University of Saint Louis

Tuguegarao City, Cagayan 3500

SCHOOL OF HEALTH AND ALLIED SCIENCES
BACHELOR OF SCIENCE IN NURSING – LEVEL III

NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective Data Alteration in body After 30 minutes of Independent Goal Met
temperature effective nursing  Build rapport.  To make the After 30 minutes of
“Nung unang gabi (hyperthemia) r/t interventions, the patient feel effective nursing
namin dito ma’aam disease process patient's comfortable interventions, the
sobrang taas po ng as manifested by temperature will with you. patient's
lagnat niya” as fever and chills be able to retain in temperature will
stated by the the normal range  Ensured  To prevent be able to retain in
patient’s mother of 36.5-37.5 C.  safety by and reduce the normal range
raising the risks of fall, of 36.5-37.5 C. 
Objective: bedside rails.
harm, and
 Fever with a injury that
latest may occur
temperature during
of 38.2 C at provision of
8:20pm of health care.
July 9, 2022
 Flushed  Positioned on  If the patient
skin warm comfort
is
to touch
 Chills and comfortable,
shivering they are likely
to recover
and have
better health
outcomes. It
also helps to
maintain the
patient's.
airway and
circulation
 University of Saint Louis
Tuguegarao City, Cagayan 3500
SCHOOL OF HEALTH AND ALLIED SCIENCES
BACHELOR OF SCIENCE IN NURSING – LEVEL III

throughout
the
procedure.

 Enhances
 Provide TSB heat loss by
evaporation
and
conduction.

 Increases
 Assess fluid metabolic
loss and rate and
facilitate oral diaphoresis.
intake

 Reduces
 Promote bed body heat
rest. production

 Dissipates
 Provide heat by
circulating air convection
using fan or
aircon.
 Increases
 Assisting comfort
patient in
changing into
dry clothing
 Prevents
 Provide oral herpetic
hygiene lesions of the
 University of Saint Louis
Tuguegarao City, Cagayan 3500
SCHOOL OF HEALTH AND ALLIED SCIENCES
BACHELOR OF SCIENCE IN NURSING – LEVEL III

mouth.

 Notes
 Monitor vital progress and
signs. changes of
condition.

 The role of
 Instructed the the S.O is to
patient SO monitor and
not to leave immediately
the patient inform the
unattended. nurse on duty
about the
needs of the
patient,
especially if
he feels pain,
so that the
healthcare
provider can
provide
immediate
care.

 To
understand
 Encouraged
the personal
the
verbalizations experience of
of concerns the patient so
that we can
respond
appropriately
 University of Saint Louis
Tuguegarao City, Cagayan 3500
SCHOOL OF HEALTH AND ALLIED SCIENCES
BACHELOR OF SCIENCE IN NURSING – LEVEL III

to the
situation.
Verbalization
of concerns
also helps the
provider to
give better
and more
appropriate
care.

 Febrile
 Watched out episodes is
for untoward typically
signs of occurs during
febrile the peak of
episodes and Dengue
untoward symptoms
symptoms. onset.

Dependent  Common
 PRN painkillers are
medication used to treat
for fever was pain and
given reduce high
Paracetamol
temperatures.
300mg IV q4
hours.
 University of Saint Louis
Tuguegarao City, Cagayan 3500
SCHOOL OF HEALTH AND ALLIED SCIENCES
BACHELOR OF SCIENCE IN NURSING – LEVEL III

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective data Deficient fluid and After 8 hours of Independent Goal Met
electrolyte effective nursing  Assessed  To monitor for After 8 hours of
July 9, 2022 at 8:20 imbalance r/t fluid interventions, the patient’s other s/s. effective nursing
pm the patient’s loss as evidenced patient will be able condition. interventions, the
mother verbalized by body weakness, to relief from body patient will be able
“ Nagsusuka rin po dry mucosa, and weakness and  Monitored vital  Accurate to relief from body
siya, bali pang 5 decreased skin have a moist signs as records are weakness and
times na po niya turgor mucous ordered critical in have a moist
hanggang kanina” membranes and assessing the mucous
good skin turgor. patient’s fluid membranes and
Objective data balance. Vital good skin turgor
 Decreased sign changes
skin turgor such as
 Body increased heart
weakness rate, decreased
 Dry oral blood pressure,
mucosa and increased
 Dried lips temperature
 Dried skin indicate
hypovolemia.
Vital signs taken on
July 9, 2022, at  Encouraged the  For hydration
8:20 SO to increase
fluid intake
 Temp: 38.2 providing
 HR: 121 appealing
 RR: 21 liquids.
 O2 sat: 98%
 BP: 110/70  Encouraged to  For hydration
mmHg eat foods with
high fluid
Laboratory Result content, such
of July 9, 2022 as watermelon
 University of Saint Louis
Tuguegarao City, Cagayan 3500
SCHOOL OF HEALTH AND ALLIED SCIENCES
BACHELOR OF SCIENCE IN NURSING – LEVEL III

 NA: and grapes.

