NURSING CARE PLAN 1
Patient’s Name: Julie Ann Degala Cabalo _
Age and Gender:
Date: 10-25-2021 _
ASSESSMENT
Subjective/s:
Stated by the mother, she had a
fever not relieved by
Paracetamol.
Then after 2 days she
experienced:
 Headache
 Loss of appetite
 Body weakness
Past medical history:
 Urinary Tract Infection
Objective/s:
V/S: Temp.: 38°C
RR: 35 bpm
CR: 98 cpm
Weighs: 15 kgs
Lab Results:
 CBC – Leukocytosis
(2.8)
 Platelet Count – 90,000
 Widals Test – positive
 NS1Ag - positive
Name of the Student Nurse: Cristyl Shine G. Bariao. _
4 y/o/F _ Ward: Pedia Ward _
NURSING GOAL/OBJECTIVES
INTERVENTION RATIONALE EVALUATION
DIAGNOSIS (PLANNING)
Hyperthermia related to After 4 hours nursing Independent: After the 4 hours
dengue virus infection intervention the patient nursing intervention
and typhoid infection will be able to:  Strictly monitor vital
 To identify if there is
the patient didn’t met
signs every 4 hours.
as evidenced by high  Attain normal any progress or the goal causing the
temperature, headache, range of
development in patient to have another
patients’ vital signs
loss of appetite, body temperature. especially the
symptoms occur and
weakness, low platelet temperature and have much higher body
 Relief from
count, positive result of blood pressure. temperature.
headache.
widals test, and NS1
 Gain energy  To help the body’s
antigen test  Provide Tepid
heat disperse by
and increase Sponge Bath.
evaporation and
appetite. conduction. For the
body to cool down.
 Provide/ encourage  To replace the fluid
the patient to drink loss due to
plenty of water. dehydration.
 Instruct the patient to  To provide comfort
not wear thick and not to stimulate
an increase to body
clothes or blanket.
temperature.
 To prevent
dehydration and to
 Observe and monitor
have an accurate data
intake and output. for intake and output.
Collaboration:
 To treat the
 Administer the hyperthermia of the
medications and IV patient and lower the
fluids as ordered. body temperature.
 NURSING CARE PLAN 2
Patient’s Name: Julie Ann Degala Cabalo _ Name of the Student Nurse: Cristyl Shine G. Bariao. _
Age and Gender: 4 y/o/F _ Ward: Pedia Ward _
Date: 10-25-2021 _
NURSING GOAL/OBJECTIVES
ASSESSMENT INTERVENTION RATIONALE EVALUATION
DIAGNOSIS (PLANNING)
Subjective/s: Hyperthermia related to After 20 hours of Independent: After 20 hours of
Her mother stated that dengue virus infection nursing interventions nursing intervention the
evidence by rashes all the patient will be able  To identify if goal was met, the
presence of rashes was  Strictly Monitor
over the body and a to: there’s any patient body
all over her body. Body
development to
high body temperature;  Displayed a Temperature. temperature return
the patients’ body
39.5°C. normal range of within the normal range
temperature.
Objective/s: body as well as other vital
 Monitor other signs such respiratory
V/S: T: 39.5°C temperature and vital signs such as  To know if the
other vital signs. vital signs were rate, heart rate, and
RR: 48 bpm respiratory rate,
range to normal blood pressure. Patient
 Attain no signs pulse rate, and
CR: 104 bpm blood pressure. state or in an rashes was diminished.
of rashes in the
abnormal state.
whole body.
 Provide Tepid
 For the body to
Sponge Bath.
cool down or
reduce body heat.
 Instruct patient to  To replace body
increase fluid fluid loss and
intake. prevent
dehydration.
 Provide seizure  To protect the
precautionary patient in possible
measures. injury if seizure
might occur.
Collaboration:  To treat the
 Administer occurrence of
cetirizine rashes and lower
medication as the body
ordered. temperature.
 NURSING CARE PLAN 3
Patient’s Name: Julie Ann Degala Cabalo _ Name of the Student Nurse: Cristyl Shine G. Bariao. _
Age and Gender: 4 y/o/F _ Ward: Pedia Ward _
Date: 10-25-2021 _
NURSING GOAL/OBJECTIVES
ASSESSMENT INTERVENTION RATIONALE EVALUATION
DIAGNOSIS (PLANNING)
Subjective/s: Impaired Skin Integrity 1 Independent: 1
After 1 day and 3  To know if there After 1 day and 3
Her mother stated that related to alternation of 2  Strictly monitor 2
skin appearance as hours of nursing is any progress hours of nursing
presence of rashes was body
evidenced by presence intervention the patient and development intervention, the goal
all over her body. temperature.
of rashes all over the will be able to: to the patient was partially met.
body and high body body Patient displayed and
 Obtain normal temperature.
