CASE PLAN ON FEVER (MEDICAL SURGICAL NURSING)
Student's Name :Kamini
:M.Sc nursing 1st year
Course and Year of study
Submitted To : Ms Anjali
( Nusing Lecturer)
HISTORY COLLECTION:
I. Biodata:
Name: Mr Kuldeep
Age: 71 years
Gender: male
Marital Status: married
Religion: hindu
Occupation: Farmer
Address: Noida
Bed number: 30
Ward number: medical ward
Date of Admission: 20/5/2021
Diagnosis/ Provisional Diagnosis: Fever (pyrexia)
Name of the consultant: Dr. Manjeet singh
II. Chief Complaints/ Presenting Complaints:
Patient is having fever since 2 months with rigors and chills ,headache, sore throat & dry coughing .
III. History of Illness:
History of present illness: Patient come with complaints of fever & headache more on the temporal and occipital areas.
History of past illness :cataract in the right eye, as a child due to trauma to the eye. He was diagnosed diabetic recently.
IV. Family History:
Parents were healthy . he has 1 brother and 2 sisters all are healthy .
Personal History -
o Smoked on/off at least 2 cigarettes/day for about 30 years. Has stopped smoking since the last 5 years. No other addictions.
o General condition -
o Compos mentis, looks moderately ill
o BP - 140/80
o Pulse - 120bts/min
o RR- 45bth/m
o Temp - 100.4F
o Weight -24.5kg
Risk factors and Etiology
RELATED TO CLIENT BOOK REVIEW INTERPRETATIONS
A bacterial infection Bacterial infection Present
Clinical features
IN CLIENT BOOK REVIEW INTERPRETATIONS
Bodyache Bodyache Present
Cough Cough Present
Headache Headache Present
Diagnostic Evaluations with interpretation
RELATED TO CLIENT BOOK REVIEW INTERPRETATIONS
CT scan CT scan done
MRI MRI done
Blood tests(ESR,CRP,HBA1C) Blood tests(ESR,CRP,HBA1C) done
Management:
RELATED TO CLIENT BOOK REVIEW INTERPRETATIONS
Cap Cefixime 400mg BD for 7
days
Tab PCM
Tab Clarithromycin 500 mg
BD for 5 days
1. MEDICAL done
IV fluids
Tab metformin 500 mg
1+0+1/INSULIN S/S
Inj panadol SOS/Sponging
Inj Folinic acid
2. NURSING Prepare to administer prescribed Present
antipyretics, antibiotics,
analgesics.
Encourage the client to gargle
with warm saline gargles and
use throat lozenges.
Instruct the client that the
temperature of saline should be
sufficiently high to be effective
and should be as hot as the
client can tolerate.
Instruct the client to apply an
ice collar to severe sore throats.
Instruct the client on proper
mouth care.
Instruct the client to have a
liquid or soft diet.
Encourage the client to increase
fluid intake to 2,000 ml/per day
Discourage the client from
eating spicy foods and drinking
juices that are acidic.
If the client is unable to drink,
fluids may be administered IV.
Instruct the client to take all
antibiotics, even if he is feeling
better
NUTRSING DIAGNOSIS ON FEVER -
Hyperthermia related to positive bacterial infection as manifested by flushed and warm to touch skin
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.
Impaired Social Interaction related to decreased level of consciousness, hospitalization, and isolation
Risk for ineffective cerebral Tissue perfusion related to cerebral edema.
Altered nutrition: less than body requirements related to restricted intake; nausea, and vomiting, swallowing and chewing difficulty.
Nursing Care Plan
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
Subjective: Hyperthermia related to Short term: within 1 hour of Independent: After all the nursing
“patient looks tired and positive bacterial infection nursing intervention the Established rapport intervention the clients body
feeling warm”as as manifested by flushed patient’s elevated to mother to gain temp subsided within the
verbalized by the patient’s and warm to touch skin. temperature of 36.2 will trust and normal range.
mother. lessen to 37.4 degree cooperation.
Objective: Celsius. Promote surface
Flushed skin Long term: within 3 cooling by means of
Skin is warm to touch consecutive days of nursing undressing ( heat
Temp: 38.2*C intervention, the patient’s loss by radiation and
body temperature will conduction)
return to its normal range. Demonstrate on how
PR: 109
to do a proper tepid
RR: 34
sponge bath using
wet and dry cloth.
Provide nutritious
diet to meet increase
metabolic demands
Dependent: Administer
antipyretic as ordered.
