Weygan, Deborah-kate A.

BSN 2B2
Actual Nursing Care Plan 1

Assessment Goals Nursing interventions Rationale Evaluation

DATA STG: DX: STG:

Subjective: Within 4 hours of Nursing 1. Monitor vital signs. >To establish baseline >Goal Met
N/A Interventions and Health data. The patient was able to
Teachings, the patient will 2. Assess for signs of >To establish appropriate maintain normal core
be able to, maintain core Hyperthermia such as: interventions. temperature as evidenced
temperature within the poor skin turgor, dry oral by latest temperature of
normal range as membranes, dry lips, and 36.6.
Objective: manifested by decreased warm skin. >Dysrhythmias are
>Skin warm to touch temperature of 37.8 to 3. Monitor heart rate and common due to electrolyte
>Diaphoresis 36.6. rhythm. imbalance, dehydration, LTG:
>Temperature-37.8 C and direct effects of >Goal Met
hyperthermia on blood The patient was able to
Nursing Diagnosis: LTG: and cardiac tissue. demonstrate improved
>Hyperthermia Within 8 hours of Nursing level of ease and comfort
Interventions and Health as evidenced by the
Teachings, the patient will >To treat underlying patient feels comfortable
be able to demonstrate cause. and has good sleep
improved level of ease and pattern.
comfort. TX: >To promote rapid core
1. Administer medications cooling.
as prescribed.
2. Assist with internal >Exposing skin to room
cooling method like tepid air decreases heat and
sponge bath. increases evaporative
3. Loosen or remove cooling.
excess clothing and
covers. >Excessive cooling or
cooling too rapidly may
cause shivering, which
4. Modify cooling increases metabolic rate
measures based on the and temperature.
patient’s physical Shivering should be
response. avoided as it will hinder
cooling efforts.
>Promotes comfort and
helps chilling since
diaphoresis occurs during
defervescence.
5. Keep clothing and bed
linens dry. >If the client is alert
enough to swallow,
provide cool liquids to
help lower the body
EDX: temperature. Additionally,
1. Encourage adequate if the patient is dehydrated
fluid intake. or diaphoretic, fluid loss
contributes to fever.
>Fever is reportable,
especially in infants and
young children with or
without other symptoms
and in older children if it
is unresponsive to
 2. Instruct the parent to antipyretic and fluids,
measure the child’s because it accompanies a
temperature, and what treatable infection(viral or
symptoms to report to the bacterial).
physician. >To prevent dehydration.

3.Discuss with the mother

the importance of
adequate fluid intake at all
times and ways to improve
hydration status when ill.

ACTUAL NURSING CARE PLAN 2

Assessment Goals Nursing Interventions Rationale Evaluation
Data STG: DX: STG:
Subjective: Within 4 hours of Nursing 1. Monitor respirations and >To establish baseline GOAL MET
N/A Interventions and breath sounds, noting rate data and interventions. >After 4 hour of Nursing
Therapeutic Managements and sounds. >This information is Interventions and
the patient will be able to, 2. Assess level of essential for identifying Therapeutic
demonstrate behaviors to consciousness/ potential for airway Managements, the
Objective: improve or maintain clear cognition and ability to problems, providing patient was able to
>Non-Productive and airway. protect own airway. baseline level of care demonstrate behaviors to
Ineffective cough needed, and influencing improve or maintain
>Not in distress choice of interventions. clear airway.
LTG: Within 8 hours of >Airway clearance is
Nursing Interventions and hindered by inadequate
Therapeutic Management, hydration and the
the patient will be able to 3. Assess the patient’s thickening of secretions.
Nursing Diagnosis: maintain airway patency. hydration status. LTG:
Ineffective Airway >Doing so would lower GOAL MET
Clearance the diaphragm and >After 8 hours of
promote chest expansion, Nursing Interventions
mobilization and to and Therapeutic
TX: breathe readily. managements, the
1. Elevate the head of the >Fluids help maintain patient was able to
head of the bed and keep the hydration and increase maintain airway patency.
patient on a moderate high ciliary action to remove
back rest. secretions and reduce
viscosity.
2. Maintain adequate >A sitting position
hydration, especially warm permits maximum lungs
liquids. excursion and chest
expansion.
>To relax smooth
 respiratory musculature,
3. Place patient with proper deduce airway edema,
body alignment for and mobilize secretions.
maximum breathing pattern.
4. Administer medications
(expectorants, anti- >To maximize effort.
inflammatory agents)

>This prevent fatigue.

EDX: >Hydration can help

1. Encourage deep-breathing prevent the accumulation
exercise and coughing of viscous secretions and
exercises. improve airway
2. Encourage adequate rest. clearance.
3. Encourage increased fluid
intake and warm liquids.

DRUG STUDY