Nursing Care Plan

PATIENT NAME: Baby Q Age: 4years old

ADDRESS: STA MARIA BULACAN
CHIEF COMPLAIN: Fever and mouth sore Sex: Male

Assessment (Cues) Nursing Diagnosis Nursing Objectives Nursing Interventions Rationale Evaluation

Subjective Data: Based on the assessment At the end of an 8 hour Independent After 8 hours of
- data, the major nursing independent and
shift of independent, and
patients parents diagnosis for a patient with ● Investigate reports of ● To assist in differentiating collaborative
report a mouth HFMD are: collaborative nursing
sore and an onset
pain, noting location, between bladder and interventions, the
intervention, the client
fever on her son duration, intensity; kidney as cause of objectives and goals are
will: bladder spasm; or dysfunction partially met
back or flank pain as evidenced by:
- the clients parents impaired oral mocus membrane● Subside the
stated that:* It started Temperature from
after her son attended ● Temp - 39.1°C, 39.1°C to 36.5 - ● Reduced high
his public daycare ● Skin is warm to touch 37.5 (normal ● Encourage increased ● Adequate fluid intake temperature of
school fluid intake. helps maintain renal the client
and flushed but awake values)
function. It is thought that
and oriented fluids can reduce risk of
● Dark Amber Urine ● Free of chills infection by decreasing the
Color ability of bacteria to ● Client’s pain
● Experience no adhere to bladder wall and difficulties
Scientific Explanation: difficulties/pain (Santillo & Lowe, 2007). when voiding
Impaired - A qualifier that when voiding are controlled
have been added to NANDA; ● Observe for changes ● Changes in urine
made worse, weakened, in urine characteristics may
● The dark amber characteristics indicate UTI and increased ● Lessened the
damaged, reduced,
deteriorated. color of the urine cloudy, bloody, foul risk of sepsis. Multistrip Dark Amber
will lessened and odor, and so forth. dipsticks can provide a urine color of
Reference: Berman, A., gradually return Test dipstick, as quick determination of pH, the client
Snyder, S., Frandsen, G. to its normal color indicated. nitrate, and leukocyte
(2015). Fundamentals of esterase that suggest
(straw, amber
Nursing (10th Edition). presence of Infection or
transparent) urinary disease.
Pearson. Chapter 12 -
Diagnosing,,p.g. 176
Objective Data: Urinary Elimination - refers
- Vital Signs to the process of emptying the
Temp - 38.1°C. urinary bladder.
Apical Pulse - 75
Pulse Oximetry - 95% Reference: Berman, A., Snyder,
BP - 120/70 S., Frandsen, G. (2015).
- HR:100 bpm Fundamentals of Nursing (10th
Edition). Pearson. Chapter 48 -
Urinary Elimination,,p.g. 1175
- Upon physical
examination Impaired Urinary
mouth sore are visible Elimination - dysfunction in
urine elimination
Reference: Berman, A., Snyder,
S., Frandsen, G. (2015).
Fundamentals of Nursing (10th
Edition). Pearson. Chapter 48 -
Urinary Elimination,,p.g. 1184
Collaborative
Urinary Tract Infection -
most common bacterial
infection in women caused by
a variety of disorders, but
bacterial infection is by far
the most common.
Escherichia coli is the most
common pathogen causing a
UTI and primarily seen in
women.
Reference: Dirksen L., Bucher
Heitkemper B. (2014) Medical-
Surgical Nursing (9th Edition).
Chapter 46 - Renal and Urologic
Problems,,p.g. 1064-1065
● Provide comfort ● Promotes relaxation,
measure like back refocuses, attention, and
rub, helping patient may enhance coping
assume position of abilities.
comfort.
● Perineal care decreases
● Advise to perform risk of skin irritation,
hygienic measures breakdown, and
like daily perineal development of ascending
care. infection.
● Encourage to void ● To flush bacteria out of
frequently (every 2-3 urethra and prevent
hours) and empty organisms from ascending
bladder completely. into the bladder
● Administer ● This medication will
paracetamol 500mg alleviate the client’s fever
as prescribed
● Monitor blood urea ● These laboratory tests
nitrogen/creatinine reflect renal function and
(BUN/Cr), white identify complications.
blood cell (WBC)
count, and urinalysis Reference: Doenges, M. (1900)
(UA). Nursing Care Plans (9th Edition).
F.A. Davis Company. Chapter 6 -
Neurological/Sensory Disorders–
Spinal Cord Injury,,p.g. 261
GROUP 2