z

NURSING
CARE
PLAN
Fontanilla, Ericka

Casballedo, Keith
z
ASSESMENT
z
Subjective
“ masakit po ang dibdib ko “ as verbalized
by the patient

“ pabalik- balik po ang lagnat ko, 2 days

na “ as verbalized by the patient
z
OBJECTIVE

 Use of accessory muscles

 Dyspnea

 Vital signs taken as:

 Temperature:39 °c
 Pulse rate: 80bpm
 Blood pressure: 120/80
z
DIAGNOSIS
z

Altered body temperature related to

bacterial invasion in the lungs as
manifested by body temperature
higher than normal
z
PLANNING
z
STO

After 4 hours of nursing intervention, the

patient’s temperature will decrease from 39
°c to normal range ( 36.5 °c to 37.2 °c )
z
INTERVENTION
z INDEPENDENT
INTERVENTION RATIONALE

Monitor patient’s temperature every To determine if the patient’s

hourly temperature is above the normal
range

Encourage the patient to rest Allows the patient to recuperate

physical strength

Encourage the patient to increase To maintain hydration status and

fluid intake increase fluid intake

Encourage the patient’s S.O to do Sponge bath with warm water

tepid sponge bath evaporates off his skin, thus cooling
off the patient

If patient is lying in bed, frequent This may help to reduce discomfort

change linen and position ( semi
fowler )
z INDEPENDENT
INTERVENTION RATIONALE

Frequently change the patient’s Because of increase in sweating

clothing

If patient’s feel cold, provide a To conserve body heat or to reduce

blanket heat loss

Apply an ice pack to armpit or Ice pack will help the patient’s body
inguinal area to reach the normal range of
temperature

Educate the patient about the do’s This helps them to better understand
and don’ts of his condition their condition and situation. And
involves and engages them in their
care and treatment plans
z DEPENDENT
INTERVENTION RATIONALE

Acetaminophen elixir 120mg every 4 Aids in reduction of bronchospasm

hours prn for temperature as ordered and mobilization of secretions

Giving paracetamol to reduce body To regulate body temperature

temperature as ordered

Administer antibiotics and monitor Prevents the spread of disease and

it’s side effect as ordered reduces serious complications of
disease

Provide supplemental fluids as Fluids are required to replace losses

ordered and aid in mobilization

Administering IV fluid as ordered Prevents dehydration

z
EVALUATION
z

After 4 hours of nursing and collaborative

intervention, the patient’s body
temperature was able to go back to normal
range of temperature

GOAL MET