Nursing Care Plan

Nursing Diagnosis Inference Planning Nursing Rationale Evaluation

Intervention
Elevated body Bites from aedes Short Term Goal: Independent Nursing After 8 hours of
temperature related aegypti Action: rendering effective
to Within 8 hours of -Monitor vital sign - Serves at baseline nursing intervention
presence of effective nursing data. the goal was
infection or Viral Invasion intervention patient - Monitor intake and -To know the fluid completely met as
inflammatory body temperature output balance of the body evidenced by
response as will be decrease patient’s body
evidence by Increased WBC from 38.6- 37.5˚C - Perform TSB - To reduce body temperature
temperature 38, temperature through decreases from
flushed and the process of 38.6-37.5˚C.
Fever Long Term Goal: conduction Patient’s skin not
warm skin to -Increase oral fluid - To prevent warm to touch.
touch After period of intake dehydration and Normal complexion
hospitalization, the support circulating of the skin.
patient will be able volume.
to know the proper - Provide safe & - To provide
management of quite environment conducive place to
hyperthermia rest .Inform the
-Inform the patient patient about proper
about proper management of
management of fever
fever - To be able for the
patient to know the
Dependent nursing proper management.
intervention:
- Administer
medications as order -To elevate the
by physicians such patient’s body
as Paracetamol or temperature.
any anti –pyretic
drugs.
Risk for Fluid volume deficit r/t increased metabolic rate (fever, infection)

Diagnosis Inference Planning Implementations Rationale Evaluation

Within 8 hours INDEPENDENT: After 8 hours
Risk for Fluid Febrile states decrease
volume body fluids through nurse-patient • Assessed etiological factors To know the cause which nurse-patient
deficit r/t perspiration and
increased increase respiration. interaction & should also be treated interaction and
metabolic
rate Bite of aedes aegypti interventions, the • Assessed skin turgor and indicator of dehydration interventions,
(fever,infectio mosquito
n) carrying a virus pt. will be able to: moisture the patient was
↓
Virus goes into the • Identify • Monitored temperature Febrile states decrease able to:
circulation
↓ appropriate body fluids through • Increase fluid
Infects cells & generate
cellular response interventions perspiration and intake
↓
Initiates destruction of • Increase fluid increase respiration • Maintain
the platelet
↓ intake • Monitored I & O balance to ensure accurate picture hydration
↑ Potential for
hemorrhage • Maintain being aware of insensible of fluid status status
↓
Stimulates intense hydration status loses • Patient’s
inflammatory response
↓ • Gave tepid sponge bath TSB promotes heat loss temperature
Reset of hypothalamic
thermosta. Redness & through conduction and decreased
Heat
↓ evaporation from 38.1 C
Headache, Vomiting,
Episstaxis, Abdominal • Advised patient to increase To maintain hydration to 37.6 C
pain
oral intake status
↓
Fluid loss
COLLABORATIVE:

• Provided supplemental Replaces lost fluid

fluids (IVF # 5 D5NM 1L @

30gtts/min) as indicated.

• Paracetamol 500mg The drug may relieve fever

q4 for fever through central action

in the hypothalamic

heat-regulating center.
DRUG STUDY

Brand name/ Classification Action Indication Adverse Effect Contraindicatio Nursing

Generic name n consideration
Produce analgesia Symptomatic relief Rash, nausea, Hypersensitivity. Patients with
Acetaminophen Nonopoiod by blocking pain of pain and fever. vomiting, blood alcoholic liver
(Paracetamol) analgesics and impulses by Relief of headache, dyscrasias , anemia, disease. Impaired
anti pyretics inhibiting synthesis toothachge, back analgesic nephropathy liver or kidney
of prostaglandin in pain, , nephrotoxicity , function
the CNS or of dysmenorrheal,myal hypersensitivity
other substances gias,neuralgias, etc. reactions
that sensitize pain Analgesics and anti
receptors to pyretic for patients
stimulation. hypersensitive to
aspirin
Brand name/ Classification Action Indication Adverse Effect Contraindication Nursing
Generic name consideration
Drugs that inhibit Drugs that inhibit Assess pt for
Generic Name: Classification: Inhibits Infections of the peristalsis. Infants peristalsis. Infants previous
Ciprofloxacin Anti-infectives bacterial DNA resp. tract, middle and children, growing and children, sensitivity
gyrase thus ear,paranasal adolescents. growing reaction
Brand Name: preventing sinuses, eyes, adolescents.
Pharex replication in kidneys, urinary Pregnancy and Assess pt for
Ciprofloxacin susceptible tract lactation Pregnancy and any s/s of
bacteria lactation infection before
& during
treatment

Assess for
adverse
reactions
assess pt. &
family’s
knowledge of
drug therapy