Nursing Care Plan
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
Subjective: Acute pain related to Within 3 hours of nursing Independent: After 3 hours of nursing
“patient complaints that he meningeal infection with intervention the patient’s Use pain rating scale intervention there is no sign
have severe pain in neck spasm of extensor muscle pain from 8 will reduce to 4 appropriate to its of facial grimace and
and back” (neck, shoulder and back) as using the facial pain rating age irritability in the patient.
manifested by positive scale. Assess for neurologic
Objective:
kernig’s and brudzinski’s exam and vital signs
Facial grimace
sign.
Irritable Position on the side
(+) Brudzinski’s sign with head gently
(+)Kernigs sign 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.
Nursing Care Plan
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION Rationale EVALUATION
Objective: Impaired Social After 8 hours of ■ Educate parents and ■ Family members The child’s
Facial grimace Interaction nursing intervention other visitors help fulfil the social and
Irritable related to The child’s social to use proper infection emotional and social developmental
(+) Brudzinski’s decreased level interaction will be control needs of the ill needs are met by
sign of Near normal despite Techniques. And contagious family members
(+)Kernigs sign consciousness, isolation. child. despite the
hospitalization, ■ Encourage parents to ■ Parental child’s
and isolation help with involvement in the illness and
daily activities such as child’s Hospitalizati
feeding and care provides the on.
Bathing. 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.
■ Have age-appropriate
■ Providing the
games and child with toys and
Toys in the room. Play games as well as
with the sensory
Child. When the child is stimulation helps the
feeling child achieve
better, encourage A sense of well-
watching being.
television/videotape or
listening to
The radio/audiotape.
■ Hearing loss is a
■ Arrange for hearing
common
assessment
Complication. Early
prior to discharge
intervention is
needed to promote g
Nursing Care Plan
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION Rationale EVALUATION
Subjective: Risk for ineffective After 8 hrs. of nursing Independent: After 8 hrs. Of
R: Provides calming
“Having difficulty in cerebral Tissue interventions, the client nursing
Decrease extraneous stimuli
effect, reduces Adverse
swallowing’’verbalize perfusion related to will demonstrate stable interventions, the
and provide comfort
physiological response
by the patient. cerebral edema client demonstrated
Vital signs and absence measures like back massage,
and promotes rest to
Objective: stable Vital signs
of signs of intracranial quiet environment, soft voice.
maintain or lower
Restlessness and absence of
pressure. intracranial pressure.
Change in motor or signs of intracranial
sensory responses Instruct patient to avoid or pressure.
R: These activities
Difficulty in limit coughing, Vomiting,
Demonstrate increase thoracic
swallowing straining at defecation,
behaviours/lifestyle and intra-abdominal
skin discoloration bearing down as possible.
changes to improve pressure which can
decrease motor
circulation. increase intracranial
response
pressure.
R: to promote
Elevate head and maintain
circulation/venous
head/neck in midline neutral
drainage
position
Prevention:
R: Seizure can occur as
Observe for seizure activity
and protect patient from result of cerebral
injury. irritation, hypoxia or
increase intracranial
pressure.
Maintain head or neck in
midline or neutral position, R: Turning head to one
support with small towel rolls side compresses the
and pillows: jugular veins and
inhibits cerebral venous
Provide rest periods between
drainage, thereby
care activities and limit
increasing intracranial
duration of procedures.
pressure.
R: Continual activity
can increase intracranial
pressure
Curative:
Administer supplemental
oxygen as indicated
R: Reduces hypoxemia.
Investigate reports of pain out
of proportion to degree of
injury: R: May reflect
developing
compartment syndrome
Administer R: used to decrease
medications(antihypertensive, edema.
diuretics)
R: Conserves energy
Rehabilitation:
and lower oxygen
Encourage quiet, restful
demand
atmosphere:
Limit daily activities and R: over exertion may
caution client to avoid cause dizziness
strenuous activities
Nursing Care Plan
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
Subjective Altered nutrition: less than The child’s weight will be ► Weight the child daily on The child shows normal
“Patient ‘s behavior is so body requirements related to stable and appropriate for the same scale and record on growth and development,
irritating and looking dull” restricted intake; nausea, and age, normal serum protein, growth chart. nausea and vomiting
as verbalized by the mother. vomiting, swallowing and moist mucous membrane and under control, adequate
► Monitor skin turgor,
Objective: chewing difficulty. adequate urine output. daily caloric intake and
mucous membrane and urine
Weak in appearance proper hydration
Nausea and vomiting output.
Irritable verbalized by the S.O.
controlled.
(+) Nausea and vomiting
► Position the infant or child
Temp: 37.4
upright after feeding.
RR 40
PR 105 ► 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.
