ASSLSSMLN1 NUkSING

DIAGNCSI
S
GCAL NUkSING
IN1LkVLN1ICN
kA1ICNALL LVALUA1IC
N
Sub[ect|ve
komlkltot
ooq tobl ko
so kooooq
boboql oq
okloq tyoo"
As verballzed
by Lhe
paLlenL

Cb[ect|ve
laclal
grlmace
8esLlessness
lrrlLablllLy
Loss of
appeLlLe
Sleep
dlsLurbance
aln Scale3
lnclslon
wound aL Lhe
rlghL upper
quadranL
- %+%
redn
ess
noLe
d
- %+%
warm
Lo
Louch
- %%
swelll
ng
- %%
draln
age
Wound
dresslng dry
and lnLacL
vlLal Slgns
8
130/70
aln
relaLed Lo
posL
surglcal
lnclslon
Short term
AfLer
__hours of
nurslng
lnLervenLlo
n Lhe
paLlenL wlll
demonsLraL
e use of
relaxaLlon
skllls /
dlverslonal
acLlvlLles

Long term
AfLer
__hours of
nurslng
lnLervenLlo
n Lhe
paLlenL wlll
verballze
decrease of
paln
aln scale
of __ Lo __
Independent
LsLabllsh rapporL Lo Lhe
paLlenL


obLaln Lhe paLlenL's
basellne vlLal slgns and
paln scale




Assess for Lhe referred
paln




Lxplaln Lhe cause of
paln


1ake Llme Lo llsLen
encourage paLlenL Lo
verballzed feellngs

AccepL paLlenL's
descrlpLlon of paln


rovlde comforL
measure %ex 1ouch
Lherapy poslLlonlng%
Lncourage use of
relaxaLlon Lechnlques
such as deep breaLhlng
exerclse muslc Lherapy

rovlde qulLe
envlronmenL and calm
acLlvlLles

Lncourage dlverslonal
acLlvlLles such as
readlng or waLchlng

Lo easlly galn
cooperaLlon
from Lhe paLlenL

1o assess Lhe
effecLlveness of
nurslng
lnLervenLlon and
obLaln basellne
for fuLure
comparlson

1o help
deLermlne
posslblllLy of
underlylng
condlLlon or
organ
dysfuncLlon
requlrlng
LreaLmenL

1o reduce
concern of
unknown

1o allevlaLe
paLlenL's anxleLy


aln ls a
sub[ecLlve and
cannoL be felL by
oLhers

1o remoLe non
pharmacologlcal
managemenL
1o dlsLracL
aLLenLlon and
reduce Lenslon



1he goal
was meL as
evldence by

oobowosoo
ooq kltot oq
tobl ko
as
verballzed
by Lhe
paLlenL

aln scale
8 120/80
88 18
878
1 37 c
88 21
888
1 38 c
lebrlle


Lelevlslon



rovlde resL perlod Lo
faclllLaLe comforL sleep
and relaxaLlon

LllmlnaLe addlLlonal
sLressor/ source of
dlscomforL whenever
posslble











Dependent
Clve analgeslcs as
order by Lhe physlclan


LvaluaLlng
effecLlveness and
observlng for any slgns
and sympLoms of
unLoward effecLs







noLlfy physlclan lf
lnLervenLlon are
unsuccessful or lf
currenL complalnL ls a
slgnlflcanL change from
paLlenL's pasL
experlence from paln











aLlenL's paln
may become
exaggeraLed as a
resulL of faLlgue

aLlenL may
experlence an
exaggeraLlon of
paln or decrease
ablllLy Lo LoleraLe
palnful sLlmull lf
envlronmenLal
lnLrapersonal
facLors are
furLher sLresslng
Lhem






1o malnLaln
accepLable level
of paln

aln medlcaLlon
are absorbed
dlfferenLly by
paLlenL so Lhelr
effecLlveness
musL be
evaluaLed from
paLlenL Lo
paLlenL urugs
can cause slde
effecL LhaL can
range from mlld
Apply warm and cold
compresses as ordered
by Lhe physlclan






and llfe
LhreaLenlng

paLlenL who
requesL paln
medlcaLlon more
frequenL may
acLually requlre
hlgher dose of
medlcaLlon


Warm compress
rushes blood Lo
affecLed slLe and
promoLe heallng
cold compress
may reduce local
edema and
promoLe
numblng and
comforL

ASSLSSMLN1 NUkSING
DIAGNCSI
S
GCAL NUkSING
IN1LkVLN1ICN
kA1ICNALL LVALUA1IC
N
Sub[ect|ve









Cb[ect|ve
lnclslon
wound aL Lhe
rlghL upper
quadranL
- %+%
redn
ess
noLe
d
- %+%
ward
k|sk for
|nfect|on
relaLed Lo
posL
operaLlve
lnclslon
Short term
AfLer __
hours of
nurslng
lnLervenLlo
n Lhe
paLlenL wlll
ldenLlfy Lhe
rlsk facLors
LhaL are
presenL



Long term
AfLer
__hours of
nurslng
lnLervenLlo
n Lhe
paLlenL
should have
Independent
LsLabllsh rapporL Lo Lhe
paLlenL


CbLaln Lhe paLlenL's
basellne vlLal slgns and
paln scale




ldenLlfy underlylng
facLors LhaL causes Lhe
lnfecLlon


rovlde a safe clean
and comforLable
envlronmenL Lo Lhe
cllenL


1o easlly galn
cooperaLlon
from Lhe paLlenL

1o assess Lhe
effecLlveness of
nurslng
lnLervenLlon and
obLaln basellne
for fuLure
comparlson

