® To prevent

dehydration/ fluid loss

thus preventing fever.

9.) Instruct to comply

with the treatment
(antibiotics)
® To prevent bacterial
resistance to the
medication and
promote recovering.

10.) Administer
antipyretic medication
as ordered.
® To decrease body
temperature.

108
 Patient: X Medical diagnosis: Cellulitis in right lower extremity and Diabetes Melllitus type 2.
Address: Bitaog, Bansalan, Davao Su Attending physician: Dr. Sarno
Age: 79 yrs. Chief complaint: Wound Swelling at Right Leg
Pain
DATE/TIME CUES NEED NURSING GOAL OF CARE NURSING EVALUATION
DIAGNOSIS INTERVENTIONS

F Subjective:
E “Sakit akong
B tiil paglihukon
R ug tarugon” as
U verbalized by
A the patient
R I
Y Objective:
* Grimace face
noted
05,
* guarding of
right foot
2010
C Pain and discomfort
O related to irritation of
G nerve endings
N secondary to diabetic
I right foot.
T After my 2 hours
® Foot pain can
V certainly be caused
E by any number of
- reasons. However,
P foot pain resulting
E from diabetes is
R both painful and
C very common for
Within my 2 hours 1) Established rapport to February 05, 2010
span of care, patient our patient. @ 9AM
will manifest relief ® To gain their
from pain as trust and “Goal Partially Met”
evidence by: cooperation.
a. an improve pain 2) Performed assessment span of care, my
level from 2 of pain including patient was able to
(moderate pain) to 1 characteristics, duration, manifest relief pain
(no pain); frequency, quality and as evidence by:
severity.
b. demonstration of ® To assess a. demonstration of
methods to relieve etiology methods to relieve
pain such as having contributory pain by talking to

109
 * Right foot E those living with diversional factors. someone; telling
warm to touch P diabetes. [A nerve activities; stories to us student
@ T problem (where the 3) Noted the location of nurses;
* Swelling U nerves themselves c. verbalization of surgical procedures.
noted A are affected by the relief from pain. ® It can influence b. verbalization of
L disease) called the amount of feeling of relief from
11am * Tenderness peripheral postoperative pain.
noted P neuropathy is the pain experienced. “Nawala-wala
A most common naman ang sakit
* with pain T source of foot pain 4) Observed nonverbal gamay dong, di
scale of 2 as T tied to diabetes. cues such as how patient lang ko kaayo
evidence by: E Peripheral sits and facial expression. mag sige ug
0 - no pain R neuropathy comes ® Observations lihok ba.”
1 - mild N in the form of may not be c. an improved pain
2 - moderate sensory, motor, and congruent with level from 2
3 - severe autonomic verbal reports (moderate pain) to 1
neuropathy.] indicating need (mild pain).
* VS for further
Temp.= 38◦ C evaluation.

110