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    Camba-Course Task 4

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    Rachelle Camba
    The patient maintained a normal body temperature below 37.5°C as evidenced by hourly temperature monitoring. Vitals monitoring provided a clear picture about the patient's condition. The interventions helped reduce the patient's fever and symptoms.

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    Camba-Course Task 4

    Uploaded by

    Rachelle Camba
    316 views5 pages
    The patient maintained a normal body temperature below 37.5°C as evidenced by hourly temperature monitoring. Vitals monitoring provided a clear picture about the patient's condition. The interventions helped reduce the patient's fever and symptoms.

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    CAMBA-COURSE TASK 4

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    The patient maintained a normal body temperature below 37.5°C as evidenced by hourly temperature monitoring. Vitals monitoring provided a clear picture about the patient's condition. The interventions helped reduce the patient's fever and symptoms.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    316 views5 pages

    Camba-Course Task 4

    Uploaded by

    Rachelle Camba
    The patient maintained a normal body temperature below 37.5°C as evidenced by hourly temperature monitoring. Vitals monitoring provided a clear picture about the patient's condition. The interventions helped reduce the patient's fever and symptoms.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 5

    CAMBA, RACHELLE S.

    BSN 2-A-21
    PHARMACOLOGY

    COURSE TASK 4
    Make a Nursing Care Plan using the nursing process applied in pharmacology learned in this course:

    Chief Complaint: Fever


    History of Present Illness:
    3 days PTA, patient experienced low grade fever (undocumented) associated with cough and colds. He self
    medicated with lagundi herbal capsule w/c afforded temporary relief.
    2 days PTA, patient still with cough, colds and low grade fever (undocumented) hence consulted a private
    physician and was given Paracetamol 500mg q4h for the fever and Ambroxol 30mg TID for 5 days w/c afforded
    temporary relief of the symptoms.
    Few hours PTA, symptoms persisted accompanied with body malaise and an episode of minimal gum
    bleeding w/c prompted the patient to consult a private physician. He was advised for admission hence transferred in
    our institute.
    Physical Examination: Patient conscious, coherent, febrile, NICRD with the ff:
    BP: 100/70 mmHg RR: 22 cpm
    CR: 82 bpm T: 38.5˚C
    HE-ENT/SKIN: Pink palpebral conjuctiva, anicteric sclera, dry lips, (+) nasal discharge, (-) tonsillopharyngeal
    congestion, (-) cervicolymphadenopathy
    CHEST: Symmetrical chest expansion, clear breath sounds, (-) retraction, (-) crackles
    Adynamic precordium, normal rate, regular rhythm, no murmur, grossly normal extremities, (-) cyanosis, (-) edema
    ABDOMEN/ RECTUM: flat abdomen, soft, tender, normoactive bowel sound
    LABORATORY TESTS: Hemoglobin 198g/dl, Hematocrit 40%, WBC 4.5/mcl. Chest X-ray- normal. Urinalysis is
    unremarkable.

    Assessment
    ✓ Diagnosis
    ✓ Background Knowledge
    ✓ Planning
    ✓ Intervention
    ✓ Rationale
    ✓ Evaluation
    ASSESSMENT NURSING GOAL PLANNING INTERVENTION RATIONALE EVALUATION
    DIAGNOSIS
    Subjective: Hyperthermia Patient • Assess the body • Assessed the • To assess the Patient maintained
    related to maintains temperature of body patients a normal body
    Patient says that " I was infectious normal the patient. temeperature condition. temperature range
    having low grade fever process as body • Identify the of the patient, • Identifying the below 37.5 c as
    associated with cough and evidenced by temperatur triggering T=38.5˚C triggering evidenced by
    increased body e range factors. • Identified the factors will helps hourly
    colds. I self medicated with
    temperature of below 37.5 • Monitor the triggering to manage the temperature
    lagundi herbal capsule , which
    38.5˚C C Heart rate, BP factors. situation monitoring
    gave me temporary relief. But and SPO2 Patient had effectively.
    now i have fever, accompanied • Monitor fluid elevated body • Vitals
    with body malaise and an intake and temperature MONITORING
    episode of minimal gum output and nasal WILL PROVIDE A
    bleeding. am feeling pain over • Eliminate discharge. clear picture
    my throat also." excess clothings • Monitored the about the
    and coverings Heart rate, patients
    Objective: • Encourage BP and SPO2. condition.
    • On P/E the patient is very ample fluid ➢ BP:100 • Monitoring th
    week. Pink palpebral intake by mouth. /70m fluid intake will
    conjuctiva, anicteric • Raise the side mHg give information
    sclera, dry lips, (+) nasal rails of the bed. ➢ RR: 22 regarding the
    discharge, (-) • Administer cpm fluid status of
    tonsillopharyngeal antipyretics and ➢ CR:82 the client.he
    congestion, (-) other bpm patient who is
    cervicolymphadenopathy medications ➢ T: significantly
    • Vitals are not stable. prescribed by 38.5˚C dehydrated is no
    patient had elevated body the physician • Monitored longer able to
    temperature. fluid intake sweat, which is
    • BP:100/70mmHg and output. necessary for
    • RR: 22 cpm Drinking evaporative
    • CR:82bpm adequately cooling and to
    • T: 38.5˚C • Eliminated reduce the body
    excess temperature.
    • Chest is clear and no clothings and • Raising the side
    abnormalities found. coverings rails will provide
    • Encouraged comfort and
    ample fluid prevents falls.
    intake by • Administering
    mouth. the antipyretics
    • Raised the and other
    side rails of prescribed
    the bed. medications
    • Administered helps to reduce
    antipyretics temperature and
    and other bleeding.
    medications
    prescribed by
    the physician

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