Serum Sickness

Cues Nursing Diagnosis Background Desired Outcomes Nursing Rationale Evaluation

knowledge Interventions
Subjective: Acute Pain related to Unpleasant sensory Verbalize sense of Apply warm Warmth can help After all of the
“Nagpuon ining inflammation of and emotional control to response compress to painful increase circulation nursing
kalintura ko kang joints and skin experience arising to acute situation joints to the joints and interventions
tigturukan ako kang eruptions, possibly from actual potential and positive outlook promote pain relief. rendered, patient
bulong” evidenced by verbal tissue damage for the future reported relief.
reports, guarding or described in terms of
Objective: distraction behaviors such damage;
BP: 130/90 and self-focus. sudden or slow
onset of any
PR: 92 intensity from mild
to severe with
RR: 22 anticipated or
predictable end and
Temp: 40.1°c a duration of less
than 6 months
Observed rashes and
hives
Hyperthermia Body temperature For the patient to Tepid Sponge Bath Non-pharmacologic At the end of the
related to elevated above demonstrate normal (TSB) performed. measures lower shift, after all the
medication as normal range body temperature body temperature nursing
Vital signs monitored interventions
evidenced by the and will not show and promote
every two hours rendered, the
increased body any associated comfort. Sponging patient was able to
temperature of complications. reduces body obtain a
Encouraged patient
40.1°c and the temperature by temperature of 38°c.
To maintain balance to drink plenty of
verbal complaint of increasing Patient experiences
of intake and output water placed in a
“Nagpuon man sana evaporation from normal fluid balance
within normal range measured bottle. as evidenced by the
ining kalintura ko skin.
equal intake and
kang tigturukan ako Administer
To obtain an output.
kang bulong” Antipyretic drug as
accurate core
ordered
temperature.
.
Because insensible
fluid loss increases
Serum Sickness

by 10% for every

1°cincrease in
temperature, patient
must increase fluid
intake to prevent
dehydration.

Antipyretics act on
hypothalamus to
regulate
temperature.

Impaired skin Altered epidermis or Verbalize feelings of -Assess blood supply To provide Display timely
integrity dermis increased self- and sensation of skin comparative healing of skin
esteem and ability to surfaces and lesions without
baseline opportunity
manage situations affected areas on a complications.
regular basis for timely
intervention when
problems are noted.
-Encourage early
ambulation or -Promotes
mobilization circulation and
reduces risks
associated with
immobility.