St.

Anthony’s College
San Jose, Antique
Nursing Department
NAME: T.X.R.
AGE: 1 year old
Drs.: L.M.P
E.L.Q.
CC: fever NURSING CARE PLAN
CUES NURSING RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE: GENERAL: INDEPENDENT:
“ Medyo init Altered body Bacterial microorganisms After 8 hours of nursing  Establish rapport  To develop trust GOAL MET
Lawas na kung temperature (e.g. pulmonary intervention, the child’s and cooperation After 8 hours of
kaptan ko” as related to pathogens) enter the temperature will decrease of nursing
verbalized by bacterial airway. These from 39C to normal range  Monitor vital signs the client intervention, the
the mother invasion in the bacteria/viruses infects (36.5-37.2C) Specially  To obtain baseline child’s temperature
lungs as the lung/s resulting to Temperature data decreased from
manifested by inflammation in the lungs  Perform a tepid 39C to normal
body and causes the signs and sponge bath  Sponge bath with range (36.5-37.2C)
temperature symptoms of pneumonia warm water
higher than (e.g. temperature may be  Encourage to wear evaporates off his
OBJECTIVE: normal greater than 37.5C), loose clothes skin, thus cooling
-Febrile; tachypnea, coughs with off the patient.
39Ctemperature greenish secretions.
(36.5-37.2C)  Encourage patient to  To maintain
-Moist skin increase fluid intake. hydration status
-Tachypnea; and increase fluid
RR=52cpm (20- SOURCE: intake helps
40cpm) http://nursingcrib.com/w  If patient feels cold lessen febrility
p- provideblanket  To conserve body
content/uploads/casestud DEPENDENT: heat or to reduce
y/NCPpneumonia.pdf  Administer heat loss
Paracetamol drops
( Calpol) 1ml for T°≥
37.8 °c