NURSING CARE PLAN

Name of Patient: Cedric Neilzen A. Refuerzo Case: r/o Kawasaki disease

NURSING NURSING NURSING

ASSESSMENT DIAGNOSIS ANALYSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
S:  P – Hyperthermia INDEPENDENT:
Infectious agents
“Nilagnat siya ng  E – Related to (Pyrogens) July 11, 2010 Provide tepid Enhances heat loss July 11, 2010
mataas kagabi at physiologic 7:45 am – 9:45 am sponge bath. by evaporation & 9:45 am
umabot ito ng 39 C response to stimulate conduction.
tapos ngayon ulit infectious process. Monocytes After 2 hours of Monitor patient’s Notes progress and Level of attainment:
nilagnat nanaman  S – as evidenced by: comprehensive vital signs (esp. changes of condition. - Goal met.
siya.” As verbalized release nursing intervention, temperature).
Pyrogenic cytokines
by the mother of the  Increased body Stimulate the temperature of AEB: After 2 hours of
patient. temperature (38.5 C) patient will subside: Promote bed rest, Reduces body heat comprehensive
 Skin: warm to touch. Anterior hypothalamus
from 38.5 C to 37.4 encourage relaxation production. nursing intervention,
 With high WBC: 21.3 x results in C. skills. the temperature of
O: 10 g/l patient subsided: from
 Increased body  RR: 35 cpm Elevated Wrap To minimize 38.5 C to 37.4 C.
temperature (38.5  PR: 130 bpm thermoregulatory set extremities with shivering.
point
C) cotton blankets.
 Skin: warm to
leads to
touch. Increased Heat COLLABORATIVE:
 With high WBC: conservation  Maintain IV fluids as  Prevents
(Vasoconstriction/behaviour
21.3 x 10 g/l changes) ordered by dehydration.
 RR: 35 cpm Increased Heat physician.
production
 PR: 130 bpm (involuntary muscular  Administer anti-  Reduces fever by
contractions) pyretic as ordered. acting directly on
Paracetamol 100mg the hypothalamic
IV PRN. heat-regulating
result in
FEVER
center to cause
vasodilation and
sweating, which
Reference: helps dissipate
NursingCrib.com heat.
 Administer  Ampicillin is used
 antibiotic as to treat diseases
ordered. caused by
Ampicilin 250mg IV bacterial
q °6. infections.
Amikacin 150mg IV Amikacin is used
OD. for short-term
treatment of
serious infections
due to susceptible
strains of Gram-
negative bacteria.

 Monitor  Laboratory tests

laboratory values may indicate
as obtained. which organism is
(Blood CS) responsible for
fever.

NURSING CARE PLAN

Name of Patient: Renato Q. Quiocho Case: (+) DM, (+) HPN

NURSING NURSING NURSING

ASSESSMENT DIAGNOSIS ANALYSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
S:  P – Imbalanced July 03, 2010 INDEPENDENT: July 03, 2010
“Hindi ako masyado Nutrition: less than 7:00 am – 3:00 pm  Weigh daily or as  Assesses 3:00 pm
makakain ng maayos body indicated. adequacy of
iha. Konti lang ang requirements. After 8 hours of nutritional intake. Level of attainment:
kinakain ko." As  E – Related to nursing interventions, Goal Partially Met.
verbalized insulin deficiency the patient will ingest  Determine  Proper
by the 2°to Diabetes appropriate amounts etiological factors assessment AEB: After 8 hours of
patient. Mellitus. of food based on his for reduced guides nursing interventions,
 S – as evidenced by: dieraty regimen, and nutritional intake. intervention. the patient ingested
 Poor appetite display usual energy For example, some appropriate
“Matagal as claimed. level. patients with amounts of food
maghilom ang  Weak in dentition based on his dieraty
sugat ko sa paa.” appearance. problems require regimen, and display
As  Decreased referral to a some usual energy
Verbalized by the muscle dentist. level.
patient. strength.
 With dry skin.  Monitor or explore  Many
O:  HGT: 291 attitudes toward psychological,
 With poor appetite mg/dl eating and food. psychosocial, and
as claimed. cultural factors
 Weak in determine the
appearance. type,
 Presence of wound amount, and
at right foot. appropriateness
 Decreased muscle of food
strength. consumed.
 With dry skin.  Ensure a pleasant
 HGT: 291 mg/dl  Suggest ways to environment,
 V/S taken as assist patient with facilitate
follows: meals as needed. proper position,
– BP: 120/70 and provide good
bpm oral hygiene and
– T: 36.6 C dentition.
– CR: 75 bpm Elevating the
– RR: 20 cpm head
(Vital signs within of bed 30 degrees
normal limits) aids in swallowing
and
reduces risk of
aspiration.

 Provide liquids  Oral route is

containing preffered when
nutrients and client is alert.
electrolytes as
soon as clien can
tolerate oral fluids;
progress to more
solid food as
tolerated.

COLLABORATIVE:

 Monitor
laboratory values
that
indicate
nutritional
wellbeing/
deterioration:
o Serum albumin This indicates degree
of protein depletion
(2.5 g/dl indicates
severe depletion; 3.8
to
4.5 g/dl is normal).

o Transferrin This is important for

iron transfer and
typically decreases as
serum protein
 decreases.

o RBC and WBC counts These are usually

decreased in
malnutrition,
indicating anemia and
decreased resistance
to infection.

o Serum electrolyte Potassium is typically

values increased and
sodium is typically
decreased in
malnutrition.

 Consult dietitian  Dietitians have a

for further greater
assessment and understanding of
recommendations the nutritional
regarding food value of foods
preferences and and may be
nutritional helpful in
support. assessing specific
ethnic or
cultural foods.

P – Risk for infection. July 05, 2010 INDEPENDENT:  Patient may be July 05, 2010
E – Related to high 7:00 am – 3:00 pm  Observe for signs admitted with 3:00 pm
glucose levels. of infection and infection, which
S – as evidenced by After 8 hours of inflammation. could have Level of attainment:
 HGT: 291 mg/dl nursing interventions, precipitated the Goal Met.
 With dry skin. the patient will ketoacidotic state,
 Presence of wound identify interventions or may develop a AEB: : After 8 hours
at right foot. to prevent or reduce nosocomial of nursing
 Weak in risk of infection. infection. interventions, the
appearance. patient was able to
 Decreased muscle  Vital signs are identify interventions
strength.  Monitor vital general indicators to prevent or reduce
signs. of circulatory risk of infection.
status and
adequacy of
perfusion.

 Reduces the risk

 Promote good of cross
hand washing by contamination.
nurse and patient.
 Peripheral
 Provide circulation may be
conscientious skin impaired, placing
care, gently patient at
massage bony increased risk for
areas. Keep the skin irritation or
skin dry, linens dry breakdown and
and wrinkle free. infection.

 Decrease
 Encourage susceptibility to
adequate dietary infection.
and fluid intake of
3000 ml per day.

COLLABORATIVE:  Identifies
 Obtain specimen organisms so
for culture and that most
sensitivities as appropriate
 indicated. drug therapy
can be instituted.

 Maintain aseptic  High glucose in

technique for IV the blood
insertion creates an
procedure, excellent
administration of medium for
medications, and bacterial growth.
providing
maintenance and
site care. Rotate
IV sites as
indicated.