NAME: ACENA, JOBELLE C.

YEAR LEVEL: BSN IV

NURSING CARE PLAN FOR FEVER

ASSESSMENT NURSING INFERENCE OBJECTIVES NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
SUBJECTIVE: Hyperthermia Infectious agents After 4 hours Independent: After 4 hours of
related to (Pyrogens) of nursing  Monitor heart  Dysrhythmias nursing
“Mainit dehydration interventions, and rhythm and ECG interventions, the
angpakiramdam
ko” as verbalized
 the patient will
maintain core
changes are
common due
patient was able
to maintain core
by the patient. Monocytes temperature temperature
to electrolyte
within normal imbalance and within normal
OBJECTIVE:  range. dehydration range.
Pyrogenic and direct
 Flushed skin, cytokines effect of Goal met.
warm to hyperthermia
touch. on blood and
 Restlessness  cardiac
Anterior tissues.
V/S taken as hypothalamus
follows:  Record all  To monitor or
 T: 38.1  sources of potentiates
 P: 70 Elevated fluid loss such fluid and
 R: 19 Thermoregulator as urine, electrolyte
 BP: 110/90 y set point vomiting, and loses.
diarrhea.

  Promote  To decrease
Increased heat surface temperature
conservation cooling by by means of
(vasoconstriction means of tepid evaporation
 or behavior sponge bath. and
changes) conduction.
Increased heat
production  Wrap  To minimize
(involuntary extremities shivering.
muscle with cotton
contraction) blankets.

  Provide
supplemental
 To offset
increased
FEVER
oxygen oxygen
demands and
consumption.

 Administer  To support
replacement circulating
fluid and volume and
electrolytes. tissue
perfusion.

 Maintain bed  To reduce

rest. metabolic
demands and
oxygen
consumption.

 Provide high  To increased

calorie diet, metabolic
tube feedings, demands.
or parenteral
nutrition.

 Administer  To facilitate
antipyretics fast recovery.
orally or
rectally as
prescribed by
the physician.
NAME: ACENA, JOBELLE C.
YEAR LEVEL: BSN IV
NURSING CARE PLAN FOR WOUND HEALING

ASSESSMENT NURSING INFERENCE OBJECTIVES NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
SUBJECTIVE: Impaired skin Diabetes Short – term:  Assess the feet  This will After the
integrity sometimes  Clean and and legs for prevent further appropriate
“Parang hindi related to affects the disinfect skin damage to nursing
gumagaling yung open wound nerves of the the wound temperature, tissues in the intervention, the
sugat sa paa ko” secondary to feet, causing a  Promote sensation, soft patient’s foot. patient was able
as verbalized by impaired loss of timely tissue injuries, to:
the patient. circulation. sensation. wound corns, calluses,
Therefore, when healing dryness,  Demonstrate
OBJECTIVE: a person with hammer toe or how to take
decreased Long – term: bunion care of open
 (+) swelling sensory  Educating the deformation, wound
of the right perception in patient pulses and
foot with foul- the feet is regarding the deep tendon  Discuss the
smelling wounded, the importance of reflexes. importance of
drainage from wound is left monitoring of hygiene in
ulceration. unnoticed and open wound  Instruct the  Educating the promoting
 With heavily may develop an and proper patient in foot patient will skin integrity.
soaked infection. wound care. care help promote
dressing. guidelines. cooperation.

 Inspect  This will keep

incision the wound in
regularly, check and
noting prevent
characteristics complications.
and integrity.
 Teach patient  Cleanliness
proper wound helps
care. prevent
infection
and its
spread.

 Encourage the  To prevent

use of pillows, pressure
foam wedges, injury.
and pressure-
reducing
devices.

 Keep a sterile  This

dressing technique
technique reduces the
during wound risk of
care. infection in
impaired
tissue
integrity.
NAME: ACENA, JOBELLE C.
YEAR LEVEL: BSN IV
NURSING CARE PLAN FOR PRESSURE ULCER