Objective/s: temperature. attain normal range of
body  Maintain strict  To keep the
V/S: T: 39.5°C temperature and body temperature and
hygiene. skin's health at
rashes will be rashes were lessen and
RR: 48 bpm its best and
gone and cured. diminishing but not
prevent any
CR: 104 bpm totally cured and gone.
severe
symptoms.
 Encourage the  Rashes might
patient to do a worsen when
proper skin care patient will over
routine like bath and use hard
warm bath. soap. For the
patient not to
have dry skin.
 Promote patient’s  To relieve
comfort. discomfort and
improve good
Collaborative: outcomes.
 Give the  To treat the
cetirizine rashes and
medication as relieve some
prescribe by the itchiness and
 doctor. redness.
DRUG STUDY 1
Patient’s Name: Julie Ann Degala Cabalo _ Name of the Student Nurse: Cristyl Shine G. Bariao. _
Age and Gender: 4 y/o/F _ Ward: Pedia Ward _
Date: 10-25-2021 _
DOSE, ROUTE,
NAME AND
FREQUENCY, AND MECHANISM ADVERSE/SIDE NURSING
CLASSIFICATION INDICATION CONTRAINDICATION
DURATION OF OF ACTION EFFECTS RESPONSIBILITY
OF DRUG
ADMINISTRATION
Drug Name: 500mg Ampicillin It is administer Ampicillin should not be Common Side effects of
Ampicillin include:
 Keep an eye out
for seizures and
Ampicillin IVT inhibits the through used to treat infections  acute tell the doctor right
third and final intravenous or caused by penicillinase- inflammatory skin away if the patient
Classification: Every 6 hours stage of intramuscular. producing bacteria. The eruption develops or
(erythema escalates seizure
Penicillin; Beta- bacterial cell Ampicillin is rationale is that ampicillin multiforme) activity.
wall formation used to treat will be inactivated by  redness and  Instruct the family
lactam antibiotics peeling of the skin to report any other
by attaching to certain penicillinase (beta- (exfoliative bothersome side
certain infections that lactamase). 
dermatitis),
rash, hives, fever,
effects, such as
severe or long-
penicillin- are caused by seizure, and lasting skin
binding proteins bacteria such as 
diarrhea
inflammation of
problems (rash,
itching) or GI
(PBPs) found meningitis the small and issues (nausea,
inside the (infection of large intestine and
colon
vomiting,
bacterial cell the membranes  inflammation of
diarrhea).
 Notify the
wall. Bacterial that surround the mouth and
tongue and yeast physician if
cell wall the brain and infection in the diarrhea,
abdominal pain,
autolytic spinal cord), mouth (oral
candidiasis/thrush) fever, and pus or
enzymes, such and infections  vomiting and mucus in the stool
as autolysins, of the throat, nausea have been assess in
 reduction of white the patient.
are then sinuses, lungs, blood cells  Keep an eye out
responsible for reproductive 
(leukopenia),
acute allergic
for signs of
anaphylaxis and
cell lysis; it's organs, urinary reaction allergic reactions,
likely that tract, and 
(anaphylaxis),
inflammation in
such as pulmonary
symptoms
Ampicillin gastrointestinal the kidney (tightness in the
interacts with tract.  dark urine, easy
bruising or
throat and chest,
an autolysin bleeding, and
wheezing, cough
dyspnea). Then,
inhibitor. persistent sore
throat. report it to the
 physician.

DRUG STUDY 2
Patient’s Name: Julie Ann Degala Cabalo _ Name of the Student Nurse: Cristyl Shine G. Bariao. _
Age and Gender: 4 y/o/F _ Ward: Pedia Ward _
Date: 10-25-2021 _
DOSE, ROUTE,
NAME AND
FREQUENCY, AND MECHANISM ADVERSE/SIDE NURSING
CLASSIFICATION INDICATION CONTRAINDICATION
DURATION OF OF ACTION EFFECTS RESPONSIBILITY
OF DRUG
ADMINISTRATION
Drug Name: 125mg/5mL-7.5 mL The activation It is used to Patients with a known It is extremely rare  Make sure the
patient isn't
Paracetamol Oral of descending treat a variety hypersensitivity or for this medicine to using any other
serotonergic of painful and idiosyncratic reaction to cause a severe paracetamol-
Classification: PRN pathways by febrile paracetamol should avoid allergic reaction. containing
Analgesics and q4h paracetamol illnesses, such using it. Also, severe However, you can medications.
