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SAN PEDRO COLLEGE

12 C. Guzman Street, Davao City

NURSING CARE PLAN

Patient: BASE, MICHELLE PULGA_ Age: _17 AOG: 34 weeks and 4 days_ Room/Bed No.: _DR4-2_ Chief Complaint: _labor pain and fever_ Civil Status: _Single_ Religion: _Roman Catholic_ Attending Physician: _Dr. Sonia Rose Valles_ Diagnosis: ____3 days PTA pt had nonproductive cough & nasal congestion_

DATE & TIME


S E P T. 12, 2 0 1 2 7:30 AM

CUES
Subjective: Lain ang ako paminaw kay init sa sud pero tugnaw ang akong lawaspaki-off daw sir sa air-con, as verbalized by the patient. Objective: restlessness irritability sweating shivering skin warm to touch

NEED
N U T R I T I O N A L A N D M E T A B

NURSING DIAGNOSIS

OBJECTIVE OF CARE

NURSING INTERVENTION

EVALUATION

Hyperthermia r/t compensatory mechanism to infection of urinary tract as manifested by temperature of 37.9C Hyperthermia is the most common sign of a systemic response to infection, and likely caused by endogenous pyrogens released by leukocytes. This happens to provide the body with greater ability to fight infection. During this process, nonspecific symptoms develop, including malaise, loss of appetite, aching, and weakness.

That within my1 span of care, my patient will be able to resume and maintain the normal range of body temperature as evidenced by: a. Decrease of body temperature b. Verbalization of comfort c. participation in activities within her capabilities d. Patient maintains normal limits of VS.

1. Establish rapport. September 12, 2012 To gain patients trust and cooperation 3:00 PM and alleviate anxiety. 2. Monitor vital signs. GOAL PARTIALLY MET To provide an accurate record of the As evidenced by: body temperature. a. Decrease of 3. Provide tepid sponge bath (if not temperature from contraindicated). 37.9C to 36.8C TSB helps in lowering the temperature b. Verbalization of through evaporation and conduction. comfort, okay-okay na 4. Remove excess clothing and covers. akong pamati, dili To promote clear flow of air in the naman haud ganina. patients area. One way of promoting c. Participation of heat loss. activities like VS, 5. Increase oral fluid intake. changing of linens, and To replenish fluid loss, support etc. circulating volume and tissue perfusion. d. VS taken. BP-100/70; 6. Maintain bedrest. PR-95; CR-103; RR To reduce metabolic demands and 20. oxygen consumption. 7. Record all sources of fluid loss such

loss of appetite yellow urine noted. (+) UTI for 30 weeks VS as of 2pm Temp-37.9C; BP100/70; PR-120; CR124; RR-22. Lab Results: WBC-13,700 cells per cubic millimeter of blood. Drugs Taken: -Paracetamol 500 g 1 tab q4 PRN -Cefalexin 500 mg TID for 7 days. -Oxymetazoline HCl (Drixine) nasal spray, 2 spray in each nostril BID.

O L I C P A T T E R N Bibliography: Smeltzer, Suzanne C. et al. Medical Surgical Nursing Volume 1, 10th Edition. Lippincott Stoppler, Mellisa PhD. Focus on Pathophysiology. Lippincott

as urine, vomiting, and diarrhea. To monitor or potentiates fluids and electrolyte loses. 8. Provide supplemental oxygen. To offset increased oxygen demands and consumption 9. Let the patient use a blanket especially to cover her extremities. To reduce shivering. 10. Adjust and monitor environmental factors like room temperature and bed linens as indicated. Room temperature may be accustomed to near normal body temperature and blankets and linens may be adjusted as indicated to regulate temperature of client. 11.Educate client of signs and symptoms of hyperthermia and help him identify factors related to occurrence of fever; discuss importance of increased fluid intake to avoid dehydration. Providing health teachings to client could help client cope with disease condition and could help prevent further complications of hyperthermia. 12. Administer antipyretics as prescribed by the physician. Antipyretics acts on the hypothalamus, reducing hyperthermia.

Bibliography: Doenges, Marilynn E. (2010). Nurses Pocket Guide (12th Edition). Davis Plus. Moorhouse, Mary Frances (2009). Nursing Care Plans. Guidelines for Planning and Documenting Patient Care. F.A. Davis.

Name: _____________________________________ Section: _____________ Group No.: __________