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    Nursing Assessment S - O Pt. May Manifest

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    k_a1990
    The patient was experiencing acute pain related to vascular enlargement and rupture from an abdominal aortic aneurysm. Nursing interventions included establishing rapport, monitoring vital signs, obtaining an assessment of the patient's pain, providing comfort measures, instructing in relaxation techniques, and administering analgesics as needed. The expected outcomes were for the patient to gain cooperation, have their pain managed at an acceptable level through pharmacological and non-pharmacological means, and to be free of worsening of their underlying condition.

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    Nursing Assessment S - O Pt. May Manifest

    Uploaded by

    k_a1990
    319 views4 pages
    The patient was experiencing acute pain related to vascular enlargement and rupture from an abdominal aortic aneurysm. Nursing interventions included establishing rapport, monitoring vital signs, obtaining an assessment of the patient's pain, providing comfort measures, instructing in relaxation techniques, and administering analgesics as needed. The expected outcomes were for the patient to gain cooperation, have their pain managed at an acceptable level through pharmacological and non-pharmacological means, and to be free of worsening of their underlying condition.

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    Nursing Assessment S> -O> Pt. May Manifest:

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    The patient was experiencing acute pain related to vascular enlargement and rupture from an abdominal aortic aneurysm. Nursing interventions included establishing rapport, monitoring vital signs, obtaining an assessment of the patient's pain, providing comfort measures, instructing in relaxation techniques, and administering analgesics as needed. The expected outcomes were for the patient to gain cooperation, have their pain managed at an acceptable level through pharmacological and non-pharmacological means, and to be free of worsening of their underlying condition.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    319 views4 pages

    Nursing Assessment S - O Pt. May Manifest

    Uploaded by

    k_a1990
    The patient was experiencing acute pain related to vascular enlargement and rupture from an abdominal aortic aneurysm. Nursing interventions included establishing rapport, monitoring vital signs, obtaining an assessment of the patient's pain, providing comfort measures, instructing in relaxation techniques, and administering analgesics as needed. The expected outcomes were for the patient to gain cooperation, have their pain managed at an acceptable level through pharmacological and non-pharmacological means, and to be free of worsening of their underlying condition.

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    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 4

    Nursing Nursing Scientific Planning Nursing Rationale Expected Outcome

    assessment Diagnosis Explanation Interventions


    S> -- Surgery is After 2-4 1. Established To gain After 2-4 hours of
    Risk for the hours of rapport. cooperation nursing
    O> Pt. may infection treatment of nursing & pt’s level intervention the
    manifest: related to choice for intervention of anxiety patient was able to
    • Rising surgical AAA more the patient identify
    temperature. wound than 5.5cm will be able 2. Monitor To get intervention to
    • Inadequate wide or to identify Vital signs baseline data reduce risk of
    acquired those that intervention infection.
    immunity. are to reduce
    enlarging. risk of 3. Observed To rule out After 2-3 days of
    The standard infection. for the worsening nursing
    treatment localized condition intervention the
    has been After 2-3 signs of patient was able to
    open days of infection at be free of purulent
    surgical nursing insertion drainage.
    repair of the intervention sites of
    aneurysm by the patient surgical
    resecting the will be able wounds.
    vessel and to be free 4. Stressed A first line of
    sewing the of purulent proper hand defense
    bypass graft drainage. hygiene by against health
    in place. all care-
    After the caregivers associated
    procedure between infection
    there will be therapies
    an open and patient.
    wound in 5. Monitored To limit
    surgical patient’s exposures,
    incision sites visitors/car thus, reduce
    that attracts egiver for cross
    bacterial respiratory contamination
    colonization. illness
    offer mask
    and tissues.
    6. Administer
    medication
    regimen
    such as
    antibiotics
    and note
    client
    response.
    Nursing assessment Nursing Scientific Planning Nursing Rationale Expected
    Diagnosis Explanation Intervention Outcome
    S> -- Acute pain 1. Established To gain
    related to rapport. cooperation &
    O> Patient vascular pt’s level of
    manifested: enlargement- anxiety
    rupture as
    • Observed evidence by 2. Monitor To get baseline
    evidence of guarding Vital signs data
    pain behavior, facial
    • Falling mask,
    blood irritability, 3. Obtained To rule out
    pressure restlessness. client’s worsening of
    • Guarding assessment underlying
    behavior of pain to condition.
    • Facial mask include
    • Sleep locations,
    disturbance characteristi
    cs, onset,
    • Restlessness
    frequency,
    • Irritability quality,
    • Change in intensity &
    abdominal aggravating
    muscle tone factors.
    from listless 4. Accept Pain is a
    to rigid client’s subjective exp.
    • Reduced descriptions & cannot be felt
    interaction of pain by others.
    with people
    &
    environmen 5. Provide To promote non-
    t comfort pharmacological
    • Impaired measure pain
    thought such as management.
    process touch,
    repositionin
    g, use of
    cold/heat
    packs, nurse
    presence.
    6. instruct in To distract
    use of attention and
    relaxation reduce tension.
    techniques,
    such as
    focused
    breathing,
    imaging.
    7. administered To maintain
    analgesics, acceptable level
    as indicated of pain.
    to maximize
    dosage as
    needed.

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