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
 C. NURSING CARE PLAN: HIGH FEVER

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION

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

Accoding to the Related to bacterial appropriate nursing 1. Promote bed Fever nursing intervention
mother " tumaas infection the patient rest 2. Prevents the patient
lagnat niya sa 39 temperature will 2. Provide oral dehydration temperature
degree celsius" Body Temperature lower down to hygience 3. Reduce maintain the normal
elevated to above normal level to: 3. Monitor Body heat level of 36.5-37.5
Objective: normal range 36.5 celsius – 37.5 Vital sign Production celsius
Temp: 39 degree celsius 4. Provide 4. Enhances
celsius tepid sponge heat loss by
bath, do not evaporation
use alcohol &
conduction
Dependent 5. Increase
1. Administer comfort
antibiotic as 6. Dissipates
ordered heat by
convection
D. COURSE IN THE WARD
SEPTEMBER 9,2019
During the first day on the MCU Pedia ward, Patient X seen on bed, Morning vital sign were
recorded as follow Blood Pressure 90/60 mmHg, Repiratory Rate: 21 breaths per minute, Pulse
Rate: 78 beats per minute, Temperature: 36. 0 Degrees Celsius and Performed Heat to toe
assessment and Gordon’s functional pattern. Endorsed accordingly.

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