PLANNING

A. NURSING CARE PLAN

Date/Shift

Assessment

01/05/16/7 Subjective:
> Dapat jud
-3/9:00
nako imaintain
ug
inom
a.m
akong
mga
tambal maam
aron
mayo
akong
sakit
unya
mag
paycheck-up
jud
ko
kanunay
sa
akong doctor
aron
mamonitor
nako
akong
sakit
>
Unsa
akong
mga
dapat buhaton
maam aron
dili
ni

Needs
S
E
L
F
E
S
T
E
E
M
N
E
E
D

Nursing

Objective of

Diagnosis
Readiness
for
enhanced
therapeutic
manageme
nt related
to
eagerness
to achieve
optimum
level of
wellness
as
evidenced
by
eagerness
to follow
treatment
regimen.

care
Within 8 hours
implementation
of
nursing
intervention will
be able to:

Rationale:
A pattern

Goal:
Remain
free
of
preventable
complications/pr
ogression
of
illness
and
sequelae.

Nursing Intervention
Independent:
*Verified
level
of
understanding
of
therapeutic regimen.
Noted specific health
goals.
Rationale: To provide
opportunity to asure
accuracy
and
completeness
of
knowledge base for
future learning.

Evaluation
GOAL MET
Within 8 hours was able
to:
*Identified and used
additional resources as
appropriate.
*Demonstrated
proactive management
*Assumed responsibility

*Identified
steps
Objectives:
necessary to reach for managing treatment
*Identify/use
desired health goals.
regimen.
additional
R: To understand the
resources
as process
enhances
appropriate
commitment and the
*Demonstrate
likelihood of achieving
proactive
the goals.
management by
39

mograbe
akong sakit?,
as verbalized
Objective:
>: The patient
shows
positivity
towards
the
treatment.
>: There are
no unexpected
acceleration of
illness
symptoms

of
regulating
and
integrating
into daily
living
program
(s) for
treatment
of illness
and its
sequalae
that is
sufficient
for meeting
healhrelated
goals and
can be
strengthen
ed

anticipating and
planning
for
eventualities of
condition/
potential
complications.
*
Assume
responsibility for
managing
treatment
regimen

*Accepted the clients

evaluation
of
own
strengths/ limitations.
R: To promote sense of
self-esteem
and
confidence to continue
efforts.
*Acknowledged
individual
efforts/
capabilities to reinforce
environment
toward
attainment of desired
outcomes.
R: To provide positive
reinforcement
encouraging continued
progress
toward
desired goals.
Dependent:
*Encouraged to follow
the time of medication
intake as prescribed by
the physician.
R:
To
avoid
complications
and
disease progression.

40

Collaborative:
*Encouraged
the
significant others to
assist,
guide
and
support the patient in
the treatment regimen.
R: To motivate
in

achieving

optimum level of
wellness.

41

Date

Assessment

Need

Nursing

Diagnosis
Physiologica Hyperthermia

Objective

Nursing

Evaluation

of Care
After 4

Intervention
Independent:

After 4 hours of

r/t

hours of

1. Monitored

appropriate nursing

January

Subjective:

5, 2016

Lain na jud ako

7/3shift

paminaw sa akong

inflammatory

appropriate

Vital Signs

intervention, GOAL IS

8:00am

lawas, init akong

process and

nursing

R: V/S

MET

paminaw as

infection as

intervention

provide

verbalized.

manifested by

the patient

accurate

temperature is

increased

will be able

indication of

within normal

body

to manifest

core

range ; 37.5

Flushed skin

temperature

the

temperature.

particularly on

R:

following:

2.

degree Celsius
Skin is

Objective:

l Need

Patients

42

face and neck

Skin very

warm to touch
Appears
weak
Increased
body
temperature
above normal
range
VS :
T: 39.3
BP:140/80

mmhg
PR: 90 bpm
RR: 21 cpm
Lab results:
Pus Cells: 0-

infection

U
L

Hypothalamus

1.

Encouraged

moderately cool

Temperature to Increase

to touch with

will

Oral Fluid

decrease

Intake

less flushness
Manifested

absence of

Body

from 39.3 to

R: To support

generate

37.5-37

circulation

arachidonic

degrees

and tissue

behaviors to

acid/prostagla

Celsius

perfusion

monitor and

ndin

2. Skin is

3. Promoted

promote

moderately

Bed rest

actively

cool to

R: To reduce

normothermia
The patient

mediated the

touch and

metabolic

central

less

demands/

response

flushness

oxygen

3.

consumption

Demonstrat

4. Provided

e behaviors

Tepid

elevated

diaphoresis
Demonstrated

together with her

significant others
understands
causes of
disease and is
ready to practice

43

hypothalamic

to monitor

set point

and promote R: Helps in

interventions to

normothermi lowering

prevent

Body initiate

body

hyperthermia

heat and

4. Identify

temperature

conservation

importance

5. Remove

including

of treatment

excess

vasoconstricti

as well as

clothing and

on

signs and

covers

piloerection

symptoms

R:

requiring

Decreases

further

warmth and

intervention

increase

evaporative

fever

Sponge Bath

specific

cooling.
Dependent:
6. Provided
44

antipyretic
meds as
ordered by
the physician
R: These
drugs inhibit
the
prostaglandi
n that serve
as mediators
of pain and
fever.
Collaborative
:
7. Educated
and advised
support
45

system
(family/
relatives)
R: Help in
knowing
what to do in
case
patients
temperature
increases
8. Monitor
Laboratory
Test
R: Serves as
basis of
clients
condition
46

whether its
normal or
has
abnormal
results.

47