Assessment (Cues) Nursing Diagnosis Nursing Objectives Nursing Interventions Rationale Evaluation

Subjective Data: Based on the assessment At the end of an 8 hour Independent After 8 hours of
- Patients parents report a data, the major nursing shift of independent, independent and
mouth a sore and an onset dependent, and ● Monitor patients vital collaborative
fever on her son diagnosis for a patient signs interventions, the
with HFMD related to collaborative nursing
- The client parents stated that objectives and goals
intervention, the client
“ It started after attended his Imbalanced Nutrition ● Improve the condition are partially met
class in public daycare will: of the oral mucous as evidenced by
Manifested by:
● Subside the membrane
Temperature
● “Mouth sore and fever
from 39.1°C to ● Improve skin integrity ● Reduced high
” as verbalized by the temperature of
36.5 - 37.5
patient guardian ● Encourage increased the client
(normal values)
Objective Data: as evidenced by fluid intake. ● Improve
- Vital Signs ● Improve skin integrity of the
● Temp - 38.1°C,
Temp - 38.1°C. integrity and oral skin and
● Skin is warm to touch
Apical Pulse - 75 mucous ● Improve nutritional mucous
and flushed
Pulse Oximetry - 95% membrane intake membranes
● Positive for Mouth sore ● Improved
BP - 120/70 ● Prevent Infection
- Skin is warm to touch, and skin rash ● Prevent Infection nutritional
● Relieve from
flushed but she is awake and intake
Scientific Explanation: pain and
oriented ● Relieve Pain ● Prevention of
- Upon physical examination Hand , Foot and Mouth discomfort infection
mouth sore and skin rash are disease - is a mild, contagious ● Relief from
visible viral infection common in . pain
young children. Symptoms
include sores in the mouth
and a rash on the hands and
feet. Hand-foot-and-mouth
disease is most commonly
.
caused by coxsackievirus
Reference: Berman, A.,
Snyder, S., Frandsen, G.
(2015). Fundamentals of
Nursing (10th Edition).
Pearson. Chapter 48 - Urinary
Elimination,,p.g. 1175