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Urdaneta City University: Nursing Care Plan

This nursing care plan addresses a patient with a fever of 38.5°C likely due to a bacterial infection as evidenced by sore throat and enlarged lymph nodes. The short term goal is to reduce the patient's temperature to 37.3°C within 2 hours with interventions like monitoring temperature, observing for chills, and providing tepid sponge baths. The long term goal is for the patient to maintain a normal temperature range and be free from chills within 3 days with continued nursing care and antipyretic medication as ordered.

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Dan Dan Manaois
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117 views3 pages

Urdaneta City University: Nursing Care Plan

This nursing care plan addresses a patient with a fever of 38.5°C likely due to a bacterial infection as evidenced by sore throat and enlarged lymph nodes. The short term goal is to reduce the patient's temperature to 37.3°C within 2 hours with interventions like monitoring temperature, observing for chills, and providing tepid sponge baths. The long term goal is for the patient to maintain a normal temperature range and be free from chills within 3 days with continued nursing care and antipyretic medication as ordered.

Uploaded by

Dan Dan Manaois
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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URDANETA CITY UNIVERSITY

San Vicente West, Urdaneta City, Philippines-2428


COLLEGE OF HEALTH SCIENCES
Bachelor of Science in Nursing

NURSING CARE PLAN

Name of Student: NAGUI, FERMARY NICOLE A. Date:


Affiliating Agency/Area: Year/Level: BSN-3

ASSESSMENT NURSING PLANNING INTERVENTION/ RATIONALE EVALUATION


DIAGNOSIS S

Short Term Goal: Independent: Short Term Goal


Evaluation
Subjective: Hyperthermia After 2 hrs. of > Monitor patient > Fever pattern may
related to nursing temperature aids in diagnosing After 2 hrs. of nursing
positive bacterial intervention the degree and underlying disease. intervention the patient
infection as patient’s elevated patterns. was able to maintain core
manifested by temperature of temperature within
sorethroat with 36.2 will lessen to normal range.
enlarged and 37.3 degree > Observe for
tender lymp celsius. shaking chills and > Chills often precede
nodes in necks. diaphoresis. during high
temperature and in
presence of
Objective: INFERENCE Long Term goal: Long Term Goal
generalized infection.
Evaluation
Vital Signs Scientific After 3 days of
Explanation nursing After 3 days of nursing
Temperature: 38.5°C, interventions the intervention the patiet
> May help reduce
febrile Infectious agent patient will > Provide tapid was able to demonstrate
fever. Use of ice water
demonstrate sponge baths and and alcohol may cause temperature within
Blood pressure: 124/76
temperature within avoid the use of ice normal range and free
Heart rate: 100 Monocytes normal range and water and alcohol chills and can elevate from chills.
free from chills. temperatue.
Respiratory rate: 16

Pyrogenic > Monitor for signs


cytokines of delericration of > May reflect
condition or failure inappropriate
to improve with antibiotic therapy.
Elevated therapy.
thermoregulatory Educative:
set point
> Encourage active
participation of > Explained every
patient care and procedure done to the
Increased Heat patient and family.
Conservation treatment
decisions.

Increased Heat
Production
Dependent:

> Administer > Used to reduce


antipyretics as fever.
ordered.
Checked by: Mr. Edward Reiner Palaganas Date:

Clinical Instructor’s Name and Signature

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