NURSING SCIENTIFIC BASIS GOAL & NURSING

CUES DIAGNOSIS OUTCOME INTERVENTION RATIONALE EVALUATION

CRITERIA S

SUBJECTIVE: Hyperthermi Chickenpox, also GOAL: NURSING GOAL MET:

“…`”, as a known as Varicella, After 8 hrs. of ACTION:  To monitor After 8 hours
verbalized by r/t viral caused by an nursing Perform nursing changes or of
the patient. infection. infectious agent interventions, care any signs of nursing
known as Herpesvirus the patient & continuous development interventions,
OBJECTIVE: varicellae, is a highly will be able to monitoring of in patient’s the patient
Received contagious and self- maintain patient’s vital condition & was able to
patient lying limited infection that body signs to ensure to maintain maintain body
on bed, most commonly temperature normal body body temperature
awake, with affects children within normal temperature & a temperature within normal
warm and between 5-10 years of range and will wholistic at normal range and
flushed skin; age. The disease has experience no functional level. range. experienced
macules & a worldwide associated no
papules seen distribution and is complications associated
on face, trunk reported throughout . INDEPENDENT: complications
and the year in regions of  To determine .
extremities; temperate climate. OUTCOME  Monitor baseline data
irritability The peak incident is CRITERIA: patient’s vital & to check
noted. generally during the The patient signs. for changes
months of and her or progress
VITAL SIGNS: March through May. significant with patient’s
T: Lifelong immunity for others will be body
P: Chickenpox generally able to: temperature.
R: follows the disease. If
Blood the patient's immune 1. Maintain  To reduce
Pressure: system does not patient’s body  Perform the risk of
totally clear the body temperature proper hand spreading
of the virus, it may to 36.5 C to hygiene the infection.
retreat to 37.5 C. before and
skin sensory nerve after care of
cell bodies where it is 2. Identify the patient.
protected from the underlying
 To reduce
patient's immune cause/
 Perform patient’s
system. Entry of contributing
tepid sponge hyperthermic
pathogens in the factors that
baths. condition &
systemic circulation lead to to provide
would trigger the hyperthermia. comfort.
circulation of toxins in
the body. This would 3.Recognize  Room
then lead to the the  Monitor temperature
release of pyrogens importance of environmental should be
as stimulated by the treatment. temperature. altered to
Hypothalamus. As a maintain
result, there would be near-normal
an increase or body
alteration in the temperature.
thermoregulation of
the body , resulting to  Provide  To keep the
an increased core recreational patient
body temperature and diversional occupied and
also known as activities to prevent from
Hyperthermia. the patient. scratching
the lesions.
 Provide
(www.healthscout.co
accurate  Provides
m; Understanding
information to support &
Pathophysiology pp.
the client’s adds up to
196- 198)
significant the family’s
others knowledge
regarding her about
condition. patient’s
condition.

DEPENDENT:
 To maintain
 Administer fluid &
IV fluids & electrolyte
medications to balance and
reduce the body
tendency of temperature
Hyperthermia. at normal
range.
 NURSING CARE PLAN

Patient’s Name : Chua, Jeshia Joy Longkines Hospital No. : 100022588308

Age : 1 y.o. Room No. : B333
Diagnosis : Physician : Dr. Cynthia Fuentes

CLINICAL PORTRAIT PERTINENT DATA

ASSESSMENT: HISTORY OF PRESENT ILLNESS:

Upon first contact, patient J.L.C. was lying on bed, A case of patient J.L.C., 1 y.o., female, Filipino and a
awake, conscious, febrile with a temperature of … C, Roman Catholic, is admitted in Chong Hua Hospital Cebu
oriented, with IVF… City last March 2, 2011 at 11:24 pm.

SIGNIFICANT FINDINGS: CHIEF COMPLAINTS:

Patient was noted to have warm and flushed skin;
macules & papules seen on face, trunk and extremities; HEALTH HISTORY RELEVANT TO PRESENT ILLNESS:
irritability noted.
VITAL SIGNS DURING ADMISSION:
VITAL SIGNS DURING FIRST CONTACT: • Temperature:
• Temperature: • Pulse Rate:
• Pulse Rate: • Respiratory Rate:
• Respiratory Rate: • Blood Pressure:
• Blood Pressure:
LABORATORY EXAMINATIONS DONE: