Question

Based on the three interventions given what would be examples of good nursing diagnoses? So for pain assessment would a good diagnosis be Acute pain or would it be ask 0-10 pain level?

3. Thermoregulation The nurse is assessing a 72 year old client at 1430 after a minor outpatient surgical procedure. What diagnosis and resulting intervention would support the data? You describe the data and diagnosis that would support the intervention listed. Example: Intervention: Cover with warm blanket. 0830 Pre-op assessments: Oral Temp 97.9 F, Pulse 78, BP 100/8o, spo2 96%, Oriented X 4, Resp 16 1430 Post-op assessments: Oral Temp 97.1 F, Pulse 68, BP 112/78, SpO2 96%, somnolent, Resp 12 Nursing Diagnosis: Risk for hypothermia r/t age sensitivity and loss through conduction AEB 0.8 degree F change from baseline. Intervention: Pain assessment. 0830 Pre-op : (Baseline) Temp--, Pulse _ , Resp 1430 Post : Temp- Pulse Nursing Diagnosis: -, BP -SpO2-_LOC: r/t AEB Intervention: Raise the head of the bed. 0830 Pre-op: (Baseline) Temp Pulse Resp 1430 Post : Temp Pulse--,Resp , Nursing Diagnosis: , BP SpO2 LOC: , LOC: -SpO2 r/t, BP AEB Intervention: Instruct client to take a deep breath. 0830 Pre-op: (Baseline) Temp-Pulse一一, Resp 1430 Post: Temp Nursing Diagnosis: BP-- , Pulse r/t AEB

Answer 1

Nursing diagnosis is

Acute pain related to surgical incision and reflex muscle spasm as evidenced by complaints of pain ,tense and guareded body posture ,facial grimacing,restlessnesss,irritability,moaning,diaphoresis and tachycardia.