Republic of the Philippines

UNIVERSITY OF EASTERN PHILIPPINES

University Town, Northern Samar

COLLEGE of NURSING and ALLIED HEALTH SCIENCES

NURSING CARE PLAN

Name of Patient: _Evan, Alisson___Date Admitted: 01/9/23 Chief Complaint: _Prolonged Fever Case Number: ___Age: 9 years old
Gender: Male Address: Biri N. Samar Ward: ___P/S - Pediatric AP: ___________________

ASSESSMENT NURSING SCIENTIFIC OBJECTIVES/PLANNING NURSING SCIENTIFIC EVALUATIO

DIAGNOSIS RATIONALE INTERVENTIONS RATIONALE N
Subjective: Hyperthermia/Altered Hyperthermia is After 4 hours of nursing 1. Recognize the signs 1. Heat-related illness
“6 days na siya Thermoregulation defined as elevated intervention, patient will be and symptoms of heat occurs when the
may hiranat” as related to illness. body temperature able to: exhaustion or heat- body’s
stated by the due to a break in related illness. thermoregulatory
system fails.
father of the thermoregulation 1. Patient maintains body
2. Loosen or remove
client that arises when a temperature below 39° C excess clothing and 2. Exposing skin to
body produces or (102.2° F). covers. room air decreases
absorbs more heat heat and increases
Objectives: than it dissipates. It 2. Patient maintains BP and 3. Provide hypothermia evaporative cooling.
Flushed skin is a sustained core HR within normal limits. blankets or cooling
and Rashes temperature beyond blankets when 3. Use cooling
the normal necessary. blankets that circulate
(+) Fever variance, usually water when the body
greater than 39 °C 4. Provide a tepid bath temperature is needed
Temp: 40’C (102.2 °F). Such or sponge bath. to be cooled quickly.
HR: 118Bpm elevations range
5. Adjust and monitor 4. A tepid sponge bath
RR: 46 from mild to environmental factors is a non-
breaths/min extreme; body like room temperature pharmacological
O2: 88% temperatures above and bed linens as measure to allow
40 °C (104 °F) can indicated. evaporative cooling.
be life-threatening. Do not use alcohol as
6. Provide nutritional it can cool the skin
support or as indicated. rapidly and may cause
shivering.
7. Encourage adequate
fluid intake 5. Room temperature
may be accustomed to
near normal body
temperature, and
blankets and linens
may be adjusted as
indicated to regulate
the patient’s
temperature.

6. Food is necessary
to meet the increased
energy demands and
high metabolic rate
caused by
accompanying
hyperthermia

7. If the client is alert

enough to swallow,
provide cool liquids to
help lower the body
temperature.
Additionally, if the
patient is dehydrated
or diaphoretic, fluid
loss contributes to
fever.
Name of Patient: _Evan, Alisson___Date Admitted: 01/9/23 Chief Complaint: _Prolonged Fever Case Number: ___Age: 9 years old
Gender: Male Address: Biri N. Samar Ward: ___P/S - Pediatric AP: ___________________

