NURSING CARE

PLAN
Case no. 3

A 7 y/o boy was lying on bed, asleep, and non - dyspneic with IV fluid of Lactated Ringer 1 Litre at 850 cc, has fever with temperature of
38.7°C, skin warm to touch and complaint of headache his mother verbalizes “masakit daw po ang kanyang ulo at ayaw po kumain”. He was
given antibiotics every 8 hours and analgesic every 4 hours. Repeat blood and urine analysis is done and still waiting for the result. During a
health assessment, his mother told the nurse that his son has on & off fever, vomits 6 times and abdominal discomfort prior to admission. His
vital signs; temperature- 39.7°C, PR- 97 bpm, BP- 110/70 mmHg, RR- 20 bpm. The white blood cells and platelet count result is below the
normal value, the urine analysis has bacteria and the stool examination is negative.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: After 6 hours of Independent: After 6 hours of

High fever caused by an effective nursing nursing
“Masakit daw po ang unknown organism that intervention; - Place a patient -A sitting position intervention the
kanyang ulo at ayaw po causes the body to react with proper body permits maximum lung goal was met:
kumain” at fight off the intruder. The patient has alignment for excursion and chest
and the patient has an maximum breathing expansion. The patient
maintained an effective
on & off fever, pattern. maintains an
Ineffective breathing breathing pattern as effective
vomitted 6 times and evidenced by normal
has abdominal pattern related to - Provide small, - Small meals helps the breathing pattern.
fatigue as evidenced rate and absence of
discomfort as said by dyspnea. frequent meals. client in digesting food
mother. by shortness of breath. easily while not needing
Establish stable
extra energy for
vital signs.
Establish a normal digestion.
Objective: range or stable vital - Provide - Prevents dehydration
Fever signs adequate fluids of the client’s body
Non dyspneic for intake.

VS:
BP: 110/70 Dependent: -Beta-adrenergic
T: 39.7°C - Provide respiratory aid agonist medications
RR: 20 bpm if necessary and relaxes the airway
PR: 97 bpm respiratory medications smooth muscles
and paracetamolsper the and cause
pediatrician’s orders. bronchodilation
to open the air
passages.
Paracetamol for the
high fever.