Date,

Shift
& Assessment Need Nursing Plan Intervention Evaluation
Time Diagnosis

Aug. Subjective: H Hyperthermia After 2 hours of 1. Monitor patient’s temperature (degree GOAL MET.
26, related to nursing and pattern), note shaking chills/profuse
2019 “Pabalik- E increased interventions, diaphoresis After 2 hours of effective
balikyungla metabolic rate the patient shall nursing intervention the
gnat ko, A R: Temperature of 38.9-41.1°Csuggest patient’s temperature
secondary to
simula pa L presence of -Demonstrate acute infectious disease process returned to normal range as
3 PM- nungnaadmi temperature manifested by:
11 PM tako,” bacterial infection
as T within normal 2. Note presence or absence of sweating
verbalized H Rationale: range, from as body attempts to increase heat loss by - temperature of 37.6 C, and
by patient. 37.9 °C to evaporation. verbalize understanding of
Presence of 36.5°C-37.5°C interventions
microorganisms R: Evaporation is decreased by
Objective: - Identify environmental factors of high humidity
P stimulates the
-Blood underlying and high ambient temperature as well as
release of pyrogen cause/contributi body factors producing loss of ability to
Pressure E
from the ng factors and sweat
120/70 R leukocytes importance of
mmHg resetting the treatment 3.Increase oral fluid intake
C body’s thermostat
- - Verbalize R: To support circulating volume and
E to febrile level understanding
Temperature and then there tissue perfusion.
: 37.9 C P of specific
would be interventions to 4. Promote bed rest, encourage relaxation
T activation of the prevent skills and diversional activities.
-Tachcardia hypothalamus,
127 BPM hyperthermia to
I which will result R: To reduce metabolic demands/oxygen
promote healthy
in increase in consumption
-Respiratory O environment.
epinephrine and
rate 5. Provide tepid sponge bath, avoid use
N norepinephrine,
25 BPM of alcohol
vasoconstriction
- of cutaneous R: May reduce fever, use of ice
-Flushed vessels. The heat water/alcohol may cause chills, actually
H
skin, warm will be produced elevating temperature. In addition,

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to touch E as peripheral alcohol is very drying.
vasodilation
A results in skin 6. Promote surface cooling, loosen
flushing and skin clothing and cool environment
L
is warm to touch. R: Heat is loss by evaporation and
T conduction.
H 7. Educate patient on the importance of
adequate fluid intake and protein diet

M R: Adequate fluid intake prevents

dehydration and protein diet promotes
A healing.
N Dependent
A 8.Administer medications as indicated to
G treat underlying cause, such as:

E -Paracetamol 500mg/tab 1 tab q 6°

M R: Paracetamol exhibits analgesic action

by peripheral blockage of pain impulse
E generation. It produces antipyresis by
inhibiting the hypothalamic heat-
N
regulating centre. Its weak anti-
T inflammatory activity is related to
inhibition of prostaglandin synthesis in
the CNS.
9. Administer replacement fluids and
electrolytes to support circulating volume
and tissue perfusion
R: In the presence of fever, the amount of
water the body loses is increased causing
dehydration and electrolyte imbalances.
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 Replacement fluid and electrolytes are
needed to compensate.
10. Provide information and involve
client in appropriate community and
national education programs.
R: To increase awareness and prevention
of communicable diseases.

Cues Needs Nursing Objective of Care Nursing Intervention Evaluation

Diagnosis
Impaired Skin After the 8 hours 1.Monitor site of impaired tissue integrity Goal Met
Subjective: A Integrity related of nursing at least once daily for color changes, The patient performed
to inflammatory intervention, the redness, swelling, warmth, pain, or other wound care and
“Naga itom C response patient will signs of infection. verbalized her
ang akong secondary to describes understanding about
tudlo” As T infection measures to R:Systematic inspection can identify proper nutritional intake
verbalized by protect and heal impending problems early. to hasten wound healing.
the patient I R: Skin is the the tissue,
primary defense including wound 2.Monitor status of skin around wound.
Objective: V of the body; it care. Monitor patient’s skin care practices,
protects the body noting type of soap or other cleansing
- Necrotic tip I against infections agents used, temperature of water, and
of the left and diseases frequency of skin cleansing.

165
index finger ( T brought about by
cyanotic the invasion of R:Individualize plan is necessary
color) Y microbes in the according to patient’s skin condition,
body. A normal needs, and preferences.
& skin is moist and
- WBC intact; dryness of 3.Provide tissue care as needed.
106. 21 E the skin is more
x10^3/Ul prone to friction R:Each type of wound is best treated
X that may result to based on its etiology. Skin wounds may
-Blood impairment of be covered with wet or dry dressings,
Pressure C the skin integrity topical creams or lubricants, hydrocolloid
120/70 mmHg as compared dressings (e.g., DuoDerm) or vapor-
E with a moist permeable membrane dressings such as
-Temperature: skin. Tegaderm
37.9 C R
4.Keep a sterile dressing technique during
-Tachcardia C wound care.
127 BPM
I R:This technique reduces the risk for
-Respiratory infection.
rate S
25 BPM 5.Premedicate for dressing changes as
E necessary.

R:Manipulation of profound or extensive

cuts or injuries may be painful.

6.Monitor patient’s continence status and

minimize exposure of skin impairment
site and other areas to moisture from
incontinence, perspiration, or wound
drainage.

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R:This is to prevent exposure to chemicals
in urine and stool that can strip or erode
the skin.

7.Educate patient about proper nutrition,

hydration, and methods to maintain tissue
integrity.

R:The patient needs proper knowledge on

his or her condition to prevent further
tissue injury.

8.Teach skin and wound assessment and

ways to monitor for signs and symptoms
of infection, complications, and healing.

R:Early assessment and intervention help

prevent the development of serious
problems.

9.Instruct patient, significant others, and

family in proper care of the wound
including hand washing, wound cleansing,
dressing changes, and application of
topical medications).

R: Accurate information increases the

patient’s ability to manage therapy
independently and reduce risk for
infection.

Independent Nursing Care:

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Administer antibiotics as ordered.

R: Wound infections may be managed

well and more efficiently with topical
agents, although intravenous antibiotics
may be indicated

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