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NURSING CARE PROCESS

ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION


DIAGNOSIS EXPLANATION

Subjective Elevated body Invasion of infectious After 30  Determined  Identification and The client’s
cues: temperature agent (Virus) triggers minutes of precipitating management of temperature decreased
“Nilalagnat above normal the immune system to nursing factors. underlying cause are as evidenced by :
na naman siya.” related to sent neutrophil and interventions, essential to recovery.  temperature
Objective Cues: respiratory tract kill offending the client will (Nursing Care Plan, =36.4 ºC
infection. organism through be able to 6th edition,
>Hyperthermic- inflammatory decrease body Gulanick/Myers pg.  warm to touch
38.3ºC response that leads to temperature. 105)
elevation of body
>Tachycardic- temperature.  Obtained age and  Extremes of age and
190 beats per weight. weight increase the
minute risk for inability to
(Medical-Surgical
control body
Nursing
>Tachypneic- 58 temperature.
Pathophysiological
breaths per (Nursing Care Plan,
Concept, pge 496)
minute 6th edition,
Gulanick/Myers pg.
>hot to touch 105)
>Flushed cheeks  Monitored axillary  Provide information
temperature. about the
effectiveness of care.
>result of CXR, (Pediatric Nursing
basal pneumonia, Care Plans, 3rd
left edition,Karla L.
Luxner,RNC,ND,pg.
>nasal flaring 453)

>irritability  Room temp or every


 Monitored number of blankets
>with ongoing IV environment should be altered to
fluid D5IMB temperature; limit / maintain near normal
regulated at 34 – add bed linens as body temperature.
35 gtts per indicated. (Pediatric Nursing
minute Care Plans, 3rd
edition,Karla L.
Luxner,RNC,ND,pg.
453)

 May reduce fever.


(Pediatric Nursing
Care Plans, 3rd
edition,Karla L.
 Provided Tepid Luxner,RNC,ND,pg.
Sponge Baths, 453)
avoid use of
alcohol.  Helps reduce skin
temperature.
(Pediatric Nursing
Care Plans, 3rd
edition,Karla L.
 Removed extra Luxner,RNC,ND,pg.
clothing and 453)
covered the child
may have on after  Information helps
the antipyeretic prevent adverse
has taken effect. effects from medicine.
(Pediatric Nursing
Care Plans, 3rd
edition,Karla L.
 Taught the mother Luxner,RNC,ND,pg.
about possible 454)
side effects of anti-
pyeretic medicine  Empowers parents to
care for their child.
(Pediatric Nursing
Care Plans, 3rd
edition,Karla L.
Luxner,RNC,ND,pg.
454)

 Provided the  Families need to


mother with learn how to prevent
instructions about future episodes of
management of hyperthermia.
childhood fever. (Nursing Care Plan,
6th edition,
Gulanick/Myers pg.
106)

 Discussed to the
mother the
precipitating
factors and  Additional fluids help
prevent elevated
preventive temperature
measures, associated with
including dehydration.
maintenance of (Pediatric Nursing
adequate fluid Care Plans, 3rd
intake, change in edition,Karla L.
environment, Luxner,RNC,ND,pg.
taking medications 454)
as prescribed.
 Decreases fever by
 Provided inhibiting effects/ heat
supplemental regulating centers
fluids and by hypothalamic
-IV - D5IMB IV action leading to
fluid regulated at sweating &
34 – 35 gtts per vasodilation.
minute,as per ( Pediatric Nursing
doctor’s order. Care Plans, 3rd
edition,Karla L.
Luxner,RNC,ND,pg.
454)
 Administered
antipyeretic
medicine as
ordered
-Paracetamol 100
mL TID.