Gonzalez, Alvin Jasper D.

BSN – 3A

NURSING CARE PLAN

NURSING
ASSESSMENT INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Fatigue related Fatigue is a Short term goal: Independent: After 8 hours of
“Tatlong araw na to decreased subjective After 8 hours of - Establish rapport - To gain nursing interventions,
akong nanghihina. hemoglobin and complaint with nursing patient’s trust the patient was able
Mabilis din akong diminished both acute and interventions, the and to:
mapagod at di ko oxygen capacity chronic patient will be able cooperation - Verbalized
na kayang gawin of the blood conditions. It is to: feelings of
yung mga araw- the self- - Verbalize - Monitor and - To check for increased energy
araw kong gawain” recognized state increased record vital signs irregular and improved
as verbalized by the in which an energy and especially the heartbeat well-being
patient individual improved well- heart rate every 4 - Performed desired
experiences an being hours activities
Objective: overwhelming - Perform
- Fever sustained sense of activities of - Monitor - To identify
- Back pain exhaustion and daily living hemoglobin, changes before
- Fatigue decreased and participate hematocrit, RBC they become
- Headache capacity for in desired counts, and potentially life-
- Tachycardia physical and activities at reticulocyte threatening
Vital signs as mental work that level of ability counts
follows: is not relieved by
T = 40 C rest. Long term goal:
P = 110 bpm After 1 week of - Encourage the - To increase
R = 25 bpm nursing patient to do activity level
BP = 130/90 mmHg interventions, the activities such as
Lab results: patient will be able self-care, sitting,
Hgb = 12.6 mg/dl to: and walking, as
Hct = 30% - Participate in tolerated
recommended
treatment - Encourage the - To conserve
program use of assistive energy and
devices such as prevent injury
wheeled walker
and long-handled
grabber

- Encourage - To provide
adequate intake energy
of foods rich in resources
fats,
carbohydrates,
proteins,
vitamins, and
minerals

- Encourage - To help
adequate intake increase Hgb
of food rich in count
iron such as red
meat and beans

- Encourage to - To keep the

increase fluid patient
intake hydrated

- Provide adequate - To prevent

rest periods further fatigue
Dependent:
- Administer - To stimulate
medications such RBC
as recombinant production in
human the bone
erythropoietin marrow

- Administer - To increase
packed RBCs oxygen-
transfusion, as carrying
necessary capacity of the
blood

- Provide - To increase
supplemental oxygenation
oxygen therapy
such as nasal
cannula, as
needed

Collaborative:
- Refer patient to - To improve
comprehensive stamina,
rehabilitation strength, and
program, muscle tone
physical and and to enhance
occupational sense of well-
therapy for being
programmed
daily exercises
and activities
FDAR

December 4, 2020

Focus

Hyperthermia related to underlying infection

Data

Subjective: “Tatlong araw na pong malakas ang aking lagnat” as verbalized by the patient

Objective: Patient was admitted with a chief complaint of chills and fever, vomiting, back pain, fatigue, and headache for three days;
With a history of travel from Palawan a week ago; Patient is conscious and oriented upon admission and with a vital signs of T = 40C,
P = 90 bpm, R= 25 bpm, BP = 130/90mm/Hg. Upon physical examination, patient had drowsiness but good orientation to time, place
and person. He had a flushed face and no petachiae or hemorrhages on skin noted. His breath sounds normal, but he has tachycardia.
He had mild tenderness on the upper right side of the abdomen and epigastrium , without abdominal distension, guarding or rebound
tenderness.

Action

After physical examination, patient had given antipyretic drug such as paracetamol 500 mg P.O. as prescribed by the physician to
relieve fever. Health teaching was also imparted such encourage to increase fluid intake to prevent dehydration and eat nutritious
foods such as green leafy vegetables and fruits to achieve fast recovery and gain energy from foods. Peripheral smear was done and
revealed few ring- forms trophozoites of Plasmodium falciparum. Antimalarial treatment was immediately initiated and his clinical
condition gradually improved.

Response

He still had low-grade fever that persisted for 6 days but then recovered and was discharged