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Assessment Diagnosis Planning Intervention Rationale Evaluation

The patient presented with hyperthermia and rashes secondary to dengue fever. The nursing care plan included interventions to lower the patient's temperature such as tepid sponge baths, cool environment, adequate hydration and antipyretics as needed. Skin care involved keeping the affected area clean, dry and removing irritants to prevent further invasion of microorganisms and skin breakdown. The goals of the plan were to lower the patient's temperature to normal range and help them manage skin discomfort through prevention and treatment measures. Evaluation showed the temperature was lowered to 37 degrees Celsius and the patient was able to participate in skin care.

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158 views2 pages

Assessment Diagnosis Planning Intervention Rationale Evaluation

The patient presented with hyperthermia and rashes secondary to dengue fever. The nursing care plan included interventions to lower the patient's temperature such as tepid sponge baths, cool environment, adequate hydration and antipyretics as needed. Skin care involved keeping the affected area clean, dry and removing irritants to prevent further invasion of microorganisms and skin breakdown. The goals of the plan were to lower the patient's temperature to normal range and help them manage skin discomfort through prevention and treatment measures. Evaluation showed the temperature was lowered to 37 degrees Celsius and the patient was able to participate in skin care.

Uploaded by

Aria
Copyright
© © All Rights Reserved
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Download as PPTX, PDF, TXT or read online on Scribd
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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Hyperthermia Within 8 hours of  Provide tepid sponge  Heat loss by means of After 8 hours of
Subjective: related to appropriate nursing bath evaporation and nursing intervention
“Mainit ang inappropriate intervention the client conduction goals and objective
pakiramdam ko” as clotting factor as will be able to maintain  Assist patient in  Increases comfort was met as evidenced
verbalized by patient evidenced by core temperature within changing into dry by :
decrease in normal range as clothing.
Objective: platelet count  Provide cool, calm  Heat loss by means of -Body temperature
V/S taken as follow: secondary to Evidenced by: body and restful convection and help lowered to 37 degree
dengue temperature is lowered environment. limits oxygen needs. Celsius.
Temperature- 38.4 hemorrhagic to 37 degree Celsius.  Maintain bed rest or  To reduce metabolic
Pulse Rate- 81 bpm fever. minimize movement demands of oxygen
Oxygen Saturation- consumptions.
98%  Discuss importance  To prevent dehydration
Respiratory Rate- 24 of adequate fluid
cpm intake particularly to
Blood Pressure- the parents.
100/80
 Strictly monitor  To know if the patients
-Flushed Skin temperature / Vital temperature went down
-Hot to touch signs to the normal value.

 Increase fluid intake  To lower the temperature

 Administer  To alleviate the fever of


medication the patients
(antipyretic or
paracetamol ) as
prescribed by the
physician.

 Refer to the  To monitor patient’s


physician if the condition.
temperature still
higher to normal
range.
ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
Subjective:  Impaired skin Within the span of our  Establish  To gain trust and Goal partially met after
“Kumakalat ang integrity care, the patient will rapport cooperation. the span of our care, the
rashes sa balat ko” related to be able to: patient was able to:
as verbalized by the presence of  Participate in  Encourage to  To assess the  Participate in
patient rashes prevention verbalize skin intensity prevention
secondary to measures & discomfort measures &
dengue fever treatment treatment
Objective: program.  Inspect skin  To assess client with program.
 With skin  Verbalize rashes. correcting or  Verbalized
rashes noted feelings & feelings & ability
minimize the
 Irritability ability to to manage
condition
noted
manage  Recommended  To reduce risk of situation
 Frequent
situation. keeping nails dermal injury when
itching
short. severe itching is
 Vital Signs:
present.
Temperature - 38.4  Kept the area
Pulse Rate - 81 bpm affected clean  To prevent further
Oxygen Saturation - and dry invasion of
98% microorganism
Respiratory Rate -  Removed
24 bpm wet/wrinkled  Moisture
Blood Pressure - linens potentiates skin
100/80 mmHg breakdown
 Instructed
patient not to
use tight  To prevent skin
clothing. irritation

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