125.7
 K: 2.99  Monitored and
record fluid  For baseline
intake data. Accurate
records are
critical in
assessing the
patient’s fluid
balance.
 Maintained on
IVF hydration  Initial goal to
as ordered correct
circulatory
volume deficit.
Isotonic saline
will rapidly
expand
extracellular
fluid volume.
The secondary
goal correction
of water deficit
is usually
accomplished
by the
hypotonic
 Ensure proper solution.
IVF regulation
 To ensure that
there is
adequate
hydration.

Dependent
 University of Saint Louis
Tuguegarao City, Cagayan 3500
SCHOOL OF HEALTH AND ALLIED SCIENCES
BACHELOR OF SCIENCE IN NURSING – LEVEL III

 Vitamins given
as ordered
 Helps in aiding
the general
health of the
patient
Collaborative:
 Obtained
specimens for
analysis of  Urine analysis
altered sodium provides
levels (e.g., information
serum and about the
urine sodium, retention or loss
urine of sodium and
osmolality, and the ability of the
urine specific kidneys to
gravity) as concentrate or
indicated. dilute urine in
response to
fluid changes.
 University of Saint Louis
Tuguegarao City, Cagayan 3500
SCHOOL OF HEALTH AND ALLIED SCIENCES
BACHELOR OF SCIENCE IN NURSING – LEVEL III

Assessment Diagnosis Planning Intervention Rationale Evaluation

Objective data Risk for bleeding After 8 hours of Independent: Goal Met
Latest laboratory related to possible nursing  Monitored  Hypotension After 8 hours of
results: thrombocytopenia interventions, the the patient’s and nursing
 Platelet count: secondary to patient will not vital signs, tachycardia interventions, the
L 56 dengue experience especially BP are initial patient will not
(reference hemorrhagic fever. bleeding as and HR. Any compensatory experience
range: 150- manifested by drop in blood mechanisms bleeding as
450) maintenance of pressure was usually noted manifested by
 Hemoglobin: blood pressure noted. with bleeding. maintenance of
118 and heart rate blood pressure
(reference within normal and heart rate
range: 140- ranges, and  Skin  Patient with within normal
180 absence of and mucous reduced ranges, and
 Hematocrit: hemorrhagic membrane platelet counts absence of
0.343 manifestations in was may hemorrhagic
(reference skin and mucous assessed for experience manifestations in
range: 0.40- membranes. signs bleeding into skin and mucous
0.54) of petechiae, tissues and membranes.
bruising, under the skin.
hematoma
Latest vital signs: formation,
 Blood or oozing
Pressure: of blood.
110/70 mmHg
 Heart rate:
121 bpm  Emphasized  This will
the use reduce any
 Patient was of trauma to
admitted with soft-bristled the gums,
a diagnosis of toothbrush, thereby
dengue with and to avoid Decreasing
warning use of dental additional
signs. floss or risk for
 University of Saint Louis
Tuguegarao City, Cagayan 3500
SCHOOL OF HEALTH AND ALLIED SCIENCES
BACHELOR OF SCIENCE IN NURSING – LEVEL III

toothpicks. bleeding.
 Emphasized  Dark colored
diet foods can
as alter the color
tolerated of the stool or
except dark vomitus, which
colored can be
foods. mistaken for
bleeding.

Dependent:
 Administered  Medications
medications prescribed
as decreases
prescribed. likelihood of
bleeding.

Collaborative
 Educated the  It allows
patient and them to
their parent report it
about the immediately
signs of to a
bleeding of healthcare
any kind that provider,
need to be which can
reported to a allow for
health care early
provider. interventions.
 University of Saint Louis
Tuguegarao City, Cagayan 3500
SCHOOL OF HEALTH AND ALLIED SCIENCES
BACHELOR OF SCIENCE IN NURSING – LEVEL III