you can't diagnose a patient without first determining the signs and symptoms that you have to support those diagnoses. to come up with a diagnosis without supporting signs and symptoms is like saying you've got a murder but no body or evidence to prove it. it's irrational. and, the interventions are strategies that target those signs and symptoms. what signs and symptoms? interventions are of 4 types:
- assess/monitor/evaluate/observe (to evaluate the patient's condition)
- care/perform/provide/assist (performing actual patient care)
- teach/educate/instruct/supervise (educating patient or caregiver)
- manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)
pain is assessed by observing the patient's behavioral and physiological responses which can be sympathetic or parasympathetic.
injury to the patient is more than just about what the patient is able to do to himself. what about what we are doing to the patient with all the gizmos we have hooked up to him? what about complications of care or complications of the disease process? anything invasive puts the patient at risk for injury or infection. bed rest subjects the patient to a number of complications: pneumonia, dvts, decubitus, renal stones, contractures, utis. even children. see http://allnurses.com/forums/f50/help...ns-286986.html - assistance - help with care plans on the general nursing student discussion forum for information on how to write a care plan.
from nurse's 5-minute clinical consult: procedures from lippincott williams & wilkins, page 370
behavioral responses include altered body position, moaning, sighing, grimacing, withdrawal, crying, restlessness, muscle twitching, irritability, and immobility.
sympathetic responses are commonly associated with mild to moderate pain and include pallor, elevated blood pressure, dilated pupils, skeletal muscle tension, dyspnea, tachycardia, and diaphoresis.
parasympathetic responses are commonly associated with severe, deep pain and include pallor, decreased blood pressure, bradycardia, nausea and vomiting, weakness, dizziness, and loss of consciousness."