NURSING EXPECTED PATIENT ASSESSMENT ACTION TEACHING

DIAGNOSES OUTCOMES interventions: interventions: interventions:

(consider orders, (consider home
(note priority for Be sure they are S. (assess /
safety, allergies, regimens,
each below) M. A. R. T. (Specific, monitor for )
code status, fall procedures,
measureable,
(Be sure to use risk, etc.) discharge plan,
achievable/
related to and etc.)
attainable, relevant
as evidenced
and time-bound)
by)

Acute pain r/t -Pain control: -Assess for pain -Pain -Discuss and
obstruction of Patient able to intensity, management teach about the
bile flow, move and walk with description of interventions patients
inflammation in minimal pain pain, and such as medication
gallbladder AEB according to patients analgesic regimen before
expressive assessment on pain experience with administration. discharge
behavior, scale. pain through
-Check patients -Teach the
activity changes, assessment and
-Self-Report of pain: medication patient how to
and positioning interviewing.
Patient able to use history and use the self-
to ease pain.
the self-report pain -Monitor for record, as well report pain tool
tool to rate the intensified pain as allergies to rate intensity
intensity of pain and of pain
-Administer
describe the pain.
nonopioid -Teach patient
analgesic for to notify a
mild to health care
moderate pain professional if
and an opioid pain level is
analgesic for consistently
moderate to above comfort
severe pain level
-Provide nursing -Reinforce the
care such as importance of
mobilization and taking
bathing during medications to
the peak effects maintain
of the analgesics comfort and
decrease pain
-Regularly
level
assess patients
pain and
 respiratory -Provide patient
status with written
instructions for
-Offer patient
medication use
non-
pharmacological -Encourage
treatments such patient to
as massage minimize
therapy, activity that
distractions, cause pain to
heat and cold intensify
application, and
-Teach family
music therapy
members how
to identify pain
in patient and
teach them
about patients
medication
regimen

Acute confusion -Cognition: Patient -Obtain patient -Promote and -Teach family to
r/t age, able to history that ensure recognize signs
dementia, communicate documents regulation of of confusion
alteration in clearly and patient bladder and
-Suggest the
sleep-wake- effectively, and alterations in bowel function
implementation
cycle AEB comprehend the cognitive through
of a caregiver or
alteration in meaning of functioning observation or
presence of
cognitive situations. Rated on catheters if
-Assess for family member
functioning, a cognition scale necessary
mental status in home with
restlessness,
- Orientation: through -Ensure patient
misperception,
Patient able to be assessment and adequate
alteration in -Encourage the
oriented to time, examination nutritional and
short-term family to take
place, location, and fluid intake
memory -Assess patients safety
person
level of -Provide precautions and
-Motor behavior: consciousness cognitive avoid/remove
Patient able to stimulation to potentially
-Assess patients
demonstrate and patient by dangerous
behavior
carry out proper having hazards in the
characteristics
conversations household
about current
and intentional -Assess patients event, previous -Teach patient
motor behaviors. memory events, or word and family
games about
-Assess for
medications
physiological -Provide basic
and encourage
alterations in nursing care
assistance such
patient such as such as feeding,
as a pill box to
hypertension, toileting, and
help patient
infection, and hydration
remember what
changes in
-Promote medications to
temperature
mobilization and take
rehabilitation of
patient
-Identify patient
as risk for
behaviors such
as falls and
perform
preventative
measures such
as making sure
they use their
call bell, and
ambulate with
assistance