1o ldenLlfy whaL
may cause Lhe
lnfecLlon


revenL
lnfecLlon
promoLe safeLy
and comforL
1he goal
was meL as
evldence by

1he paLlenL
ldenLlfy Lhe
rlsk facLors
of lnfecLlon

Lhe paLlenL
verballzed
Lhe dlfferenL
ways Lo
prevenL
lnfecLlon

Lo
Louch
- %%
sllghL
ly
swelll
ng
- %
%dral
nage
aln scale 3
laclal
grlmace
lrrlLablllLy
noLed
W8C 98/uL
vlLal slgns
8
130/70
8821
8 88
138 c




effecLlve
prevenLlon
Lo lnfecLlon

Assess Lhe paLlenL's
level of percepLlon
abouL Lhe nurslng
lnLervenLlon Lo be done

MonlLor Lhe cllenL's
skln lnLegrlLy and
permeablllLy Lo
lnfecLlon


noLe
and reporL laboraLory
values







Assess skln for colour
molsLure LexLure and
Lurgor %elasLlclLy%




Lncourage a balanced
dleL

Lncourage fluld lnLake
and adequaLe resL Lo
bolsLer Lhe lmmune
sysLem










8efore and afLer glvlng
care Lo cllenL use roper


1o ldenLlfy level
of percepLlon
and whaL
lnLervenLlon ls Lo
be done

Assess how
percepLlve ls Lhe
cllenL for
lnfecLlon


8lslng W8C
lndlcaLes body's
efforLs Lo
combaL
paLhogens very
low W8C
lndlcaLes severe
rlsk for lnfecLlon
because paLlenL
does noL have
sufflclenL W8C Lo
flghL Lhe
lnfecLlon

1o assess Lhe
effecLlveness of
nurslng
lnLervenLlon and
obLaln basellne
for fuLure
comparlson

nuLrlenLs are
Lhlngs llke faLs
proLeln
carbohydraLes
vlLamlns
mlnerals and
oLher lmporLanL
chemlcals ?ou
need proper
levels of
dlfferenL
nuLrlenLs ln
hand washlng Lechnlque
s


uependenL
Wound dresslng as
lndlcaLed uslng proper
Lechnlques



AdmlnlsLer
medlcaLlons as ordered
by Lhe physlclan


order Lo bulld
and repalr cells
keep hormones
regulaLed flghL
lnfecLlon and
malnLaln energy
levels



prevenL Lhe
spread of
dlsease and
lnfecLlon



Dressing's
usefulness is
the ability to
prevent
infection.


AnLlbloLlcs wlll
help klll and sLop
Lhe prollferaLlon
and growLh of
Lhe bacLerla
whlch could
cause lnfecLlon

















ASSLSSMLN1 NUkSING
DIAGNCSI
S
GCAL NUkSING
IN1LkVLN1ICN
kA1ICNALL LVALUA1IC
N
Sub[ect|ve
klookobobo
o oko so
opetosyoo"
As verballzed
by Lhe
paLlenL

Cb[ect|ve
narrow
focus
Cold clammy
skln
8esLlessness
ury mouLh
oor eye
conLacL
Pand
Lremors
vlLal slgns
8
130/90
898
8824
136 c

AnxleLy
relaLed Lo
change ln
healLh
sLaLus
AfLer
__mlnuLe
of nurslng
lnLervenLlo
n Lhe
paLlenL wlll
be able Lo
demonsLraL
e a poslLlve
coplng
meLhod
MonlLor vlLal slgns





observe behavlor



8e aware of defense
mechanlsm belng use

rovlde accuraLe
lnformaLlon abouL Lhe
slLuaLlon

LsLabllsh a LherapeuLlc
conveylng empaLhy and
uncondlLlonal poslLlve
reward

MalnLaln a calm and
LoleranL manner whlle
lnLeracLlng wlLh Lhe
paLlenL


Acknowledge
awareness of paLlenL
anxleLy





8educe sensory sLlmull
by malnLalnlng a quleL
envlronmenL

AsslsL ln developlng
anxleLy reduclng skllls
such as deep breaLhlng
exerclse poslLlve
vlsuallzaLlon
1o ldenLlfy
physlcal
response
assoclaLed wlLh
boLh medlcal
and emoLlonal
condlLlons

1hls cam polnL
Lo Lhe cllenL's
level of anxleLy

lnLerfere Lhe
ablllLy Lo deal
wlLh problem

Pelps Lhe
paLlenL Lo
ldenLlfy whaL ls
really based

1o avold a
conLaglous effecL
of anxleLy


Lhe paLlenL's
feellng o sLablllLy
lncrease ln a
calm and
nonLhreaLenlng
aLmosphere

acknowledgeme
nL of paLlenL's
feellngs valldaLes
Lhe feellng and
communlcaLes
accepLance of
Lhose feellngs

anxleLy may
lncrease wlLh
excesslve nolse
1he goal
was meL as
evldence by
bloJl oo
oko
klookobobo
o " as
verballzed
by Lhe
paLlenL
paLlenL
appeared
calm
good eye
conLacL
%%Lremors
noLed





uLlllzlng anxleLy
reducLlon
sLraLegles
enhances paLlenL
sense of
personal masLery
and confldence