Minimal care plan

[wishNhopeNdreamN]

Do you mind looking my plan over and giving me some feedback?

TIA!

[Daytonite, BSN, RN]

I would if you had posted it, but I am now going to bed.

[wishNhopeNdreamN]

Signs and Symptoms

Fever of 101.2

Tonsils swollen

Pt states, "It is difficult to eat or drink because of the pain"

Pt complains of fatigue

Rates throat pain a 9 on a 0-10 scale

Skin is warm and moist to touch

Pt has poor skin turgor

Divide S&S into subjective and objective data

Objective

Fever of 101.2

Tonsils Swollen

Skin is warm/moist to touch

pt. has poor skin turgor

Subjective

Pt states"difficult to eat or drink because of pain"

Pt compliains of fatigue

rates pain 9/10

List two Nursing Diagnoses include problem statement r/t cause of the problem statement a.e.b. S&S that "prove" or made problem statement apparent.

1.Acute pain r/t inflammation of the tonsils a/e/b pt. rates pain 9/10, difficulty swallowing

2. hyperthermia r/t to inflammatory response a/e/b body temperature of 101.2 F, skin warm/moist to touch, poor skin turgor

Outcome Identification/Planning:

List one outcome for each Nursing diagnoses (remember the outcome should directly relate to the problem statement of the nursing diagnoses) Remember these should be time sensitive and measurable and specific.

Outcome for nursing diagnoses one: The pt will rate pain 1 or less on a 10 point scale in 2 h at 1100, 11/10/08

Outcome for nursing diagnoses two: The pt will maintain with a body temperature WNL (97-99 F) in 2 h at 1100, 11/10/08

Nursing interventions (list 3 nursing interventions for EACH nursing diagnoses):

Nursing Diagnoses one interventions

1.Administer medications as prescribed by the physician

2.Educate pt on the importance of avoiding acidic fluids/food and rough-textured foods for 1 week, and encouraging ice cold fluids & semi-fluid foods

3.Educate pt. On non-pharmacological pain techniques such a gargling with warm saline solution q 1-2 h for the first 24-48 h

Rationale:

1.To relieve S/S of pain

2.Acidic foods and fluids & rough textured foods irritate the mucous lining of the throat and reduce pain. Cold fluids and foods have an analgesic effect on the mucous lining of the throat

3.Gargling with the warm saline solution has a soothing effect and may reduce the amount of pharmacological needs reducing the risk of adverse effects from medication

Nursing Diagnoses two Interventions

1.Offer pt. cold fluids that the pt. prefers

2.Remove excess blankets, clothing

3.Accurately record I & O, notifying primary care provider of any abnormalities

Rationale

1.By offering cold fluids the pt prefers the pt will be more expected to comply with oral hydration. The cold temperature of the fluids will decrease pt's body temperature

2.By removing excess blankets and clothing the pt will feel more comfortable and cooler

3.To detect any abnormalities that may indicate dehydration or electrolyte balance

Evaluation (outcome met, partially met, or not met). This should relate directly to your outcome statement:

Evaluation Statement for nursing diagnoses one:

Date/Time- 11/10/08 1100, goal partially met a/e/b patient rates pain 3/10

Evaluation statement for nursing diagnoses two:

Date/Time- 11/10/08 1100, goal met a/e/b patient body temperature is 98.6

[wishNhopeNdreamN]

I would if you had posted it, but I am now going to bed.

Sorry, I did but deleted it because it showed up in html code and was not readable. Sleep well, maybe tomorrow you can give it a look

[Daytonite, BSN, RN]

can't tell what is going on with this patient because you didn't provide any of the medical information.

acute pain r/t inflammation of the tonsils a/e/b pt. rates pain 9/10, difficulty swallowing

difficulty swallowing is not the same as pain, so it should not be listed as a symptom of pain. a sore throat is pain. difficulty swallowing is another diagnosis altogether,

impaired swallowing

.

hyperthermia r/t to inflammatory response a/e/b body temperature of 101.2 f, skin warm/moist to touch, poor skin turgor

poor skin turgor is a symptom of dehydration and probably

deficient fluid volume

.

this patient complains of swollen tonsils and has stated that, "it is difficult to eat or drink. . ." i would diagnosis impaired swallowing (physiological need for food/fluids and nutrition) or a deficient fluid volume (physiological need for food/fluids and nutrition) before acute pain because they are a more important physiological need than comfort (acute pain).

your interventions for the fever:

1.offer pt. cold fluids that the pt. prefers

• your rationale: by offering cold fluids the pt prefers the pt will be more expected to comply with oral hydration. the cold temperature of the fluids will decrease pt's body temperature - oral hydration is not a goal of this diagnosis. putting cold fluids into the body is not the best idea for temperature treatment. it works for pain control, but you are talking about reducing the fever here. see the rationale below.

2.remove excess blankets, clothing

• your rationale: by removing excess blankets and clothing the pt will feel more comfortable and cooler - actually, the opposite is true, if the person's temperature starts to drop in response to external cooling interventions he begins to shiver which causes more oxygen consumption and raises the body temperature and metabolism

3.accurately record i & o, notifying primary care provider of any abnormalities - how is measuring i&o going to reduce a fever?

• your rationale: to detect any abnormalities that may indicate dehydration or electrolyte balance - but this diagnosis is about hyperthermia, not dehydration and electrolyte imbalance!

your interventions are doing nothing for the patient's warm moist skin which is one of the symptoms of the hyperthermia that you mentioned. do some comfort measures for when his skin is wet with sweat from fever. you can also offer fluids when they are having a lot of diaphoresis to replace fluid loss. are you ever going to take this person's temperature? how frequently?