1.

Nursing Care Plan

Student: Niken Ariska Prawesti/131411133002
Patient Initials/Age: An.A/3years old
Dates Cared For:16/10/2015
Medical Diagnosis: Otitis Media
Definition of Medical Diagnosis: OM is a group of inflammatory diseases of the middle ear.
NURSING
EXPECTED PATIENT
NURSING
RATIONALE/PRINCIPLES
EVALUATION
DIAGNOSIS &
OUTCOMES
INTERVENTIONS
Expected Outcome
SUPPORTING DATA
Planning
Intrventions
Nursing Intervention
Assessment &
Diagnosis

Hyperthermia r/t
inflammatory process
of the infection
Subjective:
1. The parents said that
their son was had a
fever since two days
ago.
2. He has been listless
and his oral 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.

ST:
1.Monitor the temperature as
1.Patien
body much as possible
temperature
within
36.5C - 37.5C
1/2. Give compress (cold or
warm) patient in the groin and
2.Patient will maintain axila
vital
sign
(Blood
pressurePulse
and 1/3. Monitor the intake and
Resp.rate) .
output of the patient
3.Parents will verbalize
understanding
the
importance
of
temperature regulation
and
the
possible
negative effects of the
cold.

1.Monitoring
the 1.Outcome
met.
Patient
temperature continuely can maintained
body
avoid the complication early. temperatures
at
36.5C37.5C
2.Compress in the groin and
axilla can be use to decrease 2.Outcome
met.Patient
the body temperature.
maintained vital sign through
shift in normal range
3.Monitor intake and output
restrictly can be use to early 3.Outcome
not
met.SN
1/4.Monitor decreased level of warning of dehidration.
educated
patient
on
consciousness
importance of temperature
4.Change in behaviour and regulation and the possible
2.Monitor blood pressure, mentation is an early sign of negativ effects of the cold.
pulse,
temperature
and dehidration
because
of
resp.rate
hyperthermi.

2/2.Note the fluctuations in 2.The change of vital sign

blood pressure
can be used for early
LT:
indication of complication.
1.Patient will display 3.Educated the parents on
adequate
body importance of temperature 3.Prevents the dehidration by
temperatures(
temp. regulation and the possible knowing the negative effects
36.5C-37.5C,normal
negative effects of the cold.
of hyperthermia.
skin color).

2.Data Analysis
No
Data
.
1.
Subjective:
1. The parents said that their son was
had a fever since two days ago.

Etiology
Secondary infection (Influenza,streptococous)

The bacteria infected the middle ear

2. He has been listless and his oral
intake has been well below normal
Mechanism of inflamatory
Objective:
1.Temperature: 40C
Increase of body temperature
2.The Patient look listless and lost of
appetite
3.Pulse:110 per minutes,Respiration
rate:24 times per minutes.

Problems
Hyperthermia