NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Evaluation

S: “pabalik-balik pa pt. has fever aeb a To lower the temperature Independent: Temperature becomes
yung lagnat ko” temperature of 37.9oC, from 37.8oC to 37.5oC  develop rapport c 37.4oC at the end of the
o
r/t disease process and 2 the patient shift. Goal met.
O: to increased metabolic  provide a
 received pt. lying rate. comfortable
on bed c environment
D5LRiLx8o@  arrange the bed
100cc level, linens
infusing well @  positioning to
left hand. make the pt.
 conscious and comfortable
coherent  regulate the IV
 ambulatory fluid
 c flushed and  monitor vital
warm to touch signs
skin  administer TSB
 (+) back pain c a  encourage more
pain scale of fluid intake
5/10, 10 being  monitor intake-
the highest. output balance.
 good capillary Dependent:
refill  give antipyretics
 good skin turgor as ordered by the
 on EDCF diet physician
 c good appetite,  administer fluids
consumed all of and electrolytes
her foods.
 (+) abdominal replacement
pain @ the right
lower quadrant, c
pain scale of
4/10, 10 being
the highest
 not defecating
since
confinement 2
days ago
 voided freely
V/S:
T- 37.8oC
PR- 92 BPM
RR- 21
BP- 110/70