UNIVERSITY OF PANGASINAN – PANGASINAN – PHINMA PHINMA EDUCATION NETWORK DAGUPAN CITY COLLEGE OF NURSING Nursing Care Plan Name: Daniela Visperas Age: 7 y/o Medical Diagnosis: Assessment
Nursing Diagnosis
Patient Nerio Velasquez, aged 2years old, was admitted at 5:00 pm in September 13, 2011 with chief complaints of convulsions that occurred twice and fever for 5 days.
Risk for Injury Related to Seizure Activity
The mother said, “Kinombulsyon siya ng dalawang beses, on and off ang fever nang dalawang araw tapos nawala, the following day bumalik ulit. At tsaka tumaas sa 40 Degrees Celsius kaya sinugod na naming.” naming.” Objective: He showed consciousness. Bite marks under the lip – lip – NOTED. NOTED.
Nursing Analysis
Goal and Outcomes After three hours of administering antipyretic, the temperature will decrease by one Celsius. After applying TSB, the temperature will decrease by at least one Celsius.
After three hours of giving her oral antipyretic, the temperature must fall within the normal range @ 37 degrees Celsius.
Promote bed rest.
Provide cool circulating air using a fan. Assist patient into dry clothing. Provide oral hygiene.
Monitor Vital Signs.
DEPENDENT: Maintain IV fluids
Evaluation
GOAL UNMET: The To gain trust temperature increased and support by 0.5 degrees Celsius from the from an initial record of participants. 38.2 degrees Celsius. Enhances heat loss by evaporation and GOAL MET: The conduction. temperature dropped to Increases 37.6 after the TSBmetabolic rate and diaphoresis. procedure. Reduces body heat production. GOAL UNMET: The Dissipates body patient’s temperature increased to 39.5 heat by degrees Celsius. convection. Increases comfort. Prevents herpetic lesions on the mouth. Notes progress and changes of condition. Prevents dehydration.
T=36.2 Degrees Celsius P= 84 bpm R=24 cycles
as ordered by physician. Administer antipyretic as ordered. Administer antibiotic as ordered.
COLLABORATIVE: Monitor hematologic test and other pertinent lab records. Discuss condition for the patient with other members of the health care team.
Reduces fever.
Treats underlying cause.
Indicates the presence of infection and dehydration. Ensures continuous intervention.