ASSESSMEN NURSING INFERENCE OBJECTIVES NURSING RATIONALE EVALUATION

T DIAGNOSIS INTERVENTION
SUBJECTIVE: Impaired skin Pressure on Short Term: Independent: After 8 hours of
integrity soft tissues After 6-8 hours  Assess between  Pressure ulcers nursing
“meron na related to between bony of nursing folds of skin, under medical interventions
syang sugat sa pressure ulcer prominences interventions of remove anti devices are patient:
bandang pwet, secondary to ↓ nursing embolic stockings commonly reduced risk
dahil sa prolonged Compresses interventions, or devices & use a overlooked. of further
pagkakahiga immobility capillaries & the client will: mirror to see the impairment of
niya ng and occludes blood heels. Also assess skin integrity
matagal..” as unrelieved flow  Have reduced under oxygen as evidenced
verbalized by pressure as ↓ risk of further tubing especially by no actual
the patient’s evidenced by: Pressure not impairment of on the ears & the additional
granddaughter. relieved skin integrity cheek, beneath tissue
 Stage II ↓ splints and under breakdown &
OBJECTIVES: pressure Microthrombi  Patient’s medical devices. no persistent
ulcer @ L formation caregivers will reddened areas
 Stage II &R ↓ demonstrate  Note objective data  Reassessment of
pressure ulcer buttocks + occlusion in understanding of pressure ulcer ulcer is Patient’s
@L&R  Localized capillaries & & skill in care (stage, length, completed each caregivers’
buttocks injury blood flow of wound width, depth, time dressing are demonstrated
 Localized over bony ↓ wound bed changed or understanding
injury over prominen Formation of appearance, sooner if ulcer & skill in care
bony ce blister Long Term: drainage & shows of wound as
prominence  Dry & ↓ After 3-4 days condition of manifestations of evidenced by
 Dry & shallow shallow Rupture of of nursing periulcer tissue) deterioration. checking
wound wound blister interventions, Analyses of the pressure ulcer
 Reddish-pink  Reddish- ↓ the client will: trends in healing sites
open/rupture pink + open wound are important step frequently &
blister open/rupt ↓  Experience in assessment. cleansing the
ure blister Stage II healing of wound
manifestations: ulcer/regain  Increase the  To disperse aseptically.
 Stage II skin integrity frequency of turning pressure over
pressure (reduce size of (turning q2). time or PARTIALLY
ulcer @ L & ulcer) Position the client to decreasing the MET
R buttocks  Reduce risk stay off the ulcer. If tissue load
 Localized for infection there is no turning After 4 days of
injury over surface without a nursing
bony pressure ulcer, use a interventions the
prominence pressure client:
 Dry & redistribution bed &  Experienced
shallow continue turning the healing of
wound client tissue as
 Reddish-pink evidenced by
open/rupture  Elevate heels off the  Heel covers do development
blister bed by using pillows not relieve of
or heel elevation pressure, but they granulation
botts. can reduce tissue &
friction. decrease in
ulcer size.
 Maintain head of  To prevent
bed @ the lowest further  Reduce risk
elevation, if client occurrence of of infection
must have the head pressure ulcer. as evidenced
elevated to prevent by observing
aspiration, proper hand
reposition to 30 washing
degree lateral technique
position. Use seat before &
cushions & assess after wound
sacral ulcers daily. care.
 Follow body  To reduce risk of PARTIALLY
substance isolation infection MET
precautions; use
clean gloves &
clean dressing for
wound care.
Practicing proper
hand washing
before & after
wound care.

Dependent/Collaborati
ve:

 Ensure adequate  To prevent

dietary intake. malnutrition &
Review dietician’s delayed healing
recommendations.

 Prevent the ulcer  To prevent

from being contamination or
exposed to urine & spread of
feces. Use infection
indwelling
catheters, bowel
containment
systems, & topical
creams or
dressings.

 Supplement the diet  To promote

with vitamins & wound healing on
 minerals. Vitamins clients who do
C and zinc are not have adequate
commonly calories.
prescribed.

 Provide oral  Pressure ulcers

supplementations, cannot heal in
tube-feedings or clients with
hyperalimentation to severe
achieve positive malnutrition.
nitrogen balance.

 Remove devitalized  To promote faster

tissue from the healing & reduce
wound bed, except infection
in the avascular
tissue or on the
heels. Began by
cleansing the ulcer
bed with normal
saline, then use
appropriate
technique for
debridement. Once
the ulcer is free of
devitalized tissue,
apply dressing the
keep the wound bed
moist & the
surrounding skin
dry. Do not use
occlusive dressings
on ulcer.
NAME: ACENA, JOBELLE C.
YEAR LEVEL: BSN IV
NURSING CARE PLAN FOR INFLAMMATION

ASSESSMENT NURSING INFERENCE OBJECTIVES NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
SUBJECTIVE: Acute pain Pneumonia is After 4 hours Independent: After 4 hours of
related to inflammation of the of nursing  Elevate head of  Lowers nursing
“Masakit ang inflammation terminal airways and interventions, the bed, change diaphragm interventions,
dibdib ko” as and persistent alveoli caused by the patient will the position promoting the patient was
verbalized by cough. acute infection by display patent frequently. chest expansion able to display
the patient. various agents. airway with and patent airway
Pneumonia can be breath sounds expectoration with breath
OBJECTIVE: divided into 3 clearing and of secretions. sounds clearing
groups: community absence of and absence of
 Use of acquired, hospital or dyspnea.  Assist patient with  Deep breathing dyspnea.
accessory nursing home deep breathing facilitates
muscle acquired exercises. maximum
 Dyspnea (nosocomial), and expansion of
 Fatigue pneumonia in an the lungs and
immunocompromise smaller
VS taken as d person. Causes airways.
follows: include bacteria
 T- 37.3 (Streptococcus,  Demonstrate or  Coughing is a
 P- 80 Staphylococcus, help patient learn nature self-
 R- 25 Haemophilus to perform activity cleaning
influenzae, Klebsiella like splinting mechanism.
 BP- 120/80
Legionella). chest and effective Splinting
Community acquired coughing while in reduces chest
pneumonia (CAP) is upright position. discomfort, and
a disease in which an upright
individuals who not position favors
have been deeper, more
hospitalized develop forceful cough
an infection of the effort.
lungs. It is an acute
inflammatory  Force fluids at  Fluids
condition that result least 3000ml per especially
aspiration of day and offer warm liquids
oropharyngeal warm, rather than aid in
secretions or stomach cold fluids. mobilization
contents in the lungs. and
expectoration
of secretions.

Collaborative:
 Administer  Aids in
medications as reduction of
prescribe: bronchospasm
mucolytics or and
expectorants. mobilization of
secretions.

 Provide  Fluids are

supplemental required to
fluids. replace losses
and aid in
mobilization of
secretions.