Republic of the Philippines

UNIVERSITY OF NORTHERN PHILIPPINES

College of Nursing
Tamag, Vigan City, 2700 Ilocos Sur

NURSING CARE PLAN

In Partial Fulfillment
Of the Requirement For The
Virtual RLE
MDH Pedia

Presented by:
John Noeh D. Degracia
BSN II-E

Presented to:
Mrs. Winnie Ponce
University of Northern Philippines
College of Nursing
Name of Patient: Cabalo, Julie Ann Degala Age: 4 years old Address: Cabaritan, Santo Domingo, Ilocos Sur Ward: Pedia/ Room 3 Hosp. No: 23422
Date: December 06, 2021
Assessment Nursing Planning Nursing Intervention Rationale Health Teaching Evaluation
Diagnosis
SUBJECTIVE Dengue Fever; After 8 hours of  Provide Provide assistance to Encourage and After 8 hours of effective
DATA: t/c Typhoid effective nursing assistance for meet their daily needs; Explain to the family nursing intervention, the patient
Fever intervention, the ADLs. involve the family in the of the patient to: will be able to:
According to her patient will be able to:  Wash your hands.  Patient was able to maintain
fulfillment of ADL; and
mother, 5 days prior  To maintain a Frequent a normal fluid volume.
normal fluid explain the purpose of hand-washing in hot,  Patient was able to improve
to consultation, Julie bed rest to prevent
volume. soapy water is the intake of nutritional
Ann had fever not
 To improve complications and best way to control requirements.
relieved by intake of speed up the healing infection. Wash  Patient was able to reduce or
Paracetamol, then nutritional process. before eating or diminish pain including
after 2 days Julie requirements. preparing food and rashes.
Ann developed  To reduce or Monitor the status of after using the toilet.  Patient was able to resume
headache, loss of diminish pain  Encourage hydration as needed; Carry an ADLs.
including increase in fluid alcohol-based hand  Patient was able to maintain
appetite and body monitor the fluid intake
rashes. intake sanitizer for times a normal body temperature.
weakness.  To resume daily; encourage an when water isn't
According to her ADLs. increase in fluid intake; available.
mother it was her  To maintain a and collaborate with  Avoid drinking
second time to be normal body other medical team for untreated water.
admitted in the temperature. IV fluid administration. Contaminated
hospital, the first one drinking water is a
Monitor the amount of particular problem in
was when she was
 Improve caloric intake; monitor areas where typhoid
treated with Urinary fever is endemic. For
nutritional weight loss; provide a
Tract Infection. that reason, drink
intake. comfortable only bottled water or
environment during canned or bottled
meals; and encourage carbonated
an increase in protein beverages, wine and
OBJECTIVE and vitamin C intake to beer. Carbonated
DATA: meet nutritional needs. bottled water is safer
than non-carbonated
T: 38.5 °C bottled water.

RR: 35bpm; Assess the level of pain,  Ask for drinks

 Reduce or location, duration, without ice. Use
CR: 98cpm diminish pain. intensity, and bottled water to
brush your teeth, and
Weight: 15 kgs. characteristics; provide
try not to swallow
warm compresses on water in the shower.
areas with pain; and
administer analgesics as  Avoid raw fruits
prescribed. and vegetables.
Because raw
Monitor patient produce may have
temperature degree and been washed in
 Improve body contaminated water,
patterns; observe for
temperature. avoid fruits and
chills and profuse
vegetables that you
diaphoresis; provide can't peel, especially
tepid sponge baths and lettuce. To be
avoid the use of ice absolutely safe, you
water and alcohol; and may want to avoid
administer antipyretics raw foods entirely.
as prescribed.  Choose hot foods.
Avoid food that's
stored or served at
room temperature.
Steaming hot foods
are best. And
although there's no
guarantee that meals
served at the finest
 restaurants are safe,
it's best to avoid food
from street vendors
— it's more likely to
be infected.

Carry out doctor’s order Carry out doctor’s order

(Administering of medication (Administering medication)
start at 7AM)
Potassium Chloride in
 D5LRS 500 ml at 17 Lactated Ringer's and 5%
gtts/min Dextrose Injection, USP is a
sterile, nonpyrogenic
solution for fluid and
electrolyte replenishment
and caloric supply in a single
dose container for
intravenous administration.
It contains no antimicrobial
agents.

Ampicillin injection is used

to treat certain infections that
 Ampicillin 500 are caused by bacteria such
mg/IVT q 6 hrs as meningitis (infection of
ANST (-) the membranes that surround
the brain and spinal cord) and
lung, blood, heart, urinary
tract, and gastrointestinal
tract infections. Ampicillin
injection is in a class of
 medications called
penicillins

Chloramphenicol is used to
treat serious infections in
 Chloramphenicol 125 different parts of the body. It
mg -7.5 ml every 6 is sometimes given with
hrs other antibiotics. However,
chloramphenicol should not
be used for colds, flu, other
virus infections, sore throats
or other minor infections, or
to prevent infections.

Paracetamol is a common
painkiller used to treat aches
 Paracetamol 125 and pain. It can also be used
mg/5ml -7.5 ml every to reduce a high temperature.
4 hrs PRN for Temp; It's available combined with
38.0 °C other painkillers and
anti-sickness medicines. It's
also an ingredient in a wide
range of cold and flu
remedies.

Phyllanthus has been used in

 Phyllanthus Ayurvedic medicine for over
(Stimuno) 5 ml TID 2,000 years and has a wide
number of traditional uses
including internal use for
 jaundice, gonorrhea, frequent
menstruation, and diabetes
and topical use as a poultice
for skin ulcers, sores,
swelling, and itchiness.

Cetirizine is an antihistamine
 Cetirizine 5mg/5ml – medicine that helps the
5 ml OD symptoms of allergies. It's
used to treat: hay fever.
conjunctivitis (red, itchy eye)
References:
8 Postpartum Hemorrhage Nursing Care Plans

https://nurseslabs.com/postpartum-hemorrhage-nursing-care-plans/

Postpartum Discharge Instructions

https://www.hopkinsmedicine.org/howard_county_general_hospital/services/mothers_and_babies/taking_baby_home/postpartum-discharge-instructions.html