb. pg. 490

    Acute Pain Date/ Time M A Y Subjective : Sakit jud aku-ang tiil mao 2 dili ko katulog ug tarong as 2 0 1 1 Objective: -Grimaced @ face upon movement verbalized by the patient. R: Osteomyelitis causes inflammation and tissue necrosis which brings pain to the patient. Source: (Doenges,M. Cues Nursing Needs Nursing Diagnosis Objectives of Care Within the 8 hours span of care, patient will be able to report reduced pain as evidenced by clients verbalization. 1. Monitor Vital Signs. R: to have baseline data.
    2. Introduce diversional activities such

    Intervention

    Evaluation

    Cognitive- Acute Pain Perceptual Pattern R/t inflammation 2 Chronic Osteomyelitis

    May 2, 2011 @ 6:00pm GOAL UNMET The patients pain scale is still 7/10. He verbalized: Sakit pa man akoang tiil.

    as storytelling. R: to divert patients attention from pain.


    3. Provide comfort measures such as

    touch and nurses presence. R: to enhance ability to participate in activities.


    4. Adjust activities.

    R: to avoid overexertion. 5. Provide positive atmosphere. R: helps to minimize frustration.


    6. Encourage verbalization of

    feelings. R: to monitor patients status, especially data that can only be felt by her. 7. Encourage use of relaxation technique like deep breathing

    5:35 pm

    -Guarding movement -Pain scale of 7/10 -Slow movement

    2007. Nurses Pocket Guide) 8.

    exercises. R: Relieves muscle and emotional tension. Review importance of nutritious diets and adequate fluid intake. R: Provides elements necessary for tissue regeneration or healing 9. Encourage positive attitude. R: to enhance sense of well-being. 10. Administer analgesics as prescribed. R: To relieve mild or moderate pain.
    11. Encourage adequate rest periods.

    R: to prevent fatigue

    Deficient Knowledge Date/ Time M A Y Subjective : wala ko kabalo kung unsa 3 na akoang sakit,as verbalized 2 0 1 1 Objective: -External fixator on @ left leg noted. by the patient. R: knowledge for ones illness must be known so that he/she can conduct intervention upon ones illness. R: to prevent overload. Source: Discuss clients perception of need. R: can encourage continuation of efforts. Provide information relevant only to the situation. Cues Nursing Needs Activity exercise pattern Nursing Diagnosis Deficient knowledge about his own illness, chronic osteomyelitis. Objectives of Care Within the 8 hours of duty, the patient will have an efficient knowledge about his own illness. Determine clients ability/readiness and barriers to learning. R: Individual may not be physically, emotionally, or mentally capable at this time. Be alert of signs of avoidance. R: Client may need to suffer consequences of lack of knowledge before he or she is ready to accept information. Provide positive reinforcement. May 3, 2011 @ 9:00 pm GOAL MET Within the 8 hours of duty, the patient has been participative to the interventions given and was able to gather information about his own illness. Intervention Evaluation

    -confused 5:30 pm when asked about his condition.

    Nurses Pocket Guide. 11th edition.

    Relate information to clients personal desires/needs and values/belief R: so that client feels competent and respected. Involve with others who have same problem/needs/concerns R: provide role model and sharing of information. Provide mutual goal setting and learning contracts. R: clarifies expectation of teachers and learner. Provide written information/guidelines and self-learning modules for client to refer as necessary. R: reinforces learning process, allows client to proceed at own pace. Provide information about additional

    resources. R: may assist with further learning/promote learning at own pace. Deal with clients anxiety/other strong emotion. R: anxiety/other strong emotion may interfere with clients ability to learn. Provide active role for client in learning process. R: promotes sense of control over situation and is means for determining that client is assimilation/using new information.

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