NURSING CARE PLAN

CUES NURSING NURSING NURSING RATIONALE EVALUATION

DIAGNOSIS OBJECTIVES INTERVENTION
OBJECTIVE: 1. Hyperthermia Short term: Independent: Short term:
 T=39.0 r/t infection as After 2 hrs. of  Monitor VS  Change in body After 2 hrs. of nursing
 Flushed manifested by nursing especially temperature intervention, goal was
skin; flushed skin intervention, the temperature. indicates achieved as evidenced
warm to child will be able presence of by:
touch. to: infectious disease  Patient
 Alleviate and process as maintained the
maintain body manifested by normal body
temperature fever. temperature all
after 2 hours.  Encouraged increase  Prevent throughout the
 Patient’s skin fluid intake. dehydration treatment after
is cool and especially there’s 2 hours.
lessen its presence of  Patient’s skin is
flushness. sweating. cool and
 Apply tepid sponge  TSB helps in absence of
Long term: bath (TSB). lowering the flushness was
After a week of body seen.
nursing temperature.
intervention, the  Provide quiet and
child will be able well ventilated
to: environment
 Free from  Advised to wear  Gives comfort
complication loose shirts or and release body
such as brain kamiseta. heat.
damage and
neurological Collaborative:
problems.  Give  Paracetamol
medication helps lower body
(paracetamol) temperature.
PRN as
 prescribed by
the AP.

CUES NURSING NURSING NURSING RATIONALE EVALUATION

DIAGNOSIS OBJECTIVES INTERVENTION
OBJECTIVE: ACUTE PAIN R/T Short term: Independent:  Note any Short term:
 Both ear INFLAMMATION OF After 1 hr. of nursing  Monitor VS changes in After 1 hr. of nursing
reddish MIDDLE EAR. intervention, the and skin body towards intervention, goal was
 Face pain child will be able to: color. pain. achieved as evidenced
scale  Reports  Encourage  To decrease by:
ranging 4-6. reduce pain. increased susceptibility  Patient
 Returns back fluid intake. to infection. verbalized
its energy  Promote  To lessen reduced in
level and proper anxiety and pain and
demonstrate positioning find comfort demonstrate
behavior in  Provide quiet  To promote absence of sign
accordance and well non and symptoms
to pain. ventilated pharmacologic of pain.
environment pain  The patient
management. still observe
 Determine  To establish the energy
pain guideline for level that can
characteristics assessing pain be seen in
through changes. absence of
clients weaknesses
reaction and
Collaborative: performing
 Administer  Analgesic simple activity.
medication ( serves as pain
analgesic) as killer.
 prescribed by
the AP.

CUES NURSING NURSING OBJECTIVES NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
Objective: Risk for Short term: Independent: Short term:
VS taken as infection r/t After 1 hr. of nursing  Assess signs and  Fever may After 1 hr. of nursing
follow: presence of intervention, the symptoms of indicate intervention, goal was
T=39.0 pathogens as child/parents will be infection infection. achieved as evidenced by:
PR= 103 bpm evidenced by able to: especially  The child indicated
fever  Indicate temperature. absence of pain
absence of  Emphasize the  It serves for a  The child/parents
pain importance of first line of stated
 Child/parents hand washing defense understanding of
will state technique and against preventive
understanding proper hygiene. infection. measures.
of preventive
measures.  Encourage to  Vitamin C Long term:
Long term: eat nutritious helps to boost After a week of nursing
After a week of nursing foods rich in immune intervention, the child was
intervention, the child vitamin C such system and free from infection.
will be free from as citrus fruits fight against
infection. and advise to infection.
increase fluid
intake.
Collaborative:  Aid to fight
 Give medication bacterial
(antibiotic, infection and
pedia zinc) as prevent
prescribed by spread of
the AP. infection and
boost immune
system.
 NURSES NOTES

DATE/SHIFT/TIME FOCUS PROGRESS NOTES

3/3/20 Increased Body D- Temp of 39o C via axilla; Flushed
7-3 Temperature and warm to touch;  WBC
2:15 PM A- Requested AP for antipyretics;
Administered 250 mg IV
paracetamol; Monitored temp
every 1 hr.; Heath teaching
done & advised on the ff:
 Proper handwashing
 Proper hygiene
  intake of fluids
 Eat nutritious foods
rich in Vit. C such as
citrus fruits
 Get adequate rest
R- Patient verbalized
understanding; temp decreased
from 39o C to 37.1
3/3/20 Pain D- Ear ache; both ears slight
7-3 reddish; tender to touch; pain
2:15 PM scale of 4-6.
A- Administered pain medications
as ordered by the AP; applied hot
compress; assist to find position
of comfort; needs attended.
R- Patient verbalized decrease pain;
Pain scale rated 2-6.