Mariano Marcos State University

College of Health Sciences

DEPARTMENT OF NURSING
City of Batac

NCM 103 RLE: NURSING PROCESS APPLICATION

Submitted by:
MARY GRACE CABALLERO
BSN 1–D

Submitted to:
PROF. JOSEPHINE D. CERIA
Clinical Instructor

February 18, 2018

Situation:

A 15-year-old boy was brought by his mother to the RHU due to non-productive cough
with runny nose and fever for 3 days prior to consultation.
The boy is the youngest among 8 siblings of Mrs. De la Cruz. The father of the boy is
a farmer.
Upon assessment by the RHU Nurse, she observes that the boy has foul odor smell with
dirty shorts containing spilled stool (3x since he arrived at the RHU), poor skin turgor, dry skin,
sunken eyeballs, and verbalized by the patient "Nanghihina ako".
While the Nurse is taking the vital signs, she noted the skin is warm to touch, dirty
fingernails

Vital signs taken:

BP: 100/60 mmHg PR: 90/min RR: 25/min T: 38.6 degrees C

Seen by Dr. Domingo with the following orders:

• Increase fluid intake
• Paracetamol 1 tab 250mg every 4 hours
• Oresol glass every 2 hours

Manifestations:

Priority
Subjective Cues
#
• Patient verbalized, “Nanghihina ako” 4
Objective Cues
• Non-productive cough with runny nose and fever for 3 days 7
• Foul odor smell with dirty shorts containing spilled stool 5
• Poor skin turgor
3
• Dry skin
• Sunken eyeballs 6
• Skin is warm to touch 1
• Dirty fingernails 8
Vital signs taken:
• T: 38.6 degrees C 1
• BP: 100/60 mmHg 2
• PR: 90/min -
• RR: 25/min -
Nursing Diagnosis:
Deficient [isotonic] fluid volume related to fever as manifested by poor skin turgor, dry
skin, a BP of 100/60 mmHg, a temperature of 38.6 ⁰C and patient verbalizing, “Nanghihina
ako”.

Inference:
Decreased intravascular, interstitial, or intracellular fluid as caused by water loss
without a change in sodium that can result from a number of diseases that cause insensible
water losses through the skin, respiratory tract, or through increased renal secretion.

Goal:
To maintain fluid volume at a functional level.

Objectives:
After 4–6 hours of effective nursing interventions, the patient will have maintained fluid
volume at a functional level as will be manifested by good skin turgor, hydrated skin, a BP of
120/80 mmHg, subsiding of temperature from 38.6 ⁰C to 37.5 ⁰C, and patient will verbalize,
“Hindi na ako nanghihina”.

Nursing Interventions:

Dependent:
1. Increase fluid intake
2. Paracetamol 1 tab 250mg every 4 hours
3. Give Oresol glass every 2 hours
Independent:
1. Provide Tepid Sponge Bath
2. Make the client wear light clothes
3. Encourage food intake with high fluid
intake
Rationale:
To replace fluid loss
Promotes rapid core healing thus stopping
fluid loss
To replace electrolytes and fluid loss
To reduce high fever and elevated metabolic
rate by heat loss and evaporation.
Promotes eat loss by radiation and
conduction.
To promote fluid replacement

Evaluation:
After 6 hours of effective nursing interventions, the patient has maintained fluid volume
at a functional level as manifested by good skin turgor, hydrated skin, a BP of 120/80 mmHg,
subsiding of temperature from 38.6 ⁰C to 37.5 ⁰C, and the patient verbalized, “Hindi na ako
nanghihina”.