1.
Medical Problem: Anemia
RN DX (problem RT AEB)
Impaired comfort RT visible shivering, would
adjust the temperature settings, cold
temperature when lower extremities is palpated,
Pt states requested more blankets, was agitated
to have a prolonged stay
Objective Data:
Temp:97.6 F, Pulse 97 beats/min,
Resp:16 breaths/min, BP 138/74
mmHg, SPO2: 97% (on room air)
Physical assessment:
• Shivering
• Alert and Oriented x2
• Lower extremities felt cold and dry
Subjective data: Pt states:
• Requested more blankets
• When prepping hemodialysis, wanted bag
very warm to prevent stomach cramping
• Would adjust the temperature settings
• Did not know where he was and why he
was there
• Was agitated to have a prolonged stay
• Pain 3 out of 10
Short term SMART Goal
Patient will perform appropriate
interventions, with or without
significant others, as needed to
improve and/or maintain
acceptable comfort level .
Long Term SMART Goal
Patient will provide evidence for
improved comfort compared to
baseline by discharge.
Intervention with rationale:
Teach techniques to use when the
client is uncomfortable, including
relaxation techniques, guided
imagery, hand massage, and music
therapy. Rationale: many
complementary therapies can be
conducted by the nurse and then
talk to the client and family for the
use at home Blackburn et al,
2019).
Intervention with rationale:
Manipulate the environment as
necessary to improve comfort.
Rationale: the theoretical foundation of
holistic comfort , which consist of relief,
ease, and transcendence , and the
setting of physical, psychological ,
social, and environmental experiences ,
and enables the nurse to meet the
individual comfort needs of the patient
(Ng,2017).
Short term problem outcome:
Goal is in progress. Using the
teachback methods and vocalizing
what they are uncomfortable and
comfortable with.
Long term problem outcome:
Goal met. Patient could understand baseline of initial discomfort and pain and used the
interventions to improve with self-care.
Intervention with rationale:
Acts about client’s current level of comfort. This is the
first step in helping clients achieve improve comfort.
Rationale: Vuille et al (2018) found in their study that
their assessment of pain intensity using a validated pain
scale/tool should be the initial step in evaluating a
client's level of discomfort: clients self reporting of pain
quality is widely accepted as the key to effective pain-
management
Intervention with rationale:
Assess clients understanding of ranking his
or her comfort level. Rationale: teachings
that are easily understood (as well as
client participation in discussions before
discharge), which target client
comprehension of instructions, have the
potential to increase client knowledge and
strengthen the ability to self manage (Flink
& Ekstedt, 2016).
Legend
Medical Problem
RN DX
Objective Data
Subjective Data
Short term Goal
Long Term Goal
Interventions
Short Term Outcome
Long Term Outcome