Assessment Nursing Scientific Planning Nursing intervention Rationale Evaluation

Diagnosis explanation

Subjective: Increase body Underlying Following 2 *Determined present *To indentify After the 2 hours of
“Mainit ata ang temperature condition hours of illness that contributes causative agent. nursing intervention the
pakiramdam related to (Nephrolithiasis nursing to the condition patient was able to have a
ko.” alteration in the ) causes an intervention, (Nephrolithiasis) body temperature of 37.0
hypothalamic inflammatory the client will *The extremely old that is within normal
Objective: heat regulating response due to have a body *Noted patient’s age (58 and young are range.
*teary eyed center as infection temperature y.o.). more susceptible to “Umayos na ang
*warm to touch manifested by therefore within normal temperature pakiramdam ko.”
*flushed skin flushed skin, making the range. changes.
*temp: 38.2 *C warm to touch hypothalamus
and teary-eyed increase the *To lower down
appearance. body *Provided tepid sponge body temperature
temperature to bath every 30 mins. to normal range.
fight off the
infection. *To assess the
(Kozier) *Monitored body effectiveness of the
temperature every 30 intervention.
mins.
*To promote
wellness.
*Instructed the patient’s
caregiver in measures
that prevents high body
temperature such as
tepid sponge bath,
changing of clothes and
drinking cold water.
*To lower body
*Medications given as temperature
prescribed. (source: NANDA
(Paracetamol) 11TH edition)