B.

Nursing Care Plan

EXPLANATION OF THE NURSING

ASSESSMENT PLANNING RATIONALE
PROBLEM INTERVENTIONS

Patient complained of STO: èx:

Subjective:
body weakness and
G ssess v/s, G To provide
³Mainit ang loss of appetite
noting for baseline
pakiramdam ko.´ because of fever. ºithin 3 hours of
changes. data.
nursing
The stab wound on the G ssess G To check for
intervention, the
patient¶s left and hydration signs of
Objectives patient¶s
posterior scapular status dehydration
temperature will
area caused the body Tx:
G —ebrile at decrease from 380C
to respond to a
38o C to 37.50 C.
possible development G !ender TSB G Rt helps
G ppears weak
of inflammation and reduce fever
G ºarm to touch
infection, resulting G To maintain
G —lushed skin LTO: G èo bedside
to an increase in comfort
care by
G èry skin body temperature.
changing bed
noted Monocytes/macrophages
ºithin 8 hours of linens
G ºith poor are activated thus,
nursing G Onsure safety
appetite exogenous pyrogens G To avoid
by regular

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 are secreted. These intervention, the monitoring falls that
exogenous pyrogens patient¶s G nticipate may cause
are destroyed and temperature will and attend to injury
absorbed by be in the normal needs G To help
O
phagocytes and then range from 36.5 C G dminister patient in
o
synthesis and to 37.5 C. medication as his èLs
Nursing èiagnosis: secretion of ordered like G jsed to
prostaglandin in the paracetamol reduce fever
anterior hypothalamus by its
Hyperthermia occurs. The central
related to hypothalamus action on the
ingestion of micro increases set point Odx: hypothalamus
organism secondary causing now fever.

to infection G Oncourage to
increase G To avoid
fluid intake dehydration
G dvise to
remove extra
G Number of
thick
blankets
clothing or
should be
blanket
altered to
maintain
near-normal
temperature

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 G Oncourage to G To fight for
eat a well infection and
balanced diet for faster
recovery
G To further
G Oncourage to
assess
report any
patient¶s
feeling of
status
discomfort

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 EXPLANATION OF NURSING
ASSESSMENT PLANNING RATIONALE EVALUATION
THE PROBLEM INTERVENTIONS

Objectives èiarrhea is the STO: èx: STO:

passage of loose
G —ebrile at ºithin 8 hours of G ssess v/s, G To provide fter 8 hours of
and watery
38o C nursing noting for baseline nursing
stools (more
G ppears weak intervention, the changes. data. intervention, the
than 3 bowel
patient will not G Observe and G Helps patient was not
G —lushed skin movements per
manifest any record stool differentiat able to manifest
G èry skin day) often
signs of frequency, e individual any signs of
noted associated with
dehydration characteristi disease and dehydration.
G ºith poor gassiness,
bloating, and cs, amount, assess
appetite
abdominal pain. and severity of
G ºith poor
LTO: precipitating episodes LTO:
skin turgor Rt may also be
accompanied by factors
G Passed out ºithin 3 days of fter 3 days of
nausea, G Rdentify
2-3 watery nursing G voiding nursing
vomiting, and foods and
stools intervention, the intestinal intervention, the
fever. èiarrhea fluids that
within the patient will have irritants patient had a
results to loss precipitate
shift a normal bowel promotes normal bowel
of diarrhea
pattern intestinal pattern
body fluids and
rest
salts leading to

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 dehydration of
varying
Tx:
severity.
Nursing Severe G Provide a G !est
èiagnosis: dehydration may quiet decreases
cause death environment intestinal
especially in to promote motility and
!isk for fluid children. rest reduces
volume deficit metabolic
related to rate
increased bowel
movement
G To replace
G Provide water lost
and other electrolytes
fluid needs

Odx:

G Some fruits
are stool
G Oncourage to formers
eat high
fiber diet
foods like

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 banana
and apple.

G Rnstruct
patient to
avoid foods
that
are oily, G Some foods
spicy and may
precipitate
caffeine gastric
cramping.

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