ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

EXPLANATION
Subjective: Acute pain related Mycobacterium tuberculae General Independent:
“Nanghihina pa rin anak to inflammation of infection Objective: the 1. Monitor -- show changes in . After 8 hours of
ko”, as verbalized by the the pericardium patient will be vital signs specially heart rate and nursing interventions,
patient's mother. able to free from the respiration pulse rhythm brought on the patient was able to
pain and rate by acute demonstrate relaxation
Objective Organism enters pericardium discomfort inflammation. techniques and various
-body malaise . activities that are
-abnormal breath sounds Short term --Location indicated for
-restless Objectives: 2. Observate pericarditis in the individual
-PR:102bpm After 8 hours of the chest pain, note substernal pain circumstances
-RR: 70cpm Inflammatory reaction nursing interventi the time, factors - spreading to neck
-pain scale – 7/10 ons, the patient factors complication and back. But
will be able / originator, record unlike with painful After 2 months of
demonstrate the mark - nonverbal myocardial nursing interventions,
Destruction of pericardium relaxation signs of discomfort ischemic / the patient and his
techniques and such as weakness, infarction. Pain family was able to
various activities muscle tension and will increase as apply therapeutic
that are indicated tears. inspiration in, interventions
for individual change of position, regarding his/her
circumstances and decrease when disease
sitting / leaning
Long term forward.
Objectives: After
2 months of
nursing --Take control of
interventions, the 3. Maintain infection during
swelling and bedrest during the the acute phase
effusion of the period of fever and
patient’s appropriate
pericardium will indications.
disappear
 --Such measures
4. Maintain or can reduce the
create a quiet physical and
environment and a emotional
fun action such as discomfort of the
changes in position, patient.
put a cold compress
or a warm, mental
support, and so
forth. Antibiotics and
NSAIDS Can
Dependent: reduce the
1. Provide inflammatory
medicines as response and pain.
prescribed by the It also reduces
doctor fever and provide
comfort