CHAPTER 4

(NURSING PROCESS)

A. LONG TERM OBJECTIVE:

After 1 day of rendering quality of care done in the hospital which is needed to alleviate
her condition the patient would be able to:

• The patient will be able to verbalize understanding of causative factors.

• To prevent or minimize further complication by giving health teaching to the patient.
• The patient will be able to verbalize the rationale for treatment regimen
• Meeting basic self-care needs.
• Complications prevented/minimized.

B. PROBLEM LIST:
 High Fever
 Tonsilitis
 C. NURSING CARE PLAN: HIGH FEVER

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION

Subjective: Hyperthermia: After 4 hours of Independent: 1. Reduce Fever After 4 hours of

Accoding to the Related to bacterial appropriate nursing 1. Promote bed 2. Prevents nursing intervention
mother “ tumaas infection the patient rest dehydration the patient
lagnat niya sa 39 temperature will 2. Provide oral 3. Reduce Body temperature
degree 2elsius” Body Temperature lower down to hygience heat maintain the normal
elevated to above normal level to: 3. Monitor Production level of 36.5-37.5
Objective: normal range 36.5 celsius – 37.5 Vital sign 4. Enhances celsius
Temp: 39 degree celsius 4. Provide tepid heat loss by
2elsius sponge bath, evaporation
do not use & conduction
alcohol 5. Increase
comfort
Dependent 6. Dissipates
1. Administer heat by
antibiotic as convection
ordered
NURSING CARE PLAN : TONSILITIS

Assessment Nursing Planning Nursing Rationale Evaluation

Diagnosis Intervention

Impared oral After 2 hours of - Promote To Destroy the After 2 hours of

mucous membrane nursing Fluid Intake Bacteria. This also Nursing
related to infectious intervention, - Advice prevents the Intervention the
process as patient’s mother mother to resistance of the patient mother was
evidenced by will understand the continue bacteria from the able to verbalize
Imflamed Tonsils etiology and with the Antibiotics understanding of
management of antibiotics as the etiology and
tonsillitis of her prescribed Proper Suctioning management of the
chil. by the doctor will relieve patient tonsillitis
even if of difficulty
After applying the symptoms breathing as
health teachings subside secretions may
given to the mother, - Advise obstruct the airway
patient the patient’s mother to
condition will avoid sweet
improve and s and cold
recurrence of the beverage to
infectious will be the patient
avoided
D. COURSE IN THE WARD
September 9, 2019
During the first day on the health care facility, patient X seen on bed, morning vital
signs were recorded as follows Blood Pressure: None mmHg , Respiratory rate: None breaths
per minute, Temperature: None degrees Celsius. Performed Gordon’s functional pattern.
Endorsed accordingly.

E. DISCHARGE PLANNING
MEDICATIONS
Medications should be taken regularly as prescribed, on exact dosage, time, & frequency.
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