NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION

INTERVENTION

Subjective Data: Hyperthermia related to Short term goal: - Strictly monitor - The body needs
“Apat na araw ng on and Dengue virus infection as After 2 hours of nursing temperature to be kept in the
off ang fever ng anak ko” as evidenced by positive intervention, the patient normal
verbalized by the mother. immunoglobulin M should: temperature
- Decrease body range so that all
Objective Data: temperature the processes it
T- 38 ᵒC - Normalizes goes through
RR- 25 cpm respiration 23 cpm can take place
BP- 100/70 mmHg effectively
Positive immunoglobulin M
- Encourage patient to - Fluid
Diagnosis: increase oral fluid replacement is
Dengue without signs intake essential for
patients with a
high body
temperature.

- Remove excess - To provide

clothing comfort and
allows body
heat
evaporation.
 ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION
INTERVENTION

Objective Data: Abdominal pain risk for Short term goal: - Assess pain by using - Detailed
T- 38 ᵒC bleeding After 2 hours of nursing Wong- baker faces baseline to
RR- 25 cpm intervention, the patient pain rating scale know if the
BP- 100/70 mmHg should be able to show pain has
Facial grimace signs of reduced pain as changed
evidenced by:
- Observe or monitor - Attention to
- Calm facial signs and symptoms associated signs
expression associated with pain may help the
- Lowered score in such as BP, heart rate nurse in
the pain scale and temperature evaluating pain

- Respond immediately - One can most

to complaint of pain effectively deal
with pain by
preventing it.
Early
intervention
may decrease
the total
amount of
analgesic
required