LUCADIN, SARAH B.

BSN-1B

ASSESSMENT NURSING PLANNING INTERVENTI RATIONALE EVALUATION

DIAGNOSIS ON

Subjective: Risk for Short-term Provide This Goal

ineffective goal: therapeutic intervention can successfully
“Recently, I had lost my thermoregula bath or tepid promote the met; the
appetite and I tion related to After 7 hours of sponge bath. dispersal of patient will be
experienced headache hyperthermia nursing body heat, as a able to
for 2 days. I always feel as evidence by intervention, result, body maintain body
warm.” as stated by the taking body the client will temperature temperature
patient. temperature. reduce body will decrease. as evidence by
temperature. reducing the
Objective: risk factors of
Long-term goal: Administer This medication fever.
anti-pyretic provide comfort
 Shivering with goose After 3 days of medication to the client as
pimples nursing as prescribed it helps reduce
intervention, by doctor. body
 Flushed skin the client will temperature.
 Warm to touch maintain normal
body
 VS taken as follows: temperature as
evidence by
T- 39.7 0C identifying the Provide Since, the client
PR – 75 bpm risk factors of favorite food experiencing
RR – 24 (regular) fever. and loss of appetite,
BP – 120/80mmHg beverage this will help the
and teach client to
the encourage to
importance eat and drink to
of avoid
maintaining dehydration.
fluid intake.

1. FEVER/PYREXIA/HYPERTHERMIA
LUCADIN, SARAH B.

BSN-1B

2. PAIN (LOWER BACK PAIN)

ASSESSMENT NURSING PLANNING INTERVENTI RATIONALE EVALUATION

DIAGNOSIS ON

Subjective: Acute pain Short-term Administer This will help The goal is
“I felt pain in my related to goal: analgesics to provide completely
lower back for a lower back pain pain relief to met; the client
week.” As verbalized pain After 9 hours medication the patient. is able to
by the patient with a secondary to of nursing as prescribed report pain
pain score of 9 out of carrying intervention, by doctor. score of 0 out
10. heavy the client will of 10 after 2
objects, as be able to As a nurse, This will help days of
Objective: evidenced by relieve of pain. we must us to develop rendering
the pain establish a and establish nursing
 Irritable score of 9 Long-term supportive the trust and intervention.
 Febrile out of s10 goal: care for the rapport that
 Coherent and patient’s client by we must
facial After 2 days of means of build as a
 VS taken as expression. nursing listening nurse.
follows: intervention, attentively to
the client will the
T – 37.50C be able to discussion of
PR – 75 bpm report a pain the client.
RR – 22 cpm sore of 0 out
BP – 120/90 mmHg of 10 as
evidenced by Ask the This will help
improvement patient to re- us to assess
in mood and rate his or and identify
identify the her acute if the
cause of pain. pain using treatment or
the pain intervention
scale after 30 is effective.
mins of
giving the
analgesic
medications.
This will help
Position the the client to
client in a promote an
comfortable optimal
position. comfort to
reduce
restlessness.