ASSESSMENT NURSING SCIENTIFIC OBJECTIVES/PLANNING NURSING SCIENTIFIC EVALUATIO

DIAGNOSIS RATIONALE INTERVENTIONS RATIONALE N
Subjective: Imbalanced Nutrition Imbalanced After 8 hours of nursing 1. Discuss with MD Utilizing
“ Mahilig siya nutrition refers to intervention, patient will be the potential need appropriate
sa mga instant either nutrition that able to: for referral to a resources is a vital
nga pagkaon ta is more than or less dietitian. part of being a
softdrinkx” as than the body’s 1. Patient will maintain nurse. The dietitian
stated by the requirements and weight in desired goal will be able to
father of the metabolic needs. It range 2. Provide appropriately assess
client can occur with any 2. Patient will recognize nutritional the patient and
individual. Listed factors that are supplements as individualize the
below is a brief list contributing to being appropriate or patient’s plan of
Objectives: of potential causes ordered. care regarding
under or overweight
Flushed skin that may result in nutrition.
3. Patient will identify
and Rashes an individual Nutritional
experiencing an appropriate nutritional supplements may be
(+) Fever imbalance in their needs/requirements 3. Educate the prescribed as
nutrition status. 4. Patient will consume patient on the necessary by the
Temp: 40’C adequate nutrition body’s nutritional MD or dietician.
HR: 118Bpm 5. Patient will verbalize needs. The RN should
RR: 46 appropriate management . ensure the patient is
breaths/min of nutrition at home receiving and taking
O2: 88% 4. Provide the these supplements
patient with to further strengthen
resources regarding the body.
nutrition.
5. If underweight, This will allow the
provide patient with patient to gain
additional snacks in knowledge in the
between meals. area of how to
. independently care
for oneself upon
6. Provide good oral discharge
hygiene.
Good oral hygiene The patient will be
can increase an able to take these
individual’s appetite. resources home
The oral mucosa is upon discharge and
also a vital part of will further help in
salvia production the patient being
which will further aid independent in their
in the digestion of care.
food.
Patients may not be
7. Administer able to meet all the
antiemetics as body’s requirements
needed before during regular meal
meals. times. Providing
snacks in between
meals can be
8. Administer another way to meet
enteral feedings as the body’s extra
ordered. nutritional needs

Other underlying
medical conditions
may
cause nausea limitin
g the patient’s
intake of food.
Providing
appropriate
antiemetics will
allow for patient’s
appetite to
potentially increase
and tolerate intake
better.

In a more critical
care setting enteral
feedings may be
necessary, ensure
these are
administered as
ordered to meet the
body’s needs.
Name of Patient: _Evan, Alisson___Date Admitted: 01/9/23 Chief Complaint: _Prolonged Fever Case Number: ___Age: 9 years old
Gender: Male Address: Biri N. Samar Ward: ___P/S - Pediatric AP: ___________________

ASSESSMENT NURSING SCIENTIFIC OBJECTIVES/PLANNING NURSING SCIENTIFIC EVALUAT

DIAGNOSIS RATIONALE INTERVENTIONS RATIONALE ION
Subjective: Deficient knowledge A lack of cognitive After 2 hours of nursing 1. Explain to the Frequent recurrences of
“ Mahilig siya related to lack of information or intervention, patient will be client about UTI UTI may indicate that
sa mga instant information regarding psychomotor able to: risk factors, the client has difficulty
nga pagkaon ta predisposing factors ability needed for prevention, and understanding the
softdrinkx” as and prevention of the health restoration, 1. Client will verbalizes treatment. disease and complying
stated by the disease. preservation, knowledge of causes and with prescribed
father of the or health treatment of UTI, controls risk therapeutic management
client promotion is factors, and completes medical 2. Teach the client
identified as a treatment of UTI. about measures to The goal of client
knowledge deficit. prevent urinary teaching is to resolve the
Objectives: Knowledge plays tract infections. current infection and
Flushed skin an influential and prevent a
and Rashes significant part of a recurrence. Intervention
patient’s life and s may include:
(+) Fever recovery. Hygienic measures
(showering rather  Bacteria in the
Temp: 40’C than bathing in a in bath water may
HR: 118Bpm a tub). enter the urethra.
RR: 46  Can result in the
breaths/min Encourage not to stasis of urine.
O2: 88% ignore the need to  This will help in
void. preventing the
Perineal hygiene migration of the
after a bowel
pathogen in the
movement.
urethral opening
The importance and, in women,
of frequent bladder the vaginal
emptying. opening.
Use tampons for  Completely
periods. emptying the
bladder prevents
Avoid wearing tight- bladder
fitting or distention and
constricting compromised
undergarments blood supply to
made of non- the bladder wall.
breathing materials. These predispose
the client to UTI.
 Tampons are
advised during
the menstruation 
rather than
sanitary napkins
because they
keep the bladder
opening area
drier, hence
limiting the
growth of
bacteria.
 Such fabrics can
accumulate
moisture and
can provide an
environment for
bacterial
growth. Cotton
fabric and loose
fitting clotting ar
e more
encouraged.