Escara, Jeremy Hamilton P. IV-14 / Grp. 48b CONCEPT MASTER PLAN PART I 1.

Altered Body Temperature Increase Body Temperature (38.3 C) Warm to touch Flashed skin Chills Restlessness 2. Acute Pain Verbalization of Pain (6/10) Facial Grimace Guarding Behavior Restlessness Protective gestures 3. Risk for Infection Breakage of tissue Exposure to Foreign Bodies PART II, III 1. Ineffective breathing pattern r/t pain 2o Gunshot Wound Nx Interventions: a. Provide a calm environment to prevent or limit anxiety b. Elevate HOB 15o to 30o to promote maximum chest expansion c. Encourage on alternative activities that will divert attention to reduce tension d. Stress importance of good posture and effective use of accessory muscle - to maximize respiratory effort. e. Encourage adequate rest periods between activities to limit fatigues 2. Altered body temperature r/t fever 2o Autoimmune Response Nx Interventions: a. Tepid sponge bath to promote heat loss by evaporation b. Discuss importance of adequate fluid intake to avoid dehydration c. Encourage on bed rest - to reduce metabolic demands/oxygen consumption d. Encourage on use of blanket and wrap extremities to minimize shivering e. Monitor temperature at times until stable to promote wellness Poor Hygiene (+) IV contraption Elevated temperature (38.3 C) 4. Ineffective breathing Pattern Alteration in depth of breathing Tachypnea - RR: 35 Restlessness Decreased inspiratory pressure Altered chest excursion 5. Impaired physical mobility Activity intolerance (+) Pain 6/10 Restlessness (+) neck brace Lack of physical support

3. Acute pain r/t tissue breakage 2o Gunshot Wound Nx Interventions: a. Provide quite environment to limit or prevent anxiety b. Instruct on focused breathing distract attention and reduce tension. c. Encourage diversional activities to divert attention from pain and reduce tension d. Encourage on repositioning to find position of comfort e. Instruct on adequate rest periods to prevent fatigue

ASSESSMENT Location: neck anterior (L) lateral (GSW) Quality: Moderate Pain Scale 6/10 Quantity: n/a Chronology: spontaneous Setting: supine/semifowlers Associated Manifestation: Tachypnea, elevated Temperature Alleviating Factor: Meds(paracetamol), relaxation Aggreviating Factors: unknown CUES: Verbalization of Pain (6/10) RR - 35 Facial Grimace Guarding Behavior Restlessness Protective

NxDx

PLANNING

INTERVENTION Independent: Provide quite environment Instruct on focused breathing Encourage diversional activities

RATIONALE

EVALUATION

Acute pain r/t tissue Short Term: breakage 2o Gunshot To lessen the Wound as evidenced pain to a more by manifestations. tolerable level (from 6/10 to Inference: 2/10) Specificity theory. Von Frey (1895) Long Term argued that the body - Verbalization of has a separate understanding sensory system for on pain perceiving pain management just as it does for techniques. hearing and vision and this system contains its own special receptors for de:ecting pain stimuli, its own peripheral nerves and pathway to the brain, and its own area of the brain for processing pain signals. But this structure is not correct. Pattern theory. Goldschneider (1920) proposed that there is no separate system for perceiving pain, and the receptors for pain are shared with

to limit or prevent anxiety distract attention and reduce tension. to divert attention from pain and reduce tension

Encourage on repositioning

to find position of comfort

Instruct on adequate rest periods Dependent: Administer analgesic as indicated. Collaborative: Suggest parents or

to prevent fatigue

mas naka-ka pagrelax ako ng tahimik. As stated. the client agree on the technique by restating its importance. This technique was already and unconsciously applied by the client but further teaching is done to know its importance. The client chose supine or sims position suits him best when it comes to comfort. Client agrees on this technique and stated that this is what hes doing. mas mabilis parin mawala ung sakit pag gamot as stated. The client is more

- to lessen or maintain pain to a tolerable level

- to comfort

gestures

other senses, such as of touch. According to this view, people feel pain when certain patterns of neural ctivity occur, such as when appropriate types of activity reach excessively high levels in the brain. These patterns occur only with intense stimulation. Because strong and mild stimuli of the same sense modality produce different patterns of neural activity, being hit hard feels painful, but being caressed does not. Reference: Taxonomy and classification of pain. In: Niv D, Kreitler S, Diego B, Lamberto A. The Handbook of Chronic Pain. Nova Biomedical Books; 2007.

SO to be present during this condition.

clients needs and support.

comfortable on be taken care of with someone he trust more or knows. CUES: Verbalization of relief Pain scale 2/10 RR- 23 (-) facial grimace

Outcome achieved.

Escara, Jeremy Hamilton P. IV- Sec.14/Grp.48b

F:

Hyperthermia

D:

> increase in body temperature above normal range to 38.3 oC > (+) Chills, flushed skin and warm to touch

A: 4:00pm> V/S taken and recorded 4:30pm> Tepid sponge bath done > instructed SO to let patient wear loose clothing > instructed SO to provide blanket to patient when shiver > instructed SO to let patient drink lots of fluid > provided opportunity for patient to rest 6pm > due meds given

R:

8:00pm > patient was able to rest > patient temperature decrease to T= 37.5 degree Celsius/axilla