or evaluating effectiveness of analgesics, enhancing patient control of pain. Pt. Reports pain at 6 when moved in bed and during heavy breathing2. Evaluate effectiveness of drug regimen. Encourage sufficient medication to control pain; change medication or time span as appropriate. Pain perception and pain relief is subjective and thus pain management is best left to the patient’s discretion. Pt reports pain is decreased 30 min after given Tylenol PRN3. Provide comfort measures, e.g.. frequent changes of position, back rubs, support with pillows.Relieves discomfort and augments therapeutic effects of analgesia.Pt verbalizes need to sit in chair or move from chair back to bed.4. Assist with self-care activities, breathing / arm exercises, and ambulation. Prevents undue fatigue and incisional strain. Encouragement and physical assistance / support may be needed for some time before the patient is able or confident enough to perform these activities because of pain or fear of pain.Pt. Verbalizes concern about pain and care of wound site after discharged.OUTCOME/GOAL STATEMENT: .Short Term: Pt will experiences decreased pain and verbalizes pain relief with use of analgesics Long Term: Improved breathing pattern and Increased activity with pain management#4. NURSING DIAGNOSIS: Nutrition altered, less than body requirements R/T surgical procedures ( pleural tube insertion ) AEB decreased subcutaneous fat/ muscle mass, poor muscle tone. Doenges, p. 1042Intervention /Action RationalesEvaluation / Outcome Criteria1. Assess nutritional status continually, during daily nursing care, noting energy level: condition of skin, nails, hair, oral cavity, desire to eat/ anorexia. Provides the opportunity to observe deviations from normal. Patients baseline and influences choice of interventions. Pt. Suffers from cachexia 2nd to malnutrition. Signs of wasting include poor skin turgor and loss of muscle mass2. Document oral intake by us...
