Nursing Scientific

Cues Planning Implementation Rationale Evaluation

Diagnosis Explanation
Subjective: Increased Clinical signs of Short term: Independent: Short term:
body fever vary with the After 2 hours Goal
“Nilalagnat temperatur onset, course, and of nursing 1) Take the client’s vital 1) This serves as a achieved
ang baby ko”, as e related to abatement stages intervention, the signs baseline data (NSG since client’s
verbalized by the decrease of the fever. These client’s mother Procedures) mother was
client’s mother. in urine signs occur as a will be able to 2) Take note of the 2) This is important for able to
output as result of changes in enumerated client’s body temperature cases concerning the enumerated
Objective: evidenced the set point of the safety measures temperature. safety
by the temperature control and things to 3) Apply tepid sponge 3) Provides comfort; measures
• Age: 4 client’s mechanism avoid in bath decreases body while client
months body regulated by the decreasing temperature (Manual has fever.
• PR: 142 temperatur hypothalamus. In a client’s body of NSG Procedures) The client’s
bpm e which is fever, the set point temperature. 4)Avoid draft at anytime 4) May cause temperature
• RR: 58cpm 38.2oC of this hypothalamic The client’s in the room (air entering shivering or was lowered
• Temp: 38.2 thermostat changes body the room) convulsions (from 38.2 to
• Poor/non- from normal level to temperature will 5) Reassess client’s 5) To know if there are 37.2)
mobile skin a higher than decrease and body temperature. any changes in the
turgor normal values; as a his urine output (Document any changes) client’s skin Discharge
result of tissue will increase. temperature (NSG outcome:
• Dry skin
destruction, Procedures) Goal was
• Capillary
pyrogenic Discharge Plan: 6) Discuss with the 6) Impart information; achieved
refills within
substance, and After client client’s significant other enhances participation since client’s
3 seconds
dehydration of is discharged, the causative factors of of S.O. (NSG DIAG) temperature
• Client is hypothalamus. the body the client’s status returned to
active and temperature will 7) Teach the S.O. some 7) Promotes safety normal (37.2).
responsive Reference: return to its precautionary measures and security (Manual The I/0 was
• Fluid intake Kozier, 8th normal value of NSG Procedures) also
is 1655ml Edition, Unit 7, and there will be 8) Monitor I/O of the 8) I/O is also affected balanced.
• Urine output chapter 29, page a balance in the client. by fever
is 850ml 530 I/O of the client.
Collaborative:

1) Administer antipyretics 1) Reduces body

(as ordered), temperature (NANDA)
orally/rectally
2) Administer 2) To prevent or
medications as ordered control
shivering/seizures
(NANDA)
3) Administer 3) Supports circulating
replacement fluids and volume and tissue
electrolytes perfusion. (NANDA)