Emilio Aguinaldo College

College of Nursing and Midwifery

Jacob, Jasmin A. Sec. 22

06-1-41720 3rd year

Objective Nursing Diagnosis Planning Intervention Evaluation

- The patient identified - Alteration of comfort, - At the end of the shift - Determine / document - Goal Met, after 4 hours
severity of pain as 7 related to inflammation, the patient will be able presence of possible of nursing intervention
from pain scale of 0 – edema, secondary to to report a decrease of patophysiological causes the pain is decreased
10. pelvic inflammatory pain from 7 to 4. of pain. from 7 to 4.
- Guarding behavior disease. - Encourage adequate
- (+) Facial Grimace rest periods to prevent
- Diaphoresis fatigue.
- Discuss impact of pain
on lifestyle /
independence and ways
to maximize level of
functioning.
- Identify specific signs /
symptoms and changes
in pain characteristics
requiring medical follow
up.
 Emilio Aguinaldo College
College of Nursing and Midwifery

Jacob, Jasmin A. Sec. 22

06-1-41720 3rd year

Objectives Nursing Diagnosis Planning Nursing Intervention Evaluation

- Increase in body - Increase in - At the end of the shift - Administer anti pyretic, - Goal Met, after 4 hours
temperature above temperature, related to the patient’s temperature orally / rectally as of nursing intervention
normal range = inflammatory process, will decrease from ordered. the patient’s temperature
T – 38.1 ° C. manifested by warm and 38.1°C to 36°C. - Refrain from use of has been decreased from
- Flushed skin; warm to flushed skin and aspirin products in 38.1°C to 36°C.
touch. tachycardia. children.
- Tachypnea; - Promote surface
Tachycardia; (unstable cooling by means of
BP) TSB.
- Provide high calorie
diet, tube feedings or
parenteral nutrition.