Wesleyan University-Philippines

Mabini Extension, Cabanatuan City 3100, Nueva Ecija

A.Y 2023-2024

NURSING CARE PLAN

NURSING NURSING
ASSESSMENT PLANNING RATIONALE EVALUATION
DIAGNOSIS IMPLEMENTATION
Subjective Data: A potential infection- Independent: Independent: Goal Met
“Nung Monday may sinat related case of Short Term: -Monitor Vital Signs: -Early detection of changes
lang siya tas sumunod na hyperthermia characterized Within a 4-hour nursing Regularly assess body in vital signs can prompt Short Term Goal:
araw, nilagnat na, bali 3 by a body temperature rise intervention: temperature, pulse rate, timely interventions to After 4 hours of nursing
araw na siyang nilalagnat, above normal, weakness, respiratory rate, and blood prevent complications. intervention, client’s
masakit din daw ulo niya at pressure to track changes temperature was lowered
appetite loss, and  The client's elevated
katawan”, as verbalized by indicating progression or from 39.6⁰C to 38⁰C. Client
dehydration. temperature is
the patient’s mother improvement. was also able to improve
expected to decrease
input/intake of fluids as
Objective Data: from 39.6⁰C to 38⁰C. -Offer fluids frequently to -Adequate fluid intake per result of understanding
 Flushed skin  The client is prevent dehydration. helps maintain perfusion, of health teaching
 Skin is warm anticipated to increase Ensure the intake is electrolyte balance, and provided.
to touch fluid intake based on adequate to replace fluids promotes the excretion of
 Weak in health education to lost due to fever and waste products.
appearance alleviate signs of increased respiratory rate.
 Sign of dehydration. Long Term Goal:
dehydration -Ensure a comfortable -Cooling measures help After 48 hours of
evident on Long Term: room temperature and reduce fever, alleviate consecutive days of
patient’s Following 48 hours of provide cooling measures discomfort, and prevent nursing interventions, the
cracked lips such as fans, cool cloths, or hyperthermia-induced client has maintained core
consistent nursing care:
 Vital Signs taken as a cool bath to help reduce complications such as heat temperature within normal
follows: body temperature. exhaustion or heatstroke. range as evidenced by
 The client should
T : 39.6⁰C body temperature of 37⁰C
PR : 115 bpm sustain a normal core -Offer small, frequent -Proper nutrition supports and skin turgor improve
RR : 18 bpm temperature, meals high in nutrients to the immune system, aids in from dry to fair. As well as
BP : 110/80 mmHg evidenced by a support the body's tissue repair, and prevents a report of increase energy
Wesleyan University-Philippines
Mabini Extension, Cabanatuan City 3100, Nueva Ecija
A.Y 2023-2024

decrease in body immune response and malnutrition-related from the client.

temperature to 37⁰C. energy needs. complications.
 Improvement in skin
turgor, progressing -Keep the skin clean and -roper infection control
from dry to fair, is dry to prevent breakdown, practices prevent the
especially if sweating spread of infection to
expected.
excessively. others and reduce the risk
 The client should
Educate on Infection - of recurrent infections.
report an
Dependent:
enhancement in -Secure laboratory tests
energy levels. ordered by attending
physician.
Dependent:
-To understand underlying
-Administer medications in order to provide
and intravenous fluids as necessary medical and
ordered by attending nursing management.
physician.
-Fluid replacement is
essential for patients with a
Collaborative: high body temperature.
-Secure laboratory results Drugs specifically to lower
from physician’s order of client’s temperature.
tests.
Collaborative:
-To identify possible cause
and additional risk factors.
 Wesleyan University-Philippines
Mabini Extension, Cabanatuan City 3100, Nueva Ecija
A.Y 2023-2024

