Nursing Care Plan

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective Short Term Independent: 1. Influence of After 4 hours

  Hyperthermia related Goal: After 4 Assessment choice of of giving
"pabalik-balik to infection as hours of giving 1. Assess patient’s ability interventions effective
ang sakit ng ulo evidence effective to perform tasks/ noting assistance nursing
nursing reports of weakness, 2. Enhance rest interventions,
ko at lagnat ko. by temperature
interventions, fatigue and difficulty to lower the patient was
“ As the patient the patient will accomplishing task. body’s oxygen able to cope
stated. because of the signs be able to cope 2. Educative requirements, with fatigue as
  and symptoms with fatigue as Recommended quiet and reduces evidenced by
presented and with the evidenced by atmosphere; bed rest if strain on the verbalization of
Objectives: laboratory/diagnostic verbalized indicated stress-need heart and feelings of
- Vital signs: feelings of to monitor and limit lungs comfort and
test done: cbc (platelet: comfort and visitors, phone calls 3. Although help participating in
temp: 37.8,
bp: 100/60 100,hgb: 140,hct: 0.25) increase activity and repeated may be passive ROM
,cr: 102 and (+) dengue duo participation unplanned necessary,
,rr: 22. test. interruptions. self esteem is
Long Term Therapeutic enhanced
-patent appears
Goal: when pt. does Within 8 hours
weak. Within 8 hours 3. Provided/recommende things for self. of giving
-spends most of of giving d assistance with -For continous nursing
the time in bed. nursing activities/ ambulation medication and intervention,
- Unable to interventions, as necessary, allowing fast recovery. the patient was
perform some the patient will pt. to do as much as able to do
ADL’s. be able to possible simple ADLs
demonstrate an Dependent
increase in Assessment
activity Doctor’s drug order as
tolerance as indicated. paracetamol
evidenced by 500mg tablet, probiotic
doing simple
capsule, multivitamins
ADL’s
with buclizine capsule,
ascorbic acid capsule,
ferrous sulfate capsule,
 cefuroxime 500mg tablet,
stimuno capsule, -Enhances
cetirizine 10mg tablet, Ig lung
co milk formula, expansion to
omeprazole 40mg capsule maximize
oxygenation
Interdependent:
for cellular
Assessment: uptake.
Elevated head of bed as
tolerated.
Therapeutic
-Monitor the patient while -To monitor
performing ADL's. changes and
Educative: documentation.
Advice the patient to rest
but have time to exercise. -For the good
circulation of
blood and good
function of the
bones.