UNIVERSITY OF EASTERN PHILIPPINES

University Town, Northern Samar

COLLEGE of NURSING and ALLIED HEALTH SCIENCES

NURSING CARE PLAN

Name of Patient:___SHALITA SUANSINAE________ Date Admitted:____01-07-2020_____ Chief Complaint:_____________FEVER_____________ Case Number:

Age: 25 Gender:_______F______ Civil Status:_ S Address:______________SAMPAL, BULACAN___________ Ward:

ASSESSMENT NURSING DIAGNOSIS SCIENTIFIC OBJECTIVES/ NURSING INTERVENTIONS SCIENTIFIC EVALUATION

RATIONALE PLANNING RATIONALE

Subjective Data: HYPERTHERMIA Core body • Maintain core temperature Assess neurological responses, High fever accompanied • Responses to interventions,
“Gin hihinagkutan temperature above the within normal range. noting the level of consciousness by changes in mentation teaching, and actions
ak” as stated by the normal diurnal range • Be free of complications, and orientation, reaction to Central hypertension or performed
patient due to failure of such as irreversible brain or stimuli, reaction of pupils, and postural hypotension can • Attainment or progress
M. Doenges, Nurses pocket thermoregulation. neurological damage and presence of posturing or occur. toward desired outcome(s)
Objective Data: guide, 15th edition acute renal failure. seizures. Hyperventilation may • Modifications to plan of
Abnormal posturing; • Identify underlying cause or Monitor blood pressure and initially be care
seizure contributing factors and invasive hemodynamic present, but ventilatory effort
Flushed skin; skin importance of treatment, as parameters may eventually be
warm to touch; well as signs/symptoms if available impaired
vasodilation requiring further evaluation Monitor respirations. by seizures or
Hypotension; or intervention. Administer replacement fluids hypermetabolic state
tachycardia; • Demonstrate behaviors to and electrolytes (shock and acidosis).
tachypnea; apnea monitor and promote normal Maintain bedrest to support circulating
Irritability; lethargy; thermia. Administer medications, as volume and tissue
stupor; coma • Be free of seizure activity. indicated, to treat underlying to reduce metabolic
cause, such as antibiotics (for demands and oxygen
infection), dantrolene (for consumption perfusion.
malignant hyperthermia), or
beta-adrenergic blockers (for
thyroid storm).

STUDENT NURSE: _JOSEF ANGELO POLDO, STUDENT NURSE_ CLINICAL INSTRUCTOR: _____JEANETTE ROJO, RN, DNS____
 UNIVERSITY OF EASTERN PHILIPPINES
University Town, Northern Samar

COLLEGE of NURSING and ALLIED HEALTH SCIENCES

NURSING CARE PLAN

Name of Patient:___SHALITA SUANSINAE________ Date Admitted:____01-07-2020_____ Chief Complaint:________ANXIETY_________ Case Number:

Age: 25 Gender:_______F______ Civil Status:_ S Address:______________SAMPAL, BULACAN___________ Ward:

ASSESSMENT NURSING SCIENTIFIC OBJECTIVES/ NURSING INTERVENTIONS SCIENTIFIC RATIONALE EVALUATION

DIAGNOSIS RATIONALE PLANNING

Subjective Data: FEAR related to Response to • Acknowledge and discuss fears,  Stay with the very fearful client or  Presence of a calm, caring • Client’s responses to
“nahahadok siya sa Learned response perceived threat recognizing healthy versus make arrangements to have person can provide reassurance treatment plan,
kanya kamutangan to underlying that is consciously unhealthy fears. someone else be there. that individual will be safe. interventions, and actions
kaya dia siya condition recognized as a • Verbalize accurate knowledge  Discuss the client’s perceptions Sense of abandonment can performed
nahimomoroko” as danger. of and sense of safety related and fearful feelings. Active listen exacerbate fear. • Attainment or progress
stated by the patients current situation. the client’s concerns.  This promotes an atmosphere toward desired outcome(s)
mother • Demonstrate understanding  Provide an opportunity for of caring and permits • Modifications to plan of
Objective Data: M. Doenges, through use of effective coping questions and answer honestly. explanation or correction of care
Vomiting; muscle Nurses pocket behaviors (e.g., problem-solving)  Explain the relationship between misperceptions.
tension; fidgeting; guide, 15th edition and resources. disease and symptoms, if  This enhances sense of trust
pallor; pupil dilation • Display lessened fear as appropriate. and nurse-client relationship.
evidenced by appropriate range of  Identify the client’s responsibility  Providing accurate information
feelings and relief of for the solutions while reinforcing promotes understanding of why
signs/symptoms (specific to that the nurse will be available for the symptoms occur, allaying
client). help if desired or needed. anxiety about them.
 This enhances client’s sense of
control, self-worth, and
confidence in own ability,
diminishing fear.

STUDENT NURSE: _JOSEF ANGELO POLDO, STUDENT NURSE_ CLINICAL INSTRUCTOR: _____JEANETTE ROJO, RN, DNS_____

UNIVERSITY OF EASTERN PHILIPPINES

University Town, Northern Samar
 COLLEGE of NURSING and ALLIED HEALTH SCIENCES

NURSING CARE PLAN

Name of Patient:___SHALITA SUANSINAE________ Date Admitted:____01-07-2020_____ Chief Complaint:_________________________________ Case Number:

Age: 25 Gender:_______F______ Civil Status:_ S Address:______________SAMPAL, BULACAN___________ Ward:

ASSESSMENT NURSING SCIENTIFIC OBJECTIVES/ NURSING INTERVENTIONS SCIENTIFIC RATIONALE EVALUATIO

DIAGNOS RATIONALE PLANNING N
IS
Subjective Data: ANXIETY Vague uneasy feeling • Appear relaxed and Determine current prescribed medications and These medications can heighten feelings and • Client
Worried about related to of discomfort or dread report that anxiety is recent drug history of prescribed or over-the- sense of anxiety involvement
change in life event; Threat to accompanied by an reduced to a counter (OTC) medications (e.g., steroids, Establishes rapport, promotes expression of and response to
insomnia current autonomic response manageable level. thyroid preparations, weight loss pills, or feelings, and helps client/significant other look interventions,
status (the source is often • Identify healthy ways caffeine). at realities of the illness or treatment without teaching, and
nonspecific or unknown to deal with and Be available to the client for listening and confronting issues they are not ready to deal actions
Objective Date: to the individual); a express anxiety. talking. with. performed
feeling of apprehension • Demonstrate Be truthful, avoid bribing, and provide to soothe fears and provide assurance. • Attainment or
BP: 140/100 mmHg M. caused by anticipation problem-solving skills. physical comfort (e.g., hugging or rocking) Moderate anxiety heightens awareness and progress toward
Doenges, of danger. It is an • Use when dealing with a child permits the client to focus on dealing with desired
PR:90 bpm Nurses alerting sign that warns resources/support  Assist the client to use anxiety for coping with problems outcome(s)
pocket of impending danger systems effectively. the situation, if helpful. This is useful for being prepared for/dealing • Modifications
RR: 24 bpm guide, 15th and enables the Review strategies, such as role-playing, use of with anxiety provoking situations. to plan of care
edition individual to take visualizations to practice anticipated events, Drugs that often cause symptoms of anxiety
measures to deal with and prayer/meditation. include aminophylline/theophylline,
that threat. Refer to the physician for drug management anticholinergics, dopamine, levodopa,
alteration of the prescription regimen. salicylates, and steroids.

STUDENT NURSE: _JOSEF ANGELO POLDO, STUDENT NURSE_ CLINICAL INSTRUCTOR: _____JEANETTE ROJO, RN, DNS___