NURSING CARE PLAN

NURSING NURSING
ASSESSMENT PLANNING RATIONALE EVALUATION
DIAGNOSIS IMPLEMENTATION
Subjective Data: Impaired oral mucous Independent: Independent: Goal Met
“Nahihirapan daw siya membrane related to -ask the physician if he/she Antibiotics target the
kumain at masakit daw ang infectious process as Short Term: prescribe antibiotics infectious agent directly, Short Term Goal:
lalamunan” as verbalized evidenced by inflamed After 8 hours of nursing reducing inflammation and After 8 hours of nursing
by the patient’s mother. tonsils intervention: promoting healing of the intervention:
 Regularly examine oral mucous membranes. -Reduction in the size and
Objective Data: the oral cavity for redness of inflamed tonsils.
 Reddened tonsils signs of - Prescribe pain relief - analgesics reduce pain, Decrease in the patient's
 Vital Signs taken as inflammation, such medications such as making it more reported pain and
follows: as redness, acetaminophen or throat comfortable for the patient discomfort associated with
T : 37.2⁰C swelling, or lozenges to alleviate to swallow and speak, and inflamed tonsils.
PR : 167 bpm exudation on the discomfort associated with facilitating rest. Improved ability to swallow
RR : 71 bpm tonsils. inflamed tonsils. and speak without
 Encourage gentle significant difficulty.
oral care using a
soft toothbrush or Dependent Dependent: Long Term Goal:
mouth swabs to - Offer frequent oral care -Maintaining oral hygiene After 16 hours of nursing
clean the mouth using a soft toothbrush or prevents the buildup of interventions:
after meals and mouth swabs to clean the bacteria and debris,
before bedtime to mouth and remove debris. reducing the risk of -Complete resolution of
remove debris and secondary infections and inflammation and
reduce the risk of promoting healing. normalization of tonsil size
infection. and color.
- Encourage the patient to - Adequate hydration Absence of pain and
Long Term: drink plenty of fluids to supports mucous discomfort associated with
After 16 hours of nursing keep the mucous membrane integrity and the tonsils.
 Wesleyan University-Philippines
Mabini Extension, Cabanatuan City 3100, Nueva Ecija
A.Y 2023-2024

intervention: membranes moist and helps flush out toxins, Normal swallowing and
 Assess the patient's facilitate healing. promoting healing and speech function without
understanding of reducing discomfort. difficulty.
self-care measures
and provide Collaborative: Collaborative:
reinforcement or -Involve a nutritionist to -Proper nutrition is
additional assess the patient's essential for mucous
education as nutritional status and membrane healing and
needed. provide dietary overall recovery from
recommendations that infection.
support healing and meet
the patient's nutritional
needs.

NURSING CARE PLAN

NURSING NURSING
ASSESSMENT PLANNING RATIONALE EVALUATION
DIAGNOSIS IMPLEMENTATION
 Wesleyan University-Philippines
Mabini Extension, Cabanatuan City 3100, Nueva Ecija
A.Y 2023-2024

Subjective Data: Acute pain related to Independent: Independent: Goal Met

“May masakit po akong urinary tract infection as -Monitor client’s vital signs. -To monitor client’s overall
nararamdaman kapag evidenced by subjective Short Term: health status. Short Term Goal:
umiihi ako at madalas po reports of abdominal After 8 hours of nursing After 8 hours of nursing
akong umihi”, as verbalized discomfort and burning intervention: -Encourage increased fluid - Increasing fluid intake intervention the client was
by the patient. sensation during urination.  The client will be intake. can help flush out bacteria able to report reduce of
able to report from the urinary tract and pain upon urination.
Objective Data: reduced pain upon dilute urine, reducing
 Facial urination. irritation.
Grimace
 Urine analysis: Long Term: -Monitor client’s intake -To detect early signs of Long Term Goal:
Presence of After 7 days of nursing and output. dehydration and to know After 7 days of nursing
bacteria and white intervention: fluid and electrolyte intervention the client is
blood cells in urine  Client will feel balance in the body. relieved and the infection
sample. relieved, void is controlled. And can now
 Vital Signs taken as without discomfort -Provide education on the -Proper hygiene can help void without any
follows: and the infection importance of maintaining prevent further irritation discomfort
T : 38.5⁰C will be controlled. good hygiene practices, and infection of the urinary
PR : 72 bpm such as wiping from front tract.
RR : 22 bpm to back after urination to
BP : 100/80 mmHg prevent the spread of
bacteria.

Dependent: Dependent:
-Secure Urinalysis ordered -To understand underlying
by attending physician. in order to provide
necessary medical and
Wesleyan University-Philippines
Mabini Extension, Cabanatuan City 3100, Nueva Ecija
A.Y 2023-2024
-Administer medications
and intravenous fluids as
ordered by attending
physician.
Collaborative:
- Coordinate with a
physician for further
diagnostic testing, such as
a urine culture.
nursing management.
- Pain medication may be
necessary to manage
discomfort if the grimacing
is due to underlying pain.
Collaborative:
-To help determine the
specific bacteria causing the
infection and guide
antibiotic therapy for
optimal treatment.