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Comprehensive Nursing Care Plan for Fever

This document outlines a comprehensive nursing care plan for a patient named Cielo Jayleen D. Bautista, who is experiencing acute fever due to rheumatic heart disorder. The plan includes assessments, diagnoses, goals, interventions, and rationales for nursing care aimed at managing the patient's fever and overall health. The patient has met short and long-term goals, showing no signs of fever and normal vital signs after nursing interventions.

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hed-cjbautista
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13 views1 page

Comprehensive Nursing Care Plan for Fever

This document outlines a comprehensive nursing care plan for a patient named Cielo Jayleen D. Bautista, who is experiencing acute fever due to rheumatic heart disorder. The plan includes assessments, diagnoses, goals, interventions, and rationales for nursing care aimed at managing the patient's fever and overall health. The patient has met short and long-term goals, showing no signs of fever and normal vital signs after nursing interventions.

Uploaded by

hed-cjbautista
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Saint Mary’s University

SCHOOL OF HEALTH and NATURAL SCIENCES


Nursing Department
Bayombong, Nueva Vizcaya

COMPREHENSIVE NURSING CARE PLAN


NAME: Bautista, Cielo Jayleen D.
YEAR/ SECTION/ GROUP NO.: BSN 2C / GROUP 2 DATE: 04/25/24
CLINICAL INSTRUCTOR: ma’am Nicole Nathalie S. Delacruz
ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EVALUATION
EXPLANATION
SUBJECTIVE DATA: Acute Fever Fever is a cardinal sign of SHORT TERM GOAL: INDEPENDENT: SHORT TERM GOAL:
“Nilalagnat din po secondary to inflammation and immune After 1 hour of nursing -Encourage fluid intake -For avoidance of GOAL MET
ako madalas” as activation, often observed in interventions, the patient -Monitor vital signs dehydration AEB:
rheumatic heart various infectious and will be able to: -Encourage bed rest -To monitor the patient’s -patient has no signs of
verbalized by the disorder inflammatory conditions. In -Have no signs of flushed -Provide proper ventilation status flushed cheeks
patient the context of rheumatic heart skin -Perform tepid sponge bath -To help patient recover -Not warm to touch
disease (RHD), fever serves -Not warm to touch -For cooler airway -Vital signs are at normal
as a sentinel marker of the -Temperature has ventilating at the room limit specifically the
underlying autoimmune decreased -To help cooling the body temperature
response triggered by
OBJECTIVE DATA: preceding streptococcal
-Warm to touch infections. Rheumatic heart DEPENDENT: LONG TERM GOAL:
disease is a consequence of LONG TERM GOAL: -Administer medications as -for immediate GOAL MET
-Flushed cheeks untreated or inadequately After 12 hours of nursing ordered by the physician interventions AEB:
-Vital signs taken as treated Group A streptococcal interventions, the patient - Recovered patient with
follow: infections, particularly will be able to: no signs of fever
BP- 110/60 mmHg pharyngitis or impetigo. The -Have no signs of fever COLLABORATION: -Have a normal limit of
RR- 24 bpm pathogenesis of RHD involves -No flushed cheeks -Educate patient and family -For helping them when vital signs
a complex interplay between -Vital signs are at normal about the condition they are on their own -Patient and family is able
PR- 112 bpm bacterial antigens, host limits to recall the health
Temp - 38.5 C immune responses, and teachings.
genetic predisposition.

1st Floor, Constant Jurgens (UB) Building


Saint Mary’s University, Ponce St., Bayombong, Nueva Vizcaya, 3700 Philippines
Telephone: (078) 321-2221 ext. 122; Telefax: (078) 321-2117; Mobile No.: 0936-286-726

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