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NURSING CARE PLAN

ANNELORE M. ARCAY

ASSESSMENT Subjective: Ang taas ng lagnat niya, inabot pa ng 40C kagabi. As verbalized by the patients mother.

DIAGNOSIS Hyperthermia related to illness as manifested by warm, flushed skin.

PLANNING Short Term: After 4 hours of appropriate nursing interventions, the patients temperature will decrease from 38.5 C to 37.5 C.

INTERVENTIONS 1. ) Assessed vital signs and notified physician of significant changes.

RATIONALE

EVALUATION

2. ) Rendered tepid sponge bath and removed excess clothing and covers. 3.) Provided antipyretic medications as ordered.

Vital signs provide more accurate indication of core Short term: temperature. After 4 hours of nursing interventions, These decrease warmth the patients and increase evaporate temperature has cooling. decreased from 38.5 to 37.5 C. Temperatures above 40C for extended periods can cause cellular damage, delirium and convulsions. Goal was met.

Objective: - Body temperature above normal range (38.5 C, axillary) - RR=25 bpm - PR=92 bpm - Warm, flushed skin - Facial grimacing, crying Background of the Study: Hyperthermia is a sustained temperature above the normal variance; usually greater than 39C. (Mosby Nursing Care Plans, pp. 9294)

4.) Provided ample fluids by mouth.

If patient is dehydrated, fluid loss contributes to fever. To restore energy.

5.) Promote adequate sleep and rest.

NURSING CARE PLAN


ANNELORE M. ARCAY ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS 1.) Assessed airway patency. 2.) Auscultate lungs for presence of normal or adventitious breath sounds such as: decreased or absent breath sounds, wheezing and coarse sounds 3.) Assessed respirations; noted quality, rate, pattern, depth, flaring of nostrils, dyspnea on exertion, evidence of splinting, use of accessory ,muscles, and position for breathing. 4.) Assessed changes in vital signs and temperature. 5.) Assessed cough for effectiveness and productivity. 6.) Administer medications as expectorantss and mucolytics. RATIONALE Maintaining the airway is always the first priority. These may indicate presence of mucus plug, increasing airway resistance, presence of fluid along larger airways. EVALUATION

Subjective: Isang linggo na yung ubo niya pero di nya malabas yung plema. As verbalized by the patients mother. Ineffective Airway Clearance related to retained secretions as manifested by dry cough

Short term: For 4 hours of nursing interventions, the patient will maintain a patent airway.

Short term: After 4 hours of nursing intervention, the patient has maintained a patent airway. .

Objective: -dry, unproductive cough -restless -RR= 38 bpm - nebulization q4h (NSS) -has a history of Pneumonia (diagnosed July, 2013) -presence of crackles when auscultated -dry skin

Long term: After 1 day of nursing interventions, the patient will be able to expectorate all retained secretions.

Abnormality indicates respiratory compromise.

Background of the Study: Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway. (Nurses Pocket Guide 10th edition pp. 74-76)

Tachycardia may be related to increased work of breathing. Consider possible causes for ineffective cough. To loosen retained secretions.

NURSING CARE PLAN


ANNELORE M. ARCAY

7.) Assisted on nebulizer treatment. Nebulization done as per doctors order every 4 hours. 8.) Encouraged client to increase fluid intake.

Relaxes bronchial and smooth muscle by acting on bet-adrenergic receptors.

Hydration helps the viscosity of secretions thus, facilitating expectorations, Chest physiotherapy helps to aid release of secretions.

9.) Chesttapping performed after nebulization.

NURSING CARE PLAN


ANNELORE M. ARCAY

NURSING CARE PLAN


ANNELORE M. ARCAY Assessment Subjective: May mga pigsa sya sa ulo. As verbalized by the patients mother. Diagnosis Impaired skin integrity related to alterations in skin appearance as manifested by presence of boils in the scalp. Planning Short term: After 4 hours of nursing intervention, the patient will reduce scratching of scalp. Interventions 1.) Assessed skin. Noted color, turgor, and sensation. Described and measured wounds and observed changes. 2.) Demonstrated good skin hygiene, e.g., wash thoroughly, pat dry carefully and apply Betadine on boils. Rationale Establishes comparative baseline providing opportunity for timely intervention. Evaluation Short term: Goal was partially met.

Objective: Long term: -presence of boils in the scalp -frequent scratching -disruption of skin surface Background of the Study: Altered epidermis and/or dermis (The Integumentary system is the largest multifunctional organ of the body). (Nurses Pocket Guide 10th edition pp. 487-492) After 4 days of nursing intervention, the patients boils will be diminished.

Maintaining clean, dry skin provides a barrier to infection. Patting skin dry instead of rubbing reduces risk of dermal trauma to fragile skin. Improved nutrition and hydration will improve skin condition.

3.) Emphasized importance of adequate nutrition and fluid intake. 4.) Kept the affected area clean and dry

To prevent further invasion of microorganism.