Date/ Cues Need Nursing
Time Diagnosis
with Rationale
A N Hyperthermia
U Objective: U related to release
G T of endogenous
U -temp 38.6 C R pyrogens
S RR 46 I go down to the
T PR 136 O Rationale:
N Fever results from
3 -skin warm to A an imbalance
touch L between the
2010 - elimination and the
-pallor noted on M production of heat.
8am the lips and skin E Infection,
T neurologic disease,
A malignancy,
B pernicious anemia,
O thromboembolic
L disease,
I paroxysomal
C tachycardia,
congestive heart
P failure, crushing
A injury, severe
T trauma, and many
T drugs may cause
E fever. Fever is the
R effect of body’s
N response due to
infection inside the
body. ( Mosby’s
pocket dictionary of
medicine, nursing,
and allied health 4th
edition)
Objectives/ Nursing Intervention Evaluation
Plan with Rationale
Within the 4 1. Monitor and record vital signs especially Goal met
hours span of temperature
care, patient’s ® Monitoring the patient helps in the continuity of care.
temperature will Vital signs are also essential to determine deviations Within our
from normal 4 hours
normal range. span of
2. Do tepid sponge bath to the client care, the
® TSB helps in decreasing the body temp. patient’s
temperatur
3. Emphasize the importance of proper hygiene to the e went
parents. down to
® These reduce the risk of any incoming infection. 37.6 C
which is a
4. Encourage the parents to increase the Oral Fluid normal
Intake of the client. range.
® Helps in maintaining the adequate fluid in the body.
5. Promote surface cooling by means of undressing
(heat loss by radiation and conduction); cool
environment and/or fans (heat loss by convection).
6. Administer antipyretics as needed
® Administering antipyretics helps in reducing the
body temp.
7. Recheck the clients temperature
® To determine the effect of the therapeutic and
pharmacologic mgt provided.
8. Assess fluid loss and facilitates oral fluid intake or
administer IV fluids to accomplish fluid replacement.
® Increase metabolic rate and diaphoresis associated
with fever causing loss of body fluids.
Date/ Cues Need Nursing Objectives/ Nursing Intervention Evaluation
Time Diagnosis Plan with Rationale
with Rationale
A N Risk for After 4 hours • Document actual weight; do not estimate. GOAL MET
U Objective: U Imbalanced span of care, ® Patients may be unaware of their actual
G - NGT at T nutrition: Less than the patients weight or weight loss due to estimating weight. After 4
U right nare for R body requirements watcher will be • Obtain nutritional history; include family, hours span
S feeding I related to increased able to significant others, or caregiver in assessment. of care the
T O metabolic needs verbalize and ® Patient’s perception of actual intake may patients
- OTF of N caused by disease demonstrate differ. watcher
2 2300 A process or therapy understanding • Monitor laboratory values that indicate was able to
kcal/day L of the causative nutritional well-being/deterioration. verbalize
2010 - Wt: - factors when • Weigh patient weekly. understand
15kg M known and ® During aggressive nutritional support, ing of the
9am - Ht: E necessary patient can gain up to 0.5 pound/day. health
100cm T intervention. • Suggest ways to assist patient with meals as teaching
A needed. Ensure a pleasant environment, rendered.
(A 5 year B facilitate proper position, and provide good
and 1 O oral hygiene and dentition.
month L ® Elevating the head of bed 30 degrees aids
old (male) I in swallowing and reduces risk of aspiration.
child C
who is 34 • Monitor laboratory values, and report
pounds P significant changes to physician.
and is 3 A ®Laboratory values provide objective data
feet and 3 T regarding nutritional status.
inches T • Explain the importance of adequate nutrition
tall has E and fluid intake to client’s watcher.
a body R ®Clients watcher may have inadequate or
mass index N inaccurate knowledge regarding the
of 15.7, contribution of good nutrition to overall
which is at wellness.
the 60th
percentile,
and would
indicate
that your
child is at a
healthy
weight.)
Date/ Cues Need Nusring Diagnosis
Time
A Objective: N Risk for aspiration
U  With U related to presence of
G NGT at T endotracheal tube
U right nare R experience no
S intact and I ®
T patent T Both acute and
 With ET I chronic conditions
2, tube O can place patients at
2010 attached to N risk for aspiration.
CPAP A Acute conditions,
8am L such as
 Coughing
- postanesthesia
noted
M effects from surgery
E or diagnostic tests,
T occur predominantly
A in the acute care
B setting. Chronic
O conditions, including
L altered
I consciousness from
C head injury, spinal
cord injury,
P neuromuscular
A weakness,
T hemiplegia and
T dysphagia from
E stroke, use of tube
R feedings for nutrition,
N endotracheal
intubation, or
mechanical
ventilation may be
encountered in the
home, rehabilitative,
or hospital settings.
Elderly and
Objective of care Nursing Intervention Evaluation
After 8 hours span 1. Auscultate lung sounds frequently. After 8 hours span of
of care, the patient ® Bronchial auscultation of lung sounds was care patient was free
will be able to shown to be specific in identifying clients at from aspiration.
risk for aspiration.
aspiration. 2. Elevate client to the highest or best GOAL MET.
possible position for eating and drinking and
during tube feedings.
3. Provide information about the effects of
aspiration on the lungs.
® Severe coughing and cyanosis associated
with eating or drinking or feeding indicates
onset of respiratory symptoms associated
with aspiration and requires immediate
intervention.
4. Record appearance, characteristics and
duration of cough.
5. Check placement of NGT before
feeding.
® A displaced tube may erroneously
deliver tube feeding into the airway.
6. Auscultate bowel sounds to
evaluate bowel motility.
® Decreased gastrointestinal motility
increases the risk of aspiration because
food or fluids accumulate in the
stomach.
7. Keep suction setup available and
use as needed.
® This is necessary to maintain a patent
airway.
cognitively impaired
patients are at high
risk. Aspiration is a
common cause of
death in comatose
patients.

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erhealth.com/MERLI
N/Gulanick/Construct
or/index.cfm?plan=04
Date/ Cues Need Nursing Objectives/ Plan Nursing Intervention Evaluation
Time Diagnosis with Rationale
with Rationale
A A Ineffective After 8 hours span of • Assess respiratory function, e.g., breath GOAL MET
U Objective: C breathing pattern care the patient will be sounds, rate, and use of accessory muscles
G • On T related to able to maintain and secretion characteristics and amount. After 8
U endotrache I decreased lung respiratory rate at ® Provides a basis for evaluating adequacy hours span
S al tube V expansion normal range. of ventilation of care the
T attached to I • Position patient in semi- or high- Fowler’s patient was
CPAP with T position. able to
2 FiO2 100% Y ® Positioning helps maximize lung maintain
@ 4Lpm - expansion. his
2010 • Crackles E • Assess airway patency. respiratory
noted on X ® Maintain adequate airway patency. rate at
9am both lungs E normal
R
• Note retractions or flaring of nostrils. level.
upon ®These signify an increase in work of
auscultatio C
breathing.
n I
• use of S • Administer oxygen at lowest concentration
E indicated and prescribed respiratory
accessory
medications.
muscles for
P ®For management of underlying pulmonary
respiration:
A condition, respiratory distress or cyanosis.
elevated
shoulders. T • Suction airway as needed.
• respiratory T ®This is to clear secretions.
rate: RR- E • Monitor pulse oximetry, as indicated.
46cpm R ®verify maintenance/improvement in O2
• Secretion N saturation.
characteris
tics: whitish
in color