Name of Patient: Vicente Agbuya

Age: 30 Sex: Male

Diagnosis: T/C PTB Pneumonia with Congestion

PROBLEM # 2: Fever

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
S: “Mainit ang Hyperthermia related to LTO: After 2 days of 1. 1. Monitored vital 1. 1. To provide baseline Goals partially met as
pakiramdam ko”, as infectious process. nursing interventions, sign, and fluid intake and of patient’s medical status, and evidenced by:
verbalized by the the patient will manifest urine output. fluid status. - a decrease in body
patient. an improved general 2. 2. 2. To quickly dissipate temperature from 39.5°C
body condition and 3. 2. Performed tepid body heat by conduction. to 38.3°C.
O: absence of sponge bath every 30 minutes.3. 3. To dissipate body - a decrease in RR to 26
- weak and pale in complications. 4. 3. Provided good heat by convection and cpm.
appearance ventilation. evaporation.
- skin warmth to touch STO: After 8 hours of 5. 4. 4. To promote lung Goals met as evidenced
- febrile (Tᵒ = 39.5 ᵒC) nursing intervention 6. 4. Placed patient in expansion. by:
- shallow, rapid patient’s general body semi- or high-fowler’s 5. - a decrease in PR to 100
respiration (RR = condition will be position. 6. 5. To provide comfort. bpm.
39cpm) improved as evidenced7. 5. Encouraged patient7. - a decrease in dryness in
- weak, rapid pulse (PR by: to wear loose-fitting clothes. 8. 6. To restore body the lips and in the mouth.
= 120 bpm) - a decrease in body 8. 6. Encouraged strength. - verbalizes ways to
- BP = 110/80 mmHg temperature from enough bed rest. 9. prevent dehydration.
(within patient’s 39.5ᵒC to 37.5ᵒC. 9. 7. Encouraged 10. 7. To prevent
baseline BP) 1. – RR will be increase in oral fluid intake, dehydration.
- flushed skin reduced to 25 cpm. with strict aspiration 11.
- poor skin turgor 2. – PR will be precaution. 12.
- dry lips and mucosa of reduced to 100 bpm. 10. 8. Advised soft, high-
13. 8. To meet the body’s
the mouth 3. - decrease calorie diet. increased metabolism/or body’s
- restlessness dryness in oral cavity. 11. demand for energy, and to
4. - verbalizes 12. prevent aspiration.
ways to prevent 13. 9. Encouraged patient14. 9. To decrease dryness
complication such as to do frequent oral care. of the oral mucosa and lips.
dehydration. 14. 10. Explained the 15. 10. To educate the
nature of fever, prevention of patient about nature of fever,
complications, and self- prevention of complication and
management care. self-management care.
11. Administered antipyretic 16. 11. To decrease body
medications as ordered. temperature to normal range.