UNIVERSITY OF PANGASINAN PHINMA EDUCATION NETWORK DAGUPAN CITY COLLEGE OF NURSING Nursing Care Plan Name: Daniela Visperas

Age: 7 y/o Medical Diagnosis: Assessment 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. 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. Objective: He showed consciousness. Bite marks under the lip NOTED. Nursing Diagnosis Risk for Injury Related to Seizure Activity 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. Nursing Intervention INDEPENDENT: Establish rapport. Rationales To gain trust and support from the participants. Enhances heat loss by evaporation and conduction. Increases metabolic rate and diaphoresis. Reduces body heat production. Dissipates body heat by convection. Increases comfort. Prevents herpetic lesions on the mouth. Notes progress and changes of condition. Prevents dehydration. Evaluation GOAL UNMET: The temperature increased by 0.5 degrees Celsius from an initial record of 38.2 degrees Celsius.

Provide tepid sponge bath.

Assess fluid loss and facilitate oral intake. Promote bed rest.

GOAL MET: The temperature dropped to 37.6 after the TSBprocedure. GOAL UNMET: The patients temperature increased to 39.5 degrees Celsius.

Provide cool circulating air using a fan. Assist patient into dry clothing. Provide oral hygiene. Monitor Vital Signs.

DEPENDENT: Maintain IV fluids

T=36.2 Degrees Celsius P= 84 bpm R=24 cycles

as ordered by physician. Administer antipyretic as ordered. Administer antibiotic as ordered.

Reduces fever.

Treats underlying cause.

COLLABORATIVE: Monitor hematologic test and other pertinent lab records. Discuss condition for the patient with other members of the health care team.

Indicates the presence of infection and dehydration. Ensures continuous intervention.