Patients name: Jenifer Santos Constantino Age/sex: 31 years old/ Female

Address: Sto Cristo Pulilan Bulacan. Admitting Diagnosis: CVA, Type 2 DM

CC: Fever Date and time of admission: March 3,2010 @ 11:35 a.m.
Hospital: Bulacan Medical Hospital

NURSING CARE PLAN

Assessment Planning Interventionn Rationale Evaluation

Subjective:  Short Term Goal Facilitate tepid sponge bath Decrease body temperature After 1 hour of Nursing
 “May lagnat ata sya through conduction Interventions patients
mainit kasi katawan  Partly condition improved
nya” as verbalized Compensatory Facilitate increase in fluid To prevent dehydration or
by her husband intake possible fluid and
 After one hour of electrolyte imbalance
Objectives: nursing
 Temp: 37.9 ̊ C interventions Restrict tight clothing Provide comfort and allow
 RR: 26 cycle/min patients body for convection of heat.
 Increased temperature will
respiratory rate decrease from 37.9 ̊ Facilitate checking of Encourage proper
 Warm to touch C to 36.5 ̊ C temperature circulation.
 Dry lips
Facilitate administration of To compare with baseline
 Flushed face paracetamol as prescribed data
 WBC: 4000/mm⅜ by physician (mechanism of action)

Nursing Diagnosis:
Alteration
Thermoregulation,
Hypertermia R/T infection

Marilou N. Cruz C.I.: Sir Aaron Cabarloc, R.N.

BSN III SEC 5 Group 17
NCM 102
Patients name: Jenifer Santos Constantino Age/sex: 31 years old/ Female
Address: Sto Cristo Pulilan Bulacan. Admitting Diagnosis: CVA, Type 2 DM
CC: Fever Date and time of admission: March 3,2010 @ 11:35 a.m.
Hospital: Bulacan Medical Hospital
NURSING CARE PLAN

Assessment Planning Interventionn Rationale Evaluation

Subjective:  Short Term Goal  Facilitate  To prevent After 8 hours of nursing

“ may mga sugat sya sa
likod parang nagagasgas sa
higaan” as verbalized by the
husband
Objective:
 increase body temp.
of 37.9 ̊ C
 flushed skin
 warm to touch
 decrease elasticity of
the skin
 dry skin
 delayed capillary
refill of four seconds
Nursing Diagnosis:
Impaired skin integrity
related to altered body
temperature
implementation and
 Partly Compensatory posting of a turning
schedule, restricting
time in one position
 Supportive to 2 hours or less
Educative
 Facilitate the SO to
maintain functional
 After 8 hours of body alignment of
nursing the patient like
interventions, the positioning it
patients’ capillary properly.
refill must be less
than 4 seconds.  Focus on patients
ability to move
 Facilitate adequate
hydration and
nutrition
 Facilitate Clean, dry
and moisture skin
especially bony
prominences
discomfort and interventions, patient’s
injuries to the body; condition improved
to promote
circulation
 Misalignment can
lead to discomforts
and injuries to joints,
nerves or limbs.
 Immobility is greater
risk factor in skin
breakdown
 Adequate hydration
and nutrition helps
maintain skin turgor,
and suppleness.
 Smooth and supple
kin is more resistant
to injury

Marilou N. Cruz C.I.: Sir Aaron Cabarloc, R.N.

BSN III SEC 5 Group 17
NCM 102
Patients name: Jenifer Santos Constantino Age/sex: 31 years old/ Female
Address: Sto Cristo Pulilan Bulacan. Admitting Diagnosis: CVA, Type 2 DM
CC: Fever Date and time of admission: March 3,2010 @ 11:35 a.m.
Hospital: Bulacan Medical Hospital

Drug Study

GenericName Brand Classification Dosage Mechanism Indications Contraindications Side Effects Nursing
Name of actions Implications

Ceftriaxone Cefizox Cephalosporins Normally 1- Acts by Treatment of Hypersensitivity GI complaints, For IM doses
Sodium 2 g/day interfering sepsis, to Soft of 2g,
(every 24 with meningitis, cephalosphorins stools/diarrhea, divided dose
hours.) for bacterial cell abdominal and penicillins nausea equally and
severe wall infections, vomiting, give in
infections of synthesis, infections of stomatitis, different
those caused thereby the Headaches, sites.
by poorly altering the bones,joints, vertigo and Use with
susceptible osmotic soft tissue oliguria caution in
bacteria stability of and wounds, clients with
the actively infection of history of
growing kidneys and G.I. disease,
bacterial cell lower urinary especially
and resulting tract, for colitis
in its death pneumonia,
and
infections of
genital
organs
including
Gonnorrhea.

Marilou N. Cruz C.I.: Sir Aaron Cabarloc, R.N.

BSN III SEC 5 Group 17
NCM 102
Patients name: Jenifer Santos Constantino Age/sex: 31 years old/ Female
Address: Sto Cristo Pulilan Bulacan. Admitting Diagnosis: CVA, Type 2 DM
CC: Fever Date and time of admission: March 3,2010 @ 11:35 a.m.
Hospital: Bulacan Medical Hospital

Drug Study

GenericName Brand Classification Dosage Mechanism Indications Contraindications Side Effects Nursing
Name of actions Implications

Neutral Humulin R Insulin By SC, IM is a short- IDDM Hypoglycemia Lipodystrophy, Draw up

human Insulin (regular) or IV inj. acting insulin insulin Humulin R
(recombinant Dosage that has a resistance. Into syringe
DNA origin) determined relatively Local and first then
accdg to short generalized administer
requirements duration of allergic immediately
of patient. activity as reactions
compared
with other
insulins

Marilou N. Cruz C.I.: Sir Aaron Cabarloc, R.N.

BSN III SEC 5 Group 17
NCM 102