2.

Nursing Care Plan

Student: Niken Ariska Prawesti
Patient Initials/Age: An.A/3years old
Dates Cared For:14/10/2015
Medical Diagnosis: Otitis Media
Definition of Medical Diagnosis: OM is a group of inflammatory diseases of the middle ear.
NURSING DIAGNOSIS
EXPECTED PATIENT
NURSING
RATIONALE/PRINCIPL
EVALUATION
& SUPPORTING DATA
OUTCOMES
INTERVENTIONS
ES
Expected Outcomes
Assessment & Diagnosis
Planning
Intrventions
Nursing Interventions
Hyperthermia r/t
ST:
1.Monitor the temperature 1.Monitoring
the
inflammatory process of
1.Patien body temperature as much as possible
temperature continuely can
the infection
within 36.5C - 37.5C
avoid the complication
1/2. Give compress (cold early.
Subjective:
2.Patient will maintain or warm) patient in the
1. The parents said that
vital
sign
(Blood groin and axila
2.Compress in the groin
their son was had a fever
pressurePulse
and
and axilla can be use to
since two days ago.
Resp.rate) .
1/3. Monitor the intake decrease
the
body
2. He has been listless
and output of the patient
temperature.
and his oral intake has
3.Parents will verbalize
been well below normal
understanding
the 1/4.Monitor
decreased 3.Monitor intake and
importance of temperature level of consciousness
output restrictly can be use
Objective:
regulation and the possible
to early warning of
1.Temperature: 40C
negative effects of the 2.Monitor blood pressure, dehidration.
2.The Patient look listless cold.
pulse, temperature and
and lost of appetite
resp.rate
4.Change in behaviour and
3.Pulse:110 per
mentation is an early sign
minutes,Respiration
LT:
2/2.Note the fluctuations of dehidration because of
rate:24 times per minutes. 1.Patient will display in blood pressure
hyperthermi.
adequate
body

temperatures(
temp. 3.Educated the parents on
36.5C-37.5C,normal skin importance of temperature
color).
regulation and the possible
negative effects of the
cold.
Deficient fluid volume r/t
excessive increase of body
temperature
Subjective:
1. The parents said that
their son was had a fever
since two days ago.
2. He has been listless
Objetive:
1.Vital Sign :
Resp.Rate:24 times per
minutes. Pulse:110 x/
minutes. Temperature:
40Celcius
2.mucous membranes is
dry, the turgur is decreased
3.the patient look pale and
listless

1.Patient will maintains

normal blood pressure,
pulse,
and
body
temperature.
2.Maintains elastic skin
turgor, moist tongue and
mucous membranes,and
orientation to person,
place, time

2.The change of vital sign

can be used for early
indication of complication.

3.Prevents the dehidration

by knowing the negative
1.Monitor vital sign of effects of hyperthermia.
patient
every
1
hour.Observe
for 1.A
decreased
pulse
decreased pulse pressure pressure is an earlier
first, then hypotension, indicator of shock than is
tachicardia,
decreased the systolic blood pressure
volume, and increased or (Mikhail,1999).
decreased
body
temperature.
2.A 15mm Hg drop when
upright or an increase of
1/2.Check
orthostatic 15beats/minutes in the
blood pressure with client pulse rate are seen with
lying, sitting and standing. deficient fluid volume
(Metheny,2000)
2.Monitor for inelastic
skin turgor,thirst, dry 3.Tounge dryness, dryness
tounge
and
mucous of the mucous membranes
membranes, dry skin and of the mouth, uper body
weakness.
wekness,
thirst,
are
symptoms of deficient
2/2.Provide fresh water fluid
volumes
and oral fluids prefered by (Matheny,2000)

client.Provide prescribed
diet, offer snacks instruct
significant other to assist
client with feedings as
appropriate.

4.The oral route is

prefered for maintaining
fluid
balance
(Metheny,2000)

1. Data Analysis
No
Data
.
1.
Subjective:
1. The parents said that their son was
had a fever since two days ago.
2. He has been listless and his oral

Etiology

Problems
Hyperthermia

intake has been well below normal

Objective:
1.Temperature: 40C
2.The Patient look listless and lost of
appetite
3.Pulse:110 per minutes,Respiration
rate:24 times per minutes.