Nursing Problem – Pyrexia related to skin infection
Goal – Peter will have no fever in 2 hours.
Interventions
1.Apply wet cold flannel to patient forehead and back of the neck.
Rationale- By the method of conduction, this will help to bring the temperature down (Crisp & Taylor,2009).
2. Ask the patient to take extra layers of clothing off and on a table fan.
Rationale- By the method of convection, this will help to bring the temperature down (Crisp & Taylor,2009).
3.aminister anti-pyretic medication as per prescription.
Rationale- This will help to bring the temperature down (Crisp & Taylor,2009).
Evaluation- Re-check the temperature in two hours again to see if the interventions are effective for Peter.
Adapted from Crisp & Taylor. (2009).
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2.Administer pain analgesia as charted by doctor.
Rationale - Analgesia will help reduce the pain level by binding to the receptors in the central nervous system (Crisp & Taylor,2009).
3.Eliminate factors that precipitate Peter's pain level and use distraction methods such as soothing music.
Rationale- Distraction will help divert Peter's mind away from pain (Crisp & Taylor, 2009).
Evaluation - Re-assess Peter's pain level and ask him to rate the pain level on a scale of 0-10, 0 no pain and 10 worst/severe pain.
Adapted from Crisp and Taylor. (2009). Fundamentals of Nursing
Nursing Problem – Disturbed sleep pattern due to pain and discomfort
Goal – Peter will have at least 6-7 hours of straight sleep in next 48 hours.
Interventions
1.Assess Peter's sleep and activity pattern.
Rationale- Amount of sleep varies in individual with lifestyle and health.
2.Advise Peter to take analgesia before going to
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Encourage to take analgesics on time
Rationale- Analgesics can reduce pain that impedes movement (Crisp & Taylor,2009).
3. Peter to do active range of motion exercise of left leg.
Rationale- This will improve left leg muscle and joint strength (Crisp & Taylor,2009).
Evaluation- Re-assess Peter's mobility in 48 hours to see if management and treatment plan is effective.
Adapted from Crisp and Taylor. (2009). Fundamentals of Nursing
Nursing Problem – Impaired skin integrity due to wound on left leg.
Goal – Peter will experience normal healing of the wound with no skin break in next 72 hours.
Interventions
1.Assess the characteristic of wound including size, depth, colour and odour
Rationale- This will tell about the extent and management of wound (Crisp & Taylor,2009).
2. Encourage Peter to take his antibiotics on time.
Rationale- cellulites/wound infection will be managed well antibiotic (Crisp & Taylor,2009).
3. Advise Peter not to scratch or rub wound or surrounding skin.
Rationale- This can cause further injury and delay in healing (Crisp & Taylor,2009).
Evaluation- Re-assess Peter's skin integrity in 72 hours to see if wound management plan is effective.
Adapted from Crisp and Taylor. (2009). Fundamentals of