NURSING CARE PLAN

CANDIDATE NAME: KWABENA K3 ABENA

NAME OF CLIENT: MR AKPENAMAWU WARD: A/E BED NO: 05

IN-PATIENT NO: AA4O/45 AGE: 23 SEX: M RELIGION: CHRISTIAN

OCCUPATION: STUDENT DIAGNOSIS: MALARIA

PHYSICIAN/SURGEON: DR ELINOR OPERATION: NOT YET

DATE OF ADMISSION: 09/07/2023 DATE OF DISCHARGE: NOT YET

 CARE PLAN CONT’D
PATIENT’S PROBLEM:
Patient complained of having elevated body temperature

ALLERGIES
No known allergies

PATIENT’S STRENGTH
Patient can tolerate antipyretics
Patient is able to identify the rate of the hotness in the body
 CARE PLAN CONT’D
ROUTINE CARE
T.P.R.: Monitored every 1 hourly
B.P.: Monitored every 1 hour
DIET: Avoid spicy or fatty diet
FLUIDS: Liberal fluids
INTAKE & OUTPUT: Monitored and balanced in 24 hours
ORAL HYGIENE: Unassisted, twice daily with toothbrush and paste
BATH: Once daily unassisted bathroom bath
URINE TESTING: Not monitored
BODY WEIGHT: Once on admission(60kg)
ACTIVITY: Ambulant
 CARE PLAN CONT’D
DATE & TIME
09/07/2023 @ 7:30am

NURSING DIAGNOSIS
Hyperthermia related to parasitic infection in the blood(39.1°C)

OBJECTIVE/OUTCOME CRITERIA
• Patient’s body temperature will become normal within 2 hours as
evidenced by;
i) Patient verbalizing a decrease in hotness(warmness) of his body
ii) Patient’s temperature will decrease to normal range(36.2°C-37.2°C).
 CARE PLAN CONT’D
NURSING ORDERS
1) Monitor and record vital signs
2) Tepid sponge patient.
3) Help patient assume a position where he is
comfortable.
4) Administer prescribed antipyretics.
5) Encourage windows to be opened and serve cold
drinks.
6) Document all nursing orders
 CARE PLAN CONT’D
NURSING INTERVENTIONS
1) Patient vitals was checked and recorded as follows;
T=36.6°C, PR=80bmp, B.P=110/60mmHg, R=19cpm.
2) Patient was tepid sponged.
3) Patient was helped to assume a position where he is
comfortable(lateral position).
4) Patient was administered prescribed
antipyretics(Ibuprofen 400mg TID 5/7).
5) Windows were opened and cold drinks served.
6) All nursing orders were documented.
 CARE PLAN CONT’D
EVALUATION
Goal fully met at 9:30am as evidenced by;
i. Patient verbalized a decrease in his
hotness(warmness) of his body.
ii. Patient’s temperature decreased to normal
range(36.2°C-37.2°C).

THANK YOU.