COR JESU COLLEGE, INC.

College of Health Sciences

Sto. Rosario, Tres De Mayo, Digos City

Nursing Care Plan

Name of Patient: Baby G. Age: 8 years old

Chief Complaint: Fever Attending Physician: Dr. Macasaet, Aelleen P.

Goals/ Objective Nursing

Cues and Data Nursing Diagnosis Scientific Basis Rationale Evaluation
Criteria Interventions
Subjective: Hyperthermia related Fever, also known as Able to reach the Assess the patient’s To assist in creating Within 4 hours of
“ga ubo akoang anak to upper respiratory hyperthermia or normal range of the vital signs at least an accurate diagnosis nursing
more than 2 weeks tract infection. pyrexia, is a medical patient’s vital signs every 4 hours. and monitor interventions, the
na ug taas pud condition when there effectiveness of patient will have a
iyahang temperature is uncontrolled rise medical treatment, stabilized
ug ge panugnaw in the body particularly the temperature with the
siya” as verbalized temperature, antibiotics and fever- normal range and its
by the mother. measured as above reducing drugs vital signs will be
37.5 degrees Celsius. administered. normalized as well.
Objective: To regulate the The patient has
Flushed skin with a It results from the temperature of the occasional coughing.
body temperature of failure of the body’s To regulate the Remove excessive environment and The goal is partially
38.5ᴼC per axilla thermoregulatory patient’s body clothing, blankets make it more met.
Respiratory rate of : center, the temperature. and linens. Adjust comfortable for the
24 breaths per hypothalamus to the room patient
minute control the body temperature. To treat bacterial
Pulse rate of: 105 temperature between infections, this is the
beats per minute the normal range of Administer the underlying cause of
Unstable blood 36 to 37.5 degrees To control the spread prescribed antibiotic the patient’s
pressure of 100/65 Celsius. of bacteria by and anti-pyretic hyperthermia.
mmhg administering medications. To facilitate the body
Muscle rigidity; antibiotics. in cooling down and
chills Offer a tepid sponge to provide comfort.
bath. Head elevation helps
improve the
expansion of the
Elevate the head of lungs, enabling the
the bed. patient to breathe
more effectively.
 COR JESU COLLEGE, INC.,

College of Health Sciences

Sto. Rosario, Tres De Mayo, Digos City

DRUG STUDY

Generic Brand Classifications Dosage Route Mode of Drug to Drug Side effects Adverse Effects Nursing
Name Name Action interaction Interventions
paracetamol Biogesic Analgesic/antipyretic Adults and children PO Paracetamol is Acenocoumarol- Low fever with An allergic Advice the
12 years and older used to treat Paracetamol nausea, reaction, which patient or
usually take 1 to 2 many increases the stomach pain, can cause a rash guardian that
500mg tablets orally conditions anticoagulant and loss of and swelling paracetamol
every 4 to 6 hours. It such as effect of appetite,dark flushing, low can be taken
is not recommended headache, acenocoumarol. urine, clay- blood pressure and with or
to take more than 4g muscle aches, -Alcohol. Both colored stools; a fast heartbeat – without food.
(8 500mg tablets) of arthritis, paracetamol and low fever with this can sometimes Advice patient
Paracetamol in a backache, alcohol can nausea, happen when or guardian to
span of 24 hours toothaches, increase the risk of stomach pain, paracetamol is administer
because this can colds, and hepatotoxicity and loss of given in hospital paracetamol at
lead to overdose. fevers. It appetite. into a vein in your the same time
Children below 12 relieves pain arm each day.
need to take a lower in mild blood disorders,
dose,. Paracetamol arthritis but such as
(Biogesic) for Kids has no effect thrombocytopenia
oral drops contain on the (low number of
100mg paracetamol, underlying platelet cells) and
both with dosage inflammation leukopenia (low
according to and swelling number of white
10mg/kg body of the joint. blood cells)
weight every 4 liver and kidney
hours, as needed. damage, if you
take too much
(overdose) – this
 can be fatal in
severe cases.

COR JESU COLLEGE, INC.,

College of Health Sciences

Sto. Rosario, Tres De Mayo, Digos City

DRUG STUDY

Generic Brand Name Classifications Dosage Route Mode of Action Drug to Drug Side effects Adverse Effects Nursing
Name interaction Interventions
ampicillin Ampi, Penicillins, Children age IV It interference Allopurinol: acute GI: diarrhea, Monitor signs
sodium- Omnipen, Amino 1 or older IM with cell wall May increase inflammatory skin nausea, of allergic
sulbactam Penglobe, and weighing synthesis by risk of rash. eruption pseudomembranous reactions and
sodium Principen. lesser than 40 attachment to H2 antagonists, (erythema colitis, abdominal anaphylaxis,
kg: 300 penicillin-binding PPIs: May multiforme) pain, black hairy including
mg/kg/day IV proteins (PBPs), decrease redness and tongue, pulmonary
in divided inhibition of cell ampicillin peeling of the skin enterocolitis, symptoms
doses every 6 wall absorption and (exfoliative gastritis, glossitis, (tightness in
hours. peptidoglycan level. Separate dermatitis) stomatitis, the throat and
synthesis and administration rash. vomiting. chest,
Children age inactivation of times. hives. Hematologic: wheezing,
1 or older inhibitors to Methotrexate: fever. Leukopenia, cough dyspnea)
weighing 40 autolytic May increase seizure. thrombocytopenia, or skin
kg or more: enzymes. This methotrexate black hairy thrombocytophenic reactions (rash,
1.5 to 3 g IV causes disruption level, tongue. purpura, anemia, pruritus,
or IM every 6 of the bacterial increasing risk diarrhea Hypersensitivity urticaria).
hours for no cell wall and of toxicity. reactions, Notify
longer than 14 leads to bacterial Probenecid: overgrowth of physician or
days. cell death. May increase nonsusceptible nursing staff
levels of organisms. immediately if
ampicillin and these reactions
other occur
penicillins.

COR JESU COLLEGE, INC.,

College of Health Sciences

Sto. Rosario, Tres De Mayo, Digos City

DRUG STUDY

Generic Brand Classifications Dosage Route Mode of Action Drug to Drug Side effects Adverse Effects Nursing
Name Name interaction Interventions
sodium Norma Isotonic 1000 ml IV Normal Saline is a Caution must be Reactions which Adverse effects Document
chloride l intravenous @ sterile, exercised in the may occur because of normal saline baseline data.
injectio Saline solution 25ggts/m nonpyrogenic administration of the solution or may occur
n in solution for fluid of Sodium Chloride Inje the technique of secondary to Observe for
and electrolyte ction, USP to patients administration solution or signs of fluid
replenishment. receiving corticosteroids include febrile res technique of overload.
-It contains no or corticotropin. ponse, infection at administration.
antimicrobial the site of These effects Monitor
agents.-The pH is Studies have not been injection, include febrile manifestations
5.0 (4.5 to7.0).-It conducted to evaluate venous thrombosis  response, of continued
contains 9 g/L additional drug/drug or or phlebitis extend infection at the hypovolemia.
Sodium Chloride drug/food interactions ing from the site site of injection,
with an osmolarity with Sodium Chloride of injection, venous Prevent
of 308mOsmol/L. (sodium chloride extravasation, thrombosis or hypervolemia.
-It contains (sodium chloride and hypervolemia. phlebitis
154mEq/L injection) injection) extending from Elevate the head
Sodium and Injection, USP. the site of of the bed at 35
Chloride. injection, to 45 degrees.
extravasation,
and Elevate the
hypervolemia. patient’s legs.

Educate patients
and families.