 Use a medicine
Antipyretics produces a as migraines, hepatic impairment or detect symptoms of syringe to drip
central toothaches, active liver disease (IV). a major allergic liquid slowly
analgesic effect. neuralgia, colds response, such as a into the side of
There is debate and influenza, rash, the child's mouth
or use soluble
concerning its sore throats, itching/swelling paracetamol
principal backaches, (particularly of the mixed with a
mechanism of rheumatic pain, face/tongue/throat), drink for
action, which and extreme dizziness, children who
may refuse
could be dysmenorrhea. or difficulty medicine from a
reduction of breathing. spoon.
prostaglandin Overdosing on  Monitor and
(PG) formation paracetamol can assess CBC,
liver, and kidney
or influence result in liver functions.
cannabinoid damage, kidney  Monitor and
receptors via an damage, digestive Report if there’s
active disorders, heart an allergic
reactions such as
metabolite. attacks, strokes, rashes, swelling
and cardiac arrest. or itching,
extreme
dizziness, and
difficulty of
breathing.
 DRUG STUDY 3
Patient’s Name: Julie Ann Degala Cabalo _ Name of the Student Nurse: Cristyl Shine G. Bariao. _
Age and Gender: 4 y/o/F _ Ward: Pedia Ward _
Date: 10-25-2021 _
DOSE, ROUTE,
NAME AND FREQUENCY, AND
MECHANISM OF ADVERSE/SIDE NURSING
CLASSIFICATION DURATION OF INDICATION CONTRAINDICATION
ACTION EFFECTS RESPONSIBILITY
OF DRUG ADMINISTRATIO
N
Drug Name: 5mg/5mL-5mL Cetirizine works by Seasonal allergic Anyone who has a Sleepiness, weariness,  Before and during
treatment, assess
preventing cells from rhinitis and known hypersensitivity and dry mouth are the symptoms and
Cetirizine IV (Intravenous) releasing histamine most typical side
(H-1) receptors. Many
permanent allergic to cetirizine or any of keep track on the
Classification: OD effects seen by baseline.
of the signs and rhinitis symptoms its constituents should children who take  Check for signs of
Antihistamines symptoms of allergic can be relieved avoid it. Cetirizine is cetirizine. Cetirizine
a respiratory
problem, such as
reactions, such as with this medicine. also contraindicated in causes headaches in wheezing or chest
swelling of the nose Cetirizine is also people who have a children more pain.
lining, sneezing, and  If allergy testing is
itchy eyes, are caused
used to treat the history of hydroxyzine frequently than it does planned, all
cutaneous hypersensitivity, as in adults. Stomach medications must
by histamine, a be stopped 48
symptoms of cetirizine is a pain, particularly in
chemical. Cetirizine hours prior to the
children, is possible. It
inhibits the activation chronic idiopathic metabolite of could also cause 
test.
Advise the parents
of H1 receptor- urticarial. It hydroxyzine. It is also that the kid may
containing cells by major adverse effects
blocking one kind of
dramatically not suitable for children such as urination
feel dizziness,
sedation, or
histamine receptor (the reduces the under the age of two. problems. This drowsiness as a
H1 receptor). frequency, medication seldom result of the
medication.
Cetirizine and other severity, and causes a severe  Report any trouble
second-generation length of hives, as allergic reaction. breathing,
antihistamines are less Rashes, hallucinations,
well as pruritus. It tremors, loss of
drowsy because they itching/swelling
do not quickly enter also helps with hay (particularly of the
coordination, or
irregular heartbeat
the brain from the fever, insect bites, face/tongue/throat), to the physician.
bloodstream. and skin rashes. extreme dizziness, and  Instruct the parent
to report any other
Cetirizine may difficulty breathing bothersome side
produce more are all possible effects, such as
drowsiness than other symptoms of a serious severe or
antihistamines of the prolonged dry
allergic reaction. mouth or irritation
second generation. of the upper
respiratory tract.