Name: Karen Paula G.

Nabong Year & section: BSN 4D Group3

VII NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSIS
Increased body temperature related to disease process

PLANNING

IMPLEMENTATION

RATIONALE

EVALUATION

SUBJECTIVE DATA:  Mainit ang pakiramdam ko, as verbalized by the patient. OBJECTIVE DATA:  weak in appearance  warm to touch  Vital signs: *Temp- 39.3C * PR- 74 bpm * RR- 21 cpm * BP-100/60 mmHg  febrile

*Short Term Goal* -After 1-2 hours of nursing intervention, the patient will be able to decrease body temperature to 38.0 C *Long Term Goal* -After after 4-8 hours of nursing intervention, the patient will be able to decrease temperature within normal limits

INDEPENDENT: 1.) Provided a quiet & cool environment 2.) Tepid sponge bath done continuously 1.) To help in decreasing surface body temperature 2.) To promote heat loss by evaporation and conduction 3.)To provide safety and support

*Short Term Goal* -After 1-2 hours of nursing intervention, the patient was able to decrease body temperature to 38.0 C, Goal met. *Long Term Goal*

3.) Assisted patient to comfortable position and raised side rails 4.) Promoted adequate rest periods

4.) To reduce metabolic demands and prevents fatigue 5.) To prevent dehydration

-After after 4-8 hours of nursing intervention, the patient was able to decrease temperature within normal limits, Goal met.

5.) Encouraged to increase oral fluid intake DEPENDENT: 1.) Administer antipyretics like paracetamol as ordered

1.) To reduce body temperature to normal limits

Reference: Nurses Pocket Guide, Diagnosis, Prioritized Intervention and Rationales th 11 Ed., Marilyn E. Doenges, Mary Frances Moorehouse, Alice Murr, pp. 383-387

Name: Karen Paula G. Nabong Year & section: BSN 4D Group3

VII NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSIS
Decreased cardiac output related to illness

PLANNING

IMPLEMENTATION

RATIONALE

EVALUATION

SUBJECTIVE DATA: OBJECTIVE DATA:  weak in appearance  on oxygen inhalation via nasal cannula at 2-3 LPM  on cardiac monitor  Vital signs: *Temp- 36.5 C * PR- 52 bpm * RR- 20 cpm * BP-130/80 mmHg  with bradycardia

*Short Term Goal* -After 2-4 hours of nursing intervention, the patient will be able to identify ways to reduce the workload of the heart

INDEPENDENT: 1.) Provided a quiet & cool environment 1.) To promote adequate sleep & rest periods 2.) To prevent fatigue

*Short Term Goal* -After 2-4 hours of nursing intervention, the patient was able to identify ways to reduce the workload of the heart, Goal met.

2.) Assisted on performing self-care activities of patient 3.) Assisted patient to comfortable position and raised side rails 4.) Emphasized on bed rest

3.)To provide safety and support

*Long Term Goal* -After after 1-2 days of nursing intervention, the patient will be able to participate in activities to reduce the workload of the heart 5.) Encouraged to avoid straining activities (e.g., when defecating, lifting heavy objects, etc.) 6.) Advised about scheduling of activities

4.) To reduce workload of the heart 5.) To prevent stimulating the valsalva response

*Long Term Goal* -After after 1-2 days of nursing intervention, the patient was able to participate in activities to reduce the workload of the heart, Goal met.

6.) To promote adequate rest periods

Name: Karen Paula G. Nabong Year & section: BSN 4D Group3

7.) Instructed to avoid 4 Es: excessive Exercise, heightened Emotions, over Eating, & Extreme temperature/weather 8.) Encouraged about cessation of smoking

7.) To prevent putting stress on the heart

8.) To increase oxygen supply to the heart and body

DEPENDENT: 1.) Administer

Reference: Nurses Pocket Guide, Diagnosis, Prioritized Intervention and Rationales th 11 Ed., Marilyn E. Doenges, Mary Frances Moorehouse, Alice Murr, pp. 145-151

Name: Karen Paula G. Nabong Year & section: BSN 4D Group3

Name of Drug Generic Name: Atorvastatin calcium Brand name: Lipitor Classification: Antihyperlipidemic HMG-CoA reductase inhibitor Dosage, Route, Frequency 40 mg/tablet per orem once a day preferably in the evening y Indication Adjunct to diet in treatment of elevated total cholesterol, serum triglycerides, and LDL cholesterol Reduction of risk of MI & stroke in patients with type 2 diabetes and in those with multiple risk factor of CAD Reduction of risk of MI, stroke, heart failure, & angina in patient with clinically evident CAD Contraindication y Contraindicated in patients with allergy to atorvastatin, fungal byproducts, active hepatic disease or unexplained & persistent elevation of transaminase levels, pregnancy, lactation Use cautiously in patients with impaired endocrine function, history of liver disease, alcoholism Side effects CNS: headache GI: flatulence, abdominal pain, cramps, constipation, nausea, liver failure RESPIRATORY: sinusitis, pharyngitis OTHERS: rhabdomyolysis with acute renal failure, arthralgia, myalgia, infections Nursing Responsibilities y Take drug once a day, at about same time each day, preferably in the evening; may be taken with food. Advise patient not to drink grapefruit juice while taking this drug Tell patient to arrange to have periodic blood test for long term-use Advice patient to alert any health care provider that you are taking this drug; it will need to be discontinued if acute injury or illness occurs. Instruct to report muscle pain, weakness, tenderness; malaise, fever; changes in color of urine and stool; swelling.

Name: Karen Paula G. Nabong Year & section: BSN 4D Group3

Name of Drug

Dosage, Route, Frequency 2 tablets per orem once a day at bedtime y

Indication

Contraindication

Side effects

Nursing Responsibilities

Generic Name: Senna Brand name: Senokot Classification: Stimulant

Short-term relief of constipation To prevent straining To evacuate bowel for diagnostic procedures To remove ingested poison from GI tract

Contraindicated in patients hypersensitive to drug or its ingredients.

GI: excessive bowel activity, perianal irritation, abdominal cramps, weakness, dizziness, cathartic dependence

Instruct patient that it is use as a temporary measure Instruct patient to swallow tablets whole Advised not to take this drug within one hour of any other drugs Instruct to report sweating, flushing, muscle cramps, and excessive thirst

y y As adjunct in antihelminthic therapy