ASSESSMENT EXPLANATION OF THE GOAL AND OBJECTIVES INTERVENTIONS RATIONALE CRITERIA OF EVALUATION

PROBLEM

Subjective Data: The body temperature of the Goal:  Monitor patient’s  It serves as a
patient rises due to a Patient stabilized altered temperature q4 baseline data to
 Ate street foods 5 days possible ongoing infectious body thermoregulation. hours. ensure accurate
PTA as verbalized by disease process that is record of periods of
mother. related to possible intake of STO: on and off fever that
 Loss of appetite when contaminated food when the Within 2 hours of nursing may suggest
in fever as verbalized patient had eaten street intervention the patient will infection.
by the mother. foods 5 days PTA. As a be able to:
 Still feels hot and result, inflammatory and  Note for degree and  Chills and
Goal is fully met if the patient
sometimes diaphoretic infectious process happen to a) Participate in treatment pattern of shaking, sweating often
participated in treatment regimen
during hospitalization. the patient’s body. In regimen (e.g. removal of chills or profuse precede temperature
response of the body’s excess clothing, tepid sweating. spikes. (TSB, intake prescribed medications,
defense mechanism, release sponge bath) within level loosen clothing) to achieve a normal
Objective Data:
body temperature after 2 hours of
of antibodies and chemical of ability and  Assess hydration  An increase in
nursing intervention.
 Body temperature of mediators such as comfortability to achieve status. body temperature
37.5°C during Prostaglandins and a normal body tends to decrease
admission. Interleukins activate the temperature of 36.5°C to hydration status by
 Intermittent fever thermoregulatory system to 37.5°C from intermittent insensible water loss
 With list of prescribed raise the patient’s body fever. through the process
medications. temperature. b) Have a lower body of evaporation when
temperature of 36.5°C –
 WBC count of 22,000 the patient is
37.5°C upon experiencing
um/dL.
administration of sweating.
 (-) Typhi dot
prescribed medication.
 (-) Dengue NS2
After 30 mins. of health  Assess the skin  An increase in Goal fully met if the patient
education the patient and integrity. body temperature understands the relationship of fever
Nursing Diagnosis: the mother will be able to: to ongoing disease process,
alters skin integrity.
Flushing and redness understands risk of contaminated
Altered thermoregulation foods.
a) Understand the are common effects
related to possible relationship of fever of increased body
ongoing disease process to ongoing disease temperature.
as evidenced by on and process.
off fever. b) Understand the
possible risks of  Review abnormal  An increase in
eating contaminated laboratory profile the WBC count of
street foods. such as WBC count. 22,000/uL is
 indicative of active
infection.
After 30 mins of health  Perform tepid  Tepid sponge Goal met if the SO was able to
education the mother will sponge bath every bath may help demonstrate the correct way of doing
be able to demonstrate the episodes of fever reduces body TSB.
proper way of doing TSB. with the use of cold temperature to the
compress. process of
conduction.

 Provide  Room
environmental temperature should
temperature by be altered to maintain
opening windows. near-normal body
temperature.

 Loosen layers of  Used to reduce

clothing of the when fever is present
patient. to the client.

 Administer 500mg  Paracetamol

of paracetamol q reduces body
4hrs per orem as temperature by
prescribed. inhibiting synthesis
pf prostaglandin and
other chemical
mediators into the
hypothalamic center.

 Administer 500mg  Coamoxiclav

Coamoxiclav BID acts as a bactericidal
x7days every after to the active
meal. infectious process of
the patient.

 Maintain bed rest.  An increase in

physical activity
increases metabolic
rate and metabolic
demand. Thus,
increases body
 temperature.

 In order to
 Offer 1 – 2L fluids maintain body fluids
as tolerated by the and replenish
patient during the insensible water loss
shift. from an increase
body temperature.

 For patient to
 Encourage to
understand the
increase fluid intake
concept of
as tolerated by the
maintaining body
patient.
fluid and replenish
insensible water loss.

 For the patient

 Discuss the basic to understand that the
concept of fever as a fever is a normal
response to ongoing defense mechanism.
disease process.
 It is a
 Explain to the promotive and
patient the risks of preventive measure to
eating contaminated be more aware of
street foods. risks of eating
contaminated food.

 For the SO to
 Teach the SO on the gain knowledge when
proper way of doing confronted with the
the proper way of same problem.
TSB and other ways Further, it will allow
of decreasing body the SO to participate
temperature.
 in the care of the
patient.

FDAR
F: Altered thermoregulation related to possible ongoing disease process as
evidenced by on and off fever.

D: “Still feels hot and diaphoretic.” as verbalized by the patient. “Ate street
foods 5 days ago.”, “Losses of appetite when in fever” as verbalized by
mother. Body temperature of 37.5°C in during admission, intermittent fever,
with prescribed medications of paracetamol 500mg q 4hrs BID per orem and
Coamoxiclav of 500mg TID per orem every after meal x7days, latest WBC
count of 22,000 um/dL, (-) for Typhi dot and (-) for Dengue NS2…………R

A: Monitored patient’s temperature q4 hours, noted for degree and pattern of

shaking, chills or profuse sweating, then assessed hydration status, assessed
the skin integrity, reviewed abnormal laboratory profile such as WBC count,
provided environmental temperature by opening windows, loosen layers of
clothing of the patient, 8:00AM administered 500mg Coamoxiclav BID
x7days every after meal, 10:00AM administered 500mg of paracetamol q
4hrs per orem as prescribed, 10:15AM performed tepid sponge bath every
episodes of fever with the use of cold compress maintained bed rest, offered
1 – 2L fluids as tolerated by the patient during the shift, encouraged to
increase fluid intake as tolerated by the patient, discussed the basic concept
of fever as a response to ongoing disease process, explained to the patient
the risks of eating contaminated street foods, and taught the SO on the
proper way of doing the proper way of TSB and other ways of decreasing
body temperature……………………………R
R- 1:00PM the patient claimed “Okay na ako, wala na akong fever.” With
latest temperature of 37°C, RR of 16cpm, no chills and diaphoresis noted
upon evaluation ………………….………………………...………………R

Rivera, Joanne G. Mr. Juan Dela Cruz.

SLU BSN1-B2 FACULTY PRC#0390646