NURSING CARE PLAN
Name: Cruz, Liza B. Date Admitted: September 20, 2020
Age: 10 y.o. Chief Complaints: Fever
Sex: Female Diagnosis: Systemic Viral Infection
Civil Status: Child Attending Physician: Dr. Pondoc
Address: Baclayon, Bohol Ward/Area: Pedia
ASSESSMENT NURSING BACKGROUND PLANNING IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS KNOWLEDGE
Independent:
Subjective Cues: Elevated body Fever is elevated body After 8 hours of - Assess and - to obtain a Goal Met. The
“Init akong pamati temperature related temperature (> 37.8° C nursing care, the monitored the vitals baseline data and patient manifested
orally or > 38.2° C
unya luya ko kaayo”, to infectious process rectally) or an elevation patient will signs of the patient monitor any decreased body
as verbalized by the due to viral above a person’s known - manifest variations temperature from
patient. infection as normal daily value. decreased body 39 C to 37.6 C and
evidenced by Body Fever occurs when the temperature from - Assess the skin and - to obtain baseline has improved
body's thermostat
(verbalized by the temperature of 39C 39 C to normal oral mucous assessment for hydration as
(located in the
patient) and warm, flushed hypothalamus) resets at range. membranes hydration status of evidenced by moist
skin a higher temperature, -improved hydration the patient oral mucous
primarily in response to as evidenced by membranes,
Objective Cues: (Problem + Etiology an infection. Elevated moist membranes - Encourage the - to allow good air unchapped lips and
body temperature that
• Skin warm + S/Sx) is not caused by a
and good skin patient to wear circulation and skin and no profuse
to touch resetting of the turgor loose clothings ventilation sweating noted.
• Flushed skin Must be based on temperature set point is
noted assessment called hyperthermia. Specific - Perform tepid -to promote Based on the goals
• Profuse Symptoms are due Measurable sponge bath dispersal of heat and desired
sweating mainly to the condition Attainable based on principles outcomes indicated
observed causing the fever, Realistic of evaporation and
although fever itself can
• Dry oral cause chills, sweats, and
Time-bounded conduction
mucous discomfort and make
membranes patients feel flushed Based on the - Encourage the - to promote good
noted and warm. diagnosis patient to increase hydration
• Dry, chappy You get a fever because
formulated fluid intake
lips noted your body is trying to kill
• Temperature the virus or bacteria Subject Dependent:
that caused the Verb - Administer -anti-pyretic
of 39 C infection. Most of those
• lethargic Modifier Paracetamol as medications to
bacteria and viruses
do well when your body Criterion ordered
is at your normal lower body
temperature. But if you Must be based on temperature
have a fever, it is harder
(relevant, for them to the focused
measurable and survive. Fever also problem and Justify the
observable data that activates your body's etiology interventions
supports the immune system.
subjective cues) Source: MSD Manual Independent and
Professional Version dependent
[Link] interventions
Literature that Within the scope of
supports and practice of nurses
explains your
nursing diagnosis
OUTCOME PRESENT STATE TEST
Name: Cruz, Liza B. Date Admitted: September 20, 2020
Age: 10 y.o. Chief Complaints: Fever
Sex: Female Diagnosis: Systemic Viral Infection
Civil Status: Child Attending Physician: Dr. Pondoc
Address: Baclayon, Bohol Ward/Area: Pedia
CLIENT IN CONTEXT ASSESSMENT INTERVENTIONS RATIONALE EVALUATION
Chief Complaint: Subjective Cues: Independent: After the given interventions,
A case of a 10 y.o female “Init akong pamati unya luya - Assess and monitor the - to obtain a baseline data the patient manifested
child from Baclayon, Bohol ko kaayo”, as verbalized by vitals signs of the patient and monitor any variations decreased body temperature
with a complaint of fever for the patient. from 39 C to 37.6 C.
2 days.
- Assess the skin and oral - to obtain baseline
Objective Cues: mucous membranes assessment for hydration
History of Present Illness: • Skin warm to touch status of the patient
2 days prior to consultation, • Flushed skin noted
patient had an onset of • Profuse sweating - Encourage the patient to - to allow good air circulation
intermittent fever with observed wear loose clothings and ventilation
temperature ranging from • Dry oral mucous
38.2-39.2 C. 1 day prior to membranes noted - Perform tepid sponge bath -to promote dispersal of heat
consultation, patient was • Dry, chappy lips based on principles of
already lethargic with loss of noted evaporation and conduction
appetite and manifested • Temperature of 39 C
signs of dehydration, thus, • lethargic
prompted the consultation. - Encourage the patient to
Nursing Diagnoses: increase fluid intake - to promote good hydration
History of Past Illness: Elevated body temperature
Non-asthmatic related to infectious process Dependent:
No know food/drug allergies due to viral infection - Administer Paracetamol as
Complete immunization ordered -anti-pyretic medications to
Previous hospitalization: May lower body temp
4, 2018 due to Appendicitis
and had underwent surgical
operation (Appendectomy)
Socio-economic Status:
A student of a local public
school living with her
parents. Her parents are both
government employees.
Organ Involved:
Actual drawing/picture of
organ with labels. Briefly
define the organ involved.
HEALTH TEACHING PLAN
I. TOPIC
IMPORTANCE OF HANDWASHING
II. RATIONALE
To educate the patients and significant others on the importance and proper procedure of
handwashing
III. OBJECTIVES
After the health teaching, the patient and significant others will:
A. Demonstrate understanding on the importance of handwashing in disease prevention and
infection control
B. Perform the proper handwashing procedure after our demonstration
IV. HEALTH Interactive Lecture Discussion
TEACHING
METHOD
V. TARGET OB patients and their significant others
AUDIENCE
VI. DATE AND TIME September 22, 2020
VII. CONTENT 1. Definition of handwashing (provide its brief content)
2. Purpose of handwashing
3. Different diseases that can be prevented by handwashing
4. 5 Moments of Handwashing
5. Materials used in handwashing
6. Demonstration and rationalization of the steps/procedure of handwashing
7. Repeat demonstration by the audience
8. Feedbacking
VIII. EVALUATION The patients and significant others were able to verbalize understanding on the lecture and
participated in the repeat demonstration of the handwashing procedure. They were very
cooperative and appreciative of the information they have learned during the session.
IX. PREPARED BY John Santos
Grace Bersabal
DRUG STUDY
Name: Date Admitted:
Age: Chief Complaints:
Sex: Admitting Diagnosis:
Civil Status: Admitting Physician:
Address: Ward/Area:
DRUG (Preparation, CLASSIFICATION INDICATIONS MECHANISM OF CONTRAINDICATIONS NURSING
Dosage, Route & ACTION INTERVENTIONS
Frequency)
Generic and Brand Classification of the The drug is ordered for Explains how the drug Nursing considerations
Name of Drug ordered drug your patient for what produces an effect in Not given to? in giving this drug
(group of medications purpose? the body. (consider
Preparation: Vial? that work similarly, appropriateness to
Ampule? Tablet? have a similar chemical patient’s condition and
makeup, or treat similar route of drug)
Dosage: indicate unit of conditions)
measurement for dose
(mg, g, iu)
Route: IM, IV, PO
Frequency: timing (q8
hours, BID, TID, etc)
