Nursing Care Plan for alteration in Comfort Problem: Headache /
Pain Diagnosis: Alteration in comfort related to headache at the
frontal part 2* to her illness Assessment Objective: Restless
Facial Grimace Vital signs T- 39 * C P- 88 bpm R- 24 cpm BP- 110/
70 mmHg Goal At the end of 2* of rendering nsg. care, pt. will be
able to verbalize relief of pain with the scale of 0/10.
Independent: Goal Met: 1. Note for the location, scale, intensity
and onset of pain To determine the nsg. care to be given to the pt.
2. Maintain a calm and quite environment. To minimize stimulus that
could aggravate the condition of the pt. 3. Use relaxation
technique such as: heat and cold application an deep breathing
exercise To promote comfort and relaxation. 4. Provide a dim and
light but providing good ventilation. To add comfort to the pt.
Dependent: 5. Administer Ponstan 250 mg. 1 tab every 6 hours To
help relieve of pain. Ponstan 250 mg. 1 tab was given Pain noted at
the frontal part with the scale of 5/10 from 010 scale. Calm and
quite environment was provided Explained to the pt. the need for
heat and cold application; and taught the pt. to take a deep
breathe whenever pain occurs. Suggested to the pt. that dim light
provides comfort. After 2 hours of rendering care, pt. verbalized
relieve of pain. Intervention Implementation Evaluation
Subjective: Pt. verbalized of moderate pain with the scale of
5/10: 0-3 = less pain 4-7 = moderate pain 8-10 = severe pain
Nursing Care Plan for Fever Problem: Elevated body temperature
Diagnosis: Related to on going infection Assessment Objective: Weak
Warm to touch Temp. = 39 * C Goal At the end of 2 hours, pts. body
temp. will be lowered down within normal range, 36.5 * C 37.5 * C
Intervention Independent: Goal Met: 6. Monitor the core temperature
of the patient. Necessary to assess changes of temp. 7. Wear loose
clothing. To help reduce fever. Subjective: Lain akong paminaw,
init kaayo ko as verbalized by the patient. 8. Provide TSB; avoid
use of alcohol. It helps reduce fever. 9. Encourage to increase
fluid intake. Helps to reduce fever. Dependent: 10. Administer
paracetamol 500 mg. 1 tab., q 4 hours PRN for fever. Helps to
reduce fever. Administered paracetamol 500 mg. 1 tab. Temp. was
monitored for fever. Temp. 39 * C Encouraged and explained the help
of wearing loose fitting TSB done. Pts body temp. was reduce to
37.4 * C. Implementation Evaluation
