NURSING CARE PLAN

Assessment (cues) Nursing Nursing Objectives Nursing Interventions Rationale Evaluation

Subjective/Objective Diagnosis
Subjective: Hyperthermi The patient  Establish rapport  To gain trust and After 3 days of
a related to temperature will have nurse- nursing
Claudine was disease decreased from 39.1 patient interventions, the
complaining of pain process to 37 relationship patient’s pain will
at her lower back for be relieved and
a few days. During The patient lower controlled.
urination, she has back will be free from  Give a 500mg of  A paracetamol
difficulty in urination pain. paracetamol. will reduce the After 3 days or
“ang sakit ng puson fever of the nursing
ko pag umiihi” as patient interventions, the
verbalized by the patient’s lower
patient. back will be cured.
She states that she is
fond of drinking soda  Monitoring vital  To determine
and eating junk signs especially appropriate
foods daily. She temperature interventions
barely drinks water
and does not do
some exercises. Her
urine is a bit cloudy.  Encourage  Increased
Claudine’s daily meal increased fluid hydration flushes
consists of tocino, intake bacteria and
longanisa and all toxins
kinds of frozen foods
which are her food
preferences  Provide TSB  A tepid sponge
bath is done to
reduce fever
Objective:

 Increased  Recommend  It will reduce skin

body proper irritation and
temperature handwashing and prevent bacteria
above normal hygiene and infections.
range
 Warm to  Instruct the  This will help the
touch, patient to drink a patient hydrated
flushed skin plenty of water
 Awake and every day
Oriented
 Encourage the  Exercise will help
Vital Signs: patient to do the patient to
some exercises have a healthy
Temperature: 39.1 body and prevent
Apical pulse: 75/min illnesses
Pulse oximetry: 99%
Blood Pressure:
120/70