Cues and Evidences Nursing Diagnosis Objectives Interventions Rationale Evaluation

Subjective: Hyperthermia related to Within my 1 week holistic Independent After my 1 week holistic
illness (urinary tract nursing care, the client will be nursing care, the client is
The Client’s mother infection or UTI and able to decrease her  Encourage mother  Electrolytes are minerals that able to
verbalized “ning kalit ra Dengue Hemorrhagic temperature as evidenced by: to increase fluid intake to conduct an electrical charge when
siyag hilanat ug taas Fever) patient, especially fluid high mixed by water. They help  Consume 3 glasses of milk
dayun ning sunod sakit in electrolytes. regulate a variety of your body’s or 720ml a day
iyang tiyan.” Vital signs within normal most essential functions, including  Drinks clear water at 3
range: nerve signal, muscle contraction glasses or 720ml
and hydration.
T: 35.9-36.7 ̊C
Objective: PR:60-100bpm  Advice mother to promote  Bed rest is therapeutically used as  Sleeps 12hours a day
RR:12-20cpm bed rest, or limit activity. a means to decrease the metabolic
Vital signs: BP:110-140/ 60-90mmHg demand on the body and promote
T : 39.8 ̊ C recovery during an illness.
HR: 116 bpm
RR: 38 cpm  Monitor patient’s vital signs.  Body temperature is one of the  Manifest normal vitals
BP: 90/100 four main vital signs that must be below noted
monitored to ensure safe and
effective care. Monitoring those T:35.9-36.7 ̊C
makes us determine if there’s an P:60-100bpm
alteration of the previous results. R:12-20cpm
BP:110-140/ 60-90mmHg

 Perform tepid sponge bath to  Tepid sponge bath is a procedure  Manifest decrease body heat
patient that is given to a patient with fever as noted by decrease body
through the use of lukewarm water temperature during vital
and application of friction to the signs taking.
body’s surface.
 Perform cold compress to  Help to relieve pain and swelling
patient or cool a fever.

Dependent

 Administer medication as  Medicines are chemicals or  Take medication regularly

ordered the physician: compounds used to cure, halt, or and on time without any
prevent disease; ease symptoms; resistance oberved.
Paracetamol 130mg IVTT or help in the diagnosis of illness.
every 4hours for 24hrs then
PRN if Temperature is higher
than 39 degrees celcius

Collaborative

 Provide cooling blanket
Nursing Care Plan
 Cooling blanket is used to reduce  Sleep well 12 hours with no
fever, usually greater than 39.5 to signs of chills and fever as
40 degrees Celsius. noted by her vital signs at
normal range.