Problem: Headache / Pain Diagnosis: Alteration in comfort related to headache at the frontal part 2* to her illness | ||||
Assessment | Goal | Intervention | Implementation | Evaluation |
Objective: ü Restless ü Facial Grimace ü Vital signs T- 39 * C P- 88 bpm R- 24 cpm BP- 110/ 70 mmHg Subjective: Pt. verbalized of moderate pain with the scale of 5/10: 0-3 = less pain 4-7 = moderate pain 8-10 = severe pain | At the end of 2* of rendering nsg. care, pt. will be able to verbalize relief of pain with the scale of 0/10. | Independent: 1. Note for the location, scale, intensity and onset of pain § To determine the nsg. care to be given to the pt. 2. Maintain a calm and quite environment. § To minimize stimulus that could aggravate the condition of the pt. 3. Use relaxation technique such as: heat and cold application an deep breathing exercise § To promote comfort and relaxation. 4. Provide a dim and light but providing good ventilation. § To add comfort to the pt. Dependent: 5. Administer Ponstan 250 mg. 1 tab every 6 hours § To help relieve of pain. | ü Pain noted at the frontal part with the scale of 5/10 from 0-10 scale. ü Calm and quite environment was provided ü Explained to the pt. the need for heat and cold application; and taught the pt. to take a deep breathe whenever pain occurs. ü Suggested to the pt. that dim light provides comfort. ü Ponstan 250 mg. 1 tab was given | Goal Met: After 2 hours of rendering care, pt. verbalized relieve of pain. |
Categories:
Nursing Care Plan
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