PHINMA University of Pangasinan

College of Health Sciences

Patient’s Initials: J. D Age & Gender: 66 & Male Chief Complaint: Fever Name of Student Nurse: Fonbuena, Kate Ashley C.
Birthday: _____________________________________________ Admitting Diagnosis: Acute Dengue Level/block/group: 2BSN-02
Address: _____________________________________________ ________________________________________________ Hospital/area: The Medical City Pangasinan
_____________________________________________________ Date of Confinement: ______________________________ Clinical Instructor: Odessa M. Del Prado Date: 13-09-23

ASSESSMENT NURSING ANALYSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Body temperature elevated After 2 hours Independent: Independent: After 4 hours of nursing
Subjective: above normal level that is of nursing intervention - Provide tepid sponge - Heat loss by means of intervention goals and objectives
“Mataas ang lagnat ni usually caused by several client will be able to bath. evaporation and conduction. was met as evidenced by:
uncle” as verbalized by factors related to illness. maintain core temperature - Body temperature lowered to
the family of patient. As inoculation occurs, within normal range as - Provide cool -Heat loss by means of 37degree Celsius.
proliferation of virus evidenced by: environment. convection.
Objective: follows and once the virus - Body temperature is
starts to grow in number, it lowered to 37degree -Maintain bed rest or - To reduce metabolic
Vital Signs: will soon reach it celcius. minimize movement. demands of oxygen
BP: 120/80 pathogenic level that will consumption
T: 38 result into pyrexia or fever
PR: 66 as a defense mechanism of - Strictly monitor - To know if the
RR: 13 the body. temperature. patient’s
temperature went down to the
NURSING normal value.
DIAGNOSIS
Hyperthermia related to Dependent: Dependent:
inappropriate clothing - Administer - To alleviate the fever of the
factor as evidenced by paracetamol as patient.
decrease in platelet prescribed by the
count secondary to physician.
dengue hemorrhagic
fever. Collaborative: Collaborative:
- Refer to the physician - To monitor patient’s
if the temperature still condition.
higher to normal range.
ASSESSMENT EXPLANATION OF PLANNING INTERVENTIONS RATIONALE EVALUATION
THE PROBLEM