Nursing Care Plan

Patient’s Code: _JXDN___________ Age: _12__ Sex: __M____ Civil Status: Single Religion: _RC______ Date & Time of Admission: March 15, 2021; 10 am_
Room: 202
Attending Physician: Dr. Macarat________________________Chief Complaint/s: Fever and
vomiting______________________________________________________________________

Nursing Diagnosis (PES): Acute pain related to abdominal discomfort as evidenced of Epigastric pain, vomiting and fever.

Definition: Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. (International
Association for the study of pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end, and with a duration of less than 3
months.

Assessment/ Cues Planning Interventions Rationale Evaluation

(Subjective/ Objective) (Goals and Objectives)
Subjective Data LTO Independent The planned care was…
After 5 days of nursing
care, the patient will be
 The patient complaints of able to…  Measure Vital signs  Determining the continued  MET. The patient
fever and vomiting PTA. intervention when changes. has been able to
 Display laboratory
 Monitor patient’s pain. Note improve from his
results within
client report of pain in specific condition. The
normal range for
areas, whether pain is  Detect and describe pain to help patient shows...
individuals.
increasing, diffused, or in the diagnostic process;
 Maintain fluid localized. understand the cause of  Laboratory
volume at a the pain to help determine the results within
functional level. best treatment; Monitor normal range.
the pain to determine whether  Maintaining
the underlying disease or fluid volume at
disorder is improving or a functional
deteriorating, and whether level
At the end of my 8 hours
the pain treatment is working.
Objective Data of nursing care, the  The need for fluid replacement  Vomiting were
patient will be able to…. is determined by existing losses relieved.
and ongoing losses. Insufficient
 The
 Awake, alert and not in  Maintain an accurate input and renal perfusion or hypovolemia,
temperature is
cardiorespiratory distress. output record when monitoring as well as polyuria, may trigger
 Improve condition on normal
Weak looking. active fluid loss from vomiting. a decrease in urinary
in vomiting. range.
 Epigastric Tenderness- (pain production, necessitating more
 Temperature will
scale= 5/10) vigorous fluid replacement.  The pain were
be in normal
relieved and
range.  
controlled
 Report pain is
Vitals relieved or  Following the
 Temperature – 38.6 C controlled. prescribed
 Patients with mild dehydration
pharmacologic
 HR: 120 bpm  Follow prescribed caused by a high fever and
regimen.
pharmacologic vomiting should receive oral
regimen. rehydration therapy. To
Dependent
minimize high temperatures,
paracetamol is used. IV fluid is
provided to keep the patient
 Administer medications as indicated
hydrated. Depending on the
by the physician:
clinical case, the amount and
-ORS (200 cc distilled H2O + 1 sachet volume of fluid to be
ORS) to consume slowly per orem, substituted, as well as infusion
rates, will be determined.
- Paracetamol 250 mg 1 cap Q4Hr
(PRN) for fever
-IV fluid (PNSS) 1L and regulate to 20
gtts/hr

 The patient is necessary to be

updated to the information in
order to whether change or

Collaborative
 Coordinate with the laboratory
department regarding the test
that are needed to conduct.
(CBC)
continue some medications.
 To allow for therapy as part of
the recovery plan and further
assessment of the patient's
condition.

 Refer the patient to the

physicians

References: Wiwanitkit, V. (2010). Dengue fever: diagnosis and treatment. Expert review of anti-infective therapy, 8(7), 841-845.
Herdman, H. T., & Kamitsuru, S. (2017). NANDA international nursing diagnoses: Definitions & classification 2018-2020
Retrieved from: https:ross-robinson.blogspot.com/2011/02/nursing-diagnosis-and-nursing.html

Name of Student: Hannah Angelu S. Cabading Yr/Crs/Sec: BSN 2D RLE Group: _2_ CI: Hannah Angelie Rey

How to make NCP video tutorial: https://youtu.be/zBnu2AZz02Q