SYSTEMS PLUS COLLEGE FOUNDATION

Angeles City
COLLEGE OF NURSING

NURSING CARE PLAN

Name: Chona Date of Admission:
Age: 6 y/o Chief Complaint:
Sex: F Admitting Diagnosis:

Assessment Nursing Diagnosis Short-term and Long- Nursing Interventions Rationale Expected outcome
term Objectives

Subjective:
> Cough and colds 4 days
prior to admission.
Objective:
> T: 38.6 degree celsius
> Seizure Precaution (no
seizure occurance the entire
shift)
Hyperthermia may be Short-term:
related to microorganisms > After 8 hours of nursing
that cause inflammation as interventions, the patient
evidenced by high body will be able to demonstrate
temperature (38.6 degrees decrease in body
celsius) temperature and will not
experience complications.
Long-term:
> After 48 hours of nursing
interventions, the patient
will be able to demonstrate
and maintain body
temperature within normal
range and will not
experience complications.
1. Monitor the child’s 1. Most febrile seizures > After 8 hours of nursing
temperature (tympanic happen when the interventions, the patient
was able to demonstrate
or rectal temperature). temperature is greater decrease in body
2. Assess for hydration than 102.2 ºF (39ºC). It temperature and did not
status. usually occurs within experience complications.
3. Eliminate excess the first 24 hours of
clothing. illness and close > After 48 hours of nursing
interventions, the patient
4. Administer tepid monitoring of was able to demonstrate
sponge bath. temperature is essential. and maintain body
5. Advise the mother to 2. A high body temperature within normal
avoid applying cold temperature increases range and did not
experience complications.
water or alcohol to the the metabolic rate
child. hence increases the
6. Administer insensible fluid loss.
antipyretic as 3. Exposing skin to
indicated room air decreases
warmth and increases
evaporative cooling.
4. External sponging
reduces the body
temperature and
increases comfort.
5. Extreme cooling can
result in shock to a child
with an
immature nervous
system;  While applying
alcohol can cause dry
skin.
6.