Pt. stated that she has pain in her legs 8/10
Pt. stated having stiffness in bilateral legs
Tenderness and redness to bilateral legs joints.
Joint area is warm to touch
VS:BP-144/70,R-20,P-57, T-97.6,02-96% RA
Acute pain related to inflammation as evidence by pain of 8/10 tenderness, swelling and warmth.
Impaired physical mobility related presence of joint pain.
Potential for impaired skin integrity related to inflammation to bilateral legs as evidence by redness, tenderness, and warm.
Reduce inflammation result to reduction in pain to 2/10 or at a tolerable level
Pt. will be able to have full ROM to bilateral lower extremities (BLE) without complaint of pain.
Patient will have reduce inflammation to BLE to reduce risk of skin integrity
The nurse will Monitor signs and symptoms inflammation and pain throughout the shift.
The nurse will perform Full ROM to BLE to prevent contraction.
The nurse will Monitor signs and symptoms inflammation.
To assess level of inflammation and need for quick intervention. Prevent pain.
Prevent immobility and contraction.
Prevent impairment to skin integrity and reduce pain
1. Administer acetaminophen 500mg every 4 to 6 hours for pain control.
2. Apply cool compress as tolerable to reduce inflammation.
3. Elevate BLE to reduce inflammation.
4. ROM (10 to 15 repetition) to BLE every 4 hours to prevent contraction/immobilization.
5. Assess circulation, sensation and motion to BLE to ensure adequate perfusion.
6. Reposition BLE to prevent skin impairment.
Goal Not met: Pt. will have pain level of 8/10 to lower extremities with inflammation; tenderness to (BLLE).Pt. will be unable to do ROM (BLLE) at the end of the shift.
Goal met: pt. pain 2/10 and verbalize adequate relieve of Inflammations reduced.
Pt. has full ROM to BLE at the end of the shift.