nursing care plan fever

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective:

“Mataas pa rin ang lagnat

nya hanggang ngayon”as

verbalized by the patient’s

mother.

Objective:

Flushed skin

Skin is warm to touch

Temp: 38.2*C

PR: 109

RR: 34

Hyperthermia related to

positive bacterial infection

as manifested by flushed

and warm to touch skin.

Short term: within 1 hour of

nursing intervention the

patient’s elevated

temperature of 36.2 will

lessen to 37.4 degree

Celsius.

Long term: within 3

consecutive days of nursing

intervention, the patient’s

body temperature will

return to its normal range.

Independent:

Established rapport

to mother to gain

trust and

cooperation.

Promote surface

cooling by means of

undressing ( heat

loss by radiation and

conduction)

Demonstrate on how

to do a proper tepid

sponge bath using

wet and dry cloth.

Provide nutritious

diet to meet increase

metabolic demands

Dependent: Administer

antipyretic as ordered.

After all the nursing

intervention the clients body

temp subsided within the

normal range.

Nursing Care Plan 29



Subjective:

“Umiiyak yan kapag

nahahawakan yung batok

nya saka nung may ginawa

yung doctor nya” as

verbalized by the mother.

Objective:

Facial grimace

Irritable

(+) Brudzinski’s sign

(+)Kernigs sign

Acute pain related to

meningeal infection with

spasm of extensor muscle

(neck, shoulder and back) as

manifested by positive

kernig’s and brudzinski’s

sign.

Within 3 hours of nursing

intervention the patient’s

pain from 8 will reduce to 4

using the facial pain rating

scale.

Independent:

Use pain rating scale

appropriate to its age

Assess for neurologic

exam and vital signs

Position on the side

with head gently

supported in

extension

Promote rest in the

room by keeping

stimulation and the

room to minimum

Institute respiratory

isolation

Monitor and record

carefully intake and

output.

After 3 hours of nursing

intervention there is no sign

of facial grimace and

irritability in the patient.


ASSESSMENT DIAGNOSIS PLANNING INTERVENTION Rationale EVALUATION

Objective:

Facial grimace

Irritable

(+) Brudzinski’s

sign

(+)Kernigs sign

Impaired Social

Interaction related to

decreased level of

consciousness,

hospitalization, and

isolation

After 8 hours of

nursing intervention

The child’s social

interaction will be

Near normal despite

isolation.

■ Educate parents and

other visitors

to use proper infection

control

Techniques.

■ Encourage parents to

help with

daily activities such as

feeding and

Bathing.

■ Have age-appropriate

games and

Toys in the room. Play

■ Family members

help fulfil the

emotional and social

needs of the ill

And contagious

child.

■ Parental

involvement in the

child’s

care provides the

child with a sense

of security and

emotional

wellbeing. Parents

have a sense of

control and a feeling

that they are

doing something to

enhance the

Child’s recovery.

■ Providing the

child with toys and

games as well as

The child’s social and

developmental

needs are met by family

members

despite the child’s

illness and

Hospitalization.

with the

Child. When the child is

feeling

better, encourage

watching

television/videotape or

listening to

The radio/audiotape.

■ Arrange for hearing

assessment

prior to discharge

sensory

stimulation helps the

child achieve

A sense of well-

being.

■ Hearing loss is a

common

Complication. Early

intervention is

needed to promote g

32


ASSESSMENT DIAGNOSIS PLANNING INTERVENTION Rationale EVALUATION

Subjective: Risk for ineffective After 8 hrs. of nursing Independent: After 8 hrs. Of

“masakit ang ulo ko as

verbalized by the

patient.

Objective:

Restlessness

Change in motor or

sensory responses

Difficulty in

swallowing

skin discoloration

decrease motor

response

cerebral Tissue

perfusion related to

cerebraledema

interventions, the client

will demonstrate stable

Vital signs and absence

of signs of intracranial

pressure.

Demonstrate

behaviours/lifestyle

changes to improve

circulation.

Decrease extraneous stimuli

and provide comfort

measures like back massage,

quiet environment, soft voice.

Instruct patient to avoid or

limit coughing, Vomiting,

straining at defecation,

bearing down as possible.

Elevate head and maintain

head/neck in midline neutral

position

Prevention:

Observe for seizure activity

and protect patient from

injury.

Maintain head or neck in

midline or neutral position,

support with small towel rolls

R: Provides calming

effect, reduces Adverse

physiological response

and promotes rest to

maintain or lower

intracranial pressure.

R: These activities

increase thoracic and

intra-abdominal

pressure which can

increase intracranial

pressure.

R: to promote

circulation/venous

drainage

R: Seizure can occur as

result of cerebral

irritation, hypoxia or

increase intracranial

pressure.

R: Turning head to one

nursing

interventions, the

client demonstrated

stable Vital signs

and absence of

signs of intracranial

pressure.

and pillows:

Provide rest periods between

care activities and limit

duration of procedures.

Curative:

Administer supplemental

oxygen as indicated

Investigate reports of pain out

of proportion to degree of

injury:

Administer

medications(antihypertensive,

diuretics)

Rehabilitation:

side compresses the

jugular veins and

inhibits cerebral venous

drainage, thereby

increasing intracranial

pressure.

R: Continual activity

can increase intracranial

pressure

R: Reduces hypoxemia.

R: May reflect

developing

compartment syndrome

R: used to decrease

edema.

Encourage quiet, restful

atmosphere:

Limit daily activities and

caution client to avoid

strenuous activities

R: Conserves energy

and lower oxygen

demand

R: over exertion may

cause dizziness

35



Subjective

“Dalawang araw na sya

nagsususka” as verbalized by

Altered nutrition: less than

body requirements related to

restricted intake; nausea, and

The child’s weight will be

stable and appropriate for age,

normal serum protein, moist

► Weight the child daily on

the same scale and record on

growth chart.

The child shows normal

growth and development,

nausea and vomiting

the mother.

Objective:

Weak in appearance

Irritable

(+) Nausea and vomiting

Temp: 37.4

RR 40

PR 105

vomiting, swallowing and

chewing difficulty.

mucous membrane and

adequate urine output.

Nausea and vomiting

controlled.

► Monitor skin turgor,

mucous membrane and urine

output.

► Position the infant or child

upright after feeding.

► Provide a flexible feeding

schedule with small feedings

of favourite foods.

► Minimise handling around

feeding times.

► Assist the child with

chewing with the child’s chin

and jaw in the nurse’s hand, if

swallowing is impaired & if so

feed by NG Tube.

► Consult dietician.

► Assess level of

consciousness before giving

liquids.

under control, adequate

daily caloric intake and

proper hydration

verbalized by the S.O.

nursing care plan fever

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