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vincent-quitoriano
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This is an ncp for fever
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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
Subjective:
“Mataas pa rin ang lagnat
nya hanggang ngayon”as
verbalized by the patient’s
mother.
Objective:
Flushed skin
Skin is warm to touch
Temp: 38.2*C
PR: 109
RR: 34
Hyperthermia related to
positive bacterial infection
as manifested by flushed
and warm to touch skin.
Short term: within 1 hour of
nursing intervention the
patient’s elevated
temperature of 36.2 will
lessen to 37.4 degree
Celsius.
Long term: within 3
consecutive days of nursing
intervention, the patient’s
body temperature will
return to its normal range.
Independent:
Established rapport
to mother to gain
trust and
cooperation.
Promote surface
cooling by means of
undressing ( heat
loss by radiation and
conduction)
Demonstrate on how
to do a proper tepid
sponge bath using
wet and dry cloth.
Provide nutritious
diet to meet increase
metabolic demands
Dependent: Administer
antipyretic as ordered.
After all the nursing
intervention the clients body
temp subsided within the
normal range.
Nursing Care Plan 29
Nursing Care Plan 30
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
Subjective:
“Umiiyak yan kapag
nahahawakan yung batok
nya saka nung may ginawa
yung doctor nya” as
verbalized by the mother.
Objective:
Facial grimace
Irritable
(+) Brudzinski’s sign
(+)Kernigs sign
Acute pain related to
meningeal infection with
spasm of extensor muscle
(neck, shoulder and back) as
manifested by positive
kernig’s and brudzinski’s
sign.
Within 3 hours of nursing
intervention the patient’s
pain from 8 will reduce to 4
using the facial pain rating
scale.
Independent:
Use pain rating scale
appropriate to its age
Assess for neurologic
exam and vital signs
Position on the side
with head gently
supported in
extension
Promote rest in the
room by keeping
stimulation and the
room to minimum
Institute respiratory
isolation
Monitor and record
carefully intake and
output.
After 3 hours of nursing
intervention there is no sign
of facial grimace and
irritability in the patient.
Nursing Care Plan 31
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION Rationale EVALUATION
Objective:
Facial grimace
Irritable
(+) Brudzinski’s
sign
(+)Kernigs sign
Impaired Social
Interaction related to
decreased level of
consciousness,
hospitalization, and
isolation
After 8 hours of
nursing intervention
The child’s social
interaction will be
Near normal despite
isolation.
■ Educate parents and
other visitors
to use proper infection
control
Techniques.
■ Encourage parents to
help with
daily activities such as
feeding and
Bathing.
■ Have age-appropriate
games and
Toys in the room. Play
■ Family members
help fulfil the
emotional and social
needs of the ill
And contagious
child.
■ Parental
involvement in the
child’s
care provides the
child with a sense
of security and
emotional
wellbeing. Parents
have a sense of
control and a feeling
that they are
doing something to
enhance the
Child’s recovery.
■ Providing the
child with toys and
games as well as
The child’s social and
developmental
needs are met by family
members
despite the child’s
illness and
Hospitalization.
with the
Child. When the child is
feeling
better, encourage
watching
television/videotape or
listening to
The radio/audiotape.
■ Arrange for hearing
assessment
prior to discharge
sensory
stimulation helps the
child achieve
A sense of well-
being.
■ Hearing loss is a
common
Complication. Early
intervention is
needed to promote g
32
Nursing Care Plan 33
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION Rationale EVALUATION
Subjective: Risk for ineffective After 8 hrs. of nursing Independent: After 8 hrs. Of
“masakit ang ulo ko as
verbalized by the
patient.
Objective:
Restlessness
Change in motor or
sensory responses
Difficulty in
swallowing
skin discoloration
decrease motor
response
cerebral Tissue
perfusion related to
cerebraledema
interventions, the client
will demonstrate stable
Vital signs and absence
of signs of intracranial
pressure.
Demonstrate
behaviours/lifestyle
changes to improve
circulation.
Decrease extraneous stimuli
and provide comfort
measures like back massage,
quiet environment, soft voice.
Instruct patient to avoid or
limit coughing, Vomiting,
straining at defecation,
bearing down as possible.
Elevate head and maintain
head/neck in midline neutral
position
Prevention:
Observe for seizure activity
and protect patient from
injury.
Maintain head or neck in
midline or neutral position,
support with small towel rolls
R: Provides calming
effect, reduces Adverse
physiological response
and promotes rest to
maintain or lower
intracranial pressure.
R: These activities
increase thoracic and
intra-abdominal
pressure which can
increase intracranial
pressure.
R: to promote
circulation/venous
drainage
R: Seizure can occur as
result of cerebral
irritation, hypoxia or
increase intracranial
pressure.
R: Turning head to one
nursing
interventions, the
client demonstrated
stable Vital signs
and absence of
signs of intracranial
pressure.
and pillows:
Provide rest periods between
care activities and limit
duration of procedures.
Curative:
Administer supplemental
oxygen as indicated
Investigate reports of pain out
of proportion to degree of
injury:
Administer
medications(antihypertensive,
diuretics)
Rehabilitation:
side compresses the
jugular veins and
inhibits cerebral venous
drainage, thereby
increasing intracranial
pressure.
R: Continual activity
can increase intracranial
pressure
R: Reduces hypoxemia.
R: May reflect
developing
compartment syndrome
R: used to decrease
edema.
Encourage quiet, restful
atmosphere:
Limit daily activities and
caution client to avoid
strenuous activities
R: Conserves energy
and lower oxygen
demand
R: over exertion may
cause dizziness
35
Nursing Care Plan 36
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
Subjective
“Dalawang araw na sya
nagsususka” as verbalized by
Altered nutrition: less than
body requirements related to
restricted intake; nausea, and
The child’s weight will be
stable and appropriate for age,
normal serum protein, moist
► Weight the child daily on
the same scale and record on
growth chart.
The child shows normal
growth and development,
nausea and vomiting
the mother.
Objective:
Weak in appearance
Irritable
(+) Nausea and vomiting
Temp: 37.4
RR 40
PR 105
vomiting, swallowing and
chewing difficulty.
mucous membrane and
adequate urine output.
Nausea and vomiting
controlled.
► Monitor skin turgor,
mucous membrane and urine
output.
► Position the infant or child
upright after feeding.
► Provide a flexible feeding
schedule with small feedings
of favourite foods.
► Minimise handling around
feeding times.
► Assist the child with
chewing with the child’s chin
and jaw in the nurse’s hand, if
swallowing is impaired & if so
feed by NG Tube.
► Consult dietician.
► Assess level of
consciousness before giving
liquids.
under control, adequate
daily caloric intake and
proper hydration
verbalized by the S.O.
37