ACTIVITY 1: CASE STUDY

Situation:
Anthony, a 36 years-old male, an American citizen, and now currently residing in Cebu City,
Philippines. He was brought to the Cebu City Hospital yesterday. He is having chills and has a
complains of frequent high fever. He said that “before I was admitted, I was having cold and
my body temperature was too high than the normal human body temperature”.

BP: 160/100 mmHg PR:130 bpm CLIENT: Anthony

CARE PLAN: Yasmien Marie S. Puda
T: 40°C RR: 27 cpm DATE INITIATED: November 14, 2022

Assessment Diagnosis Planning Intervention Evaluation

Subjective: Pyrexia related to Short term: Independent: Goal met:
He is having chills elevated body The patient will have The patient will The doctor's
and a frequent high temperature as a rest to reduce his receive prescribed
fever. evidence by body heat production instruction on medications helped
frequent high fever within the time how to use the patient
and a temperature duration of 3-6 treatments. completely recover
of 40 C. hours. from his pyrexia.
Objective: Dependent:
Hypertensive The patient will On a time scale of Due to the nurse's
(BP= 160/100 receive treatments 3-6 hours, the comfort, the
mmHg) and will be nurse will patient recovered
Tachycardia monitored by the evaluate the more quickly.
(PR+-= 130 bpm)- nurse. patient and give
Alternation of them comfort.
Respiratory rate Long term:
(27 cpm) After 1-2 weeks, the
Labored/ difficulty patient will maintain When pyrexia is
breathing- Fever under control
a normal body
(T-40 C)
temperature as within 4-6 hours,
Restlessness-
evidence by having a the nurse will
Dyspnea
body temperature of give the patient
36.5 C explicit
instructions on
what to eat and
what to avoid.

Collaborative:
As prescribed by
the doctor, the
nurse will
administer
acetaminophen
or ibuprofen to
the patient.