Question

Make a Nursing Care Plan using the nursing process applied in pharmacology learned in this course:

Chief Complaint: Fever

History of Present Illness:

3 days PTA, patient experienced low grade fever (undocumented) associated with cough and colds. He self medicated with lagundi herbal capsule w/c afforded temporary relief.

            2 days PTA, patient still with cough, colds and low grade fever (undocumented) hence consulted a private physician and was given Paracetamol 500mg q4h for the fever and Ambroxol 30mg TID for 5 days w/c afforded temporary relief of the symptoms.

            Few hours PTA, symptoms persisted accompanied with body malaise and an episode of minimal gum bleeding w/c prompted the patient to consult a private physician. He was advised for admission hence transferred in our institute.

Physical Examination: Patient conscious, coherent, febrile, NICRD with the ff:

BP: 100/70 mmHg                                     
RR: 22 cpm

CR: 82 bpm                                                       
T: 38.5˚C

HE-ENT/SKIN: Pink palpebral conjuctiva, anicteric sclera, dry lips, (+) nasal discharge, (-) tonsillopharyngeal congestion, (-) cervicolymphadenopathy

CHEST: Symmetrical chest expansion, clear breath sounds, (-) retraction, (-) crackles

Adynamic precordium, normal rate, regular rhythm, no murmur, grossly normal extremities, (-) cyanosis, (-) edema

ABDOMEN/ RECTUM: flat abdomen, soft, tender, normoactive bowel sound

ASSESSMENT
DIAGNOSIS
BACKGROUND KNOWLEDGE
PLANNING
INTERVENTION
RATIONALE
EVALUATION

Answer 1

Assessment	Nursing diagnosis	GOal	Planning	Intervention	Rationale	Evaluation
Subjectivve data Patient says that " I was having low grade fever associated with cough and colds. I self medicated with lagundi herbal capsule , which gave me temporary relief. But now i have fever, accompanied with body malaise and an episode of minimal gum bleeding. am feeling pain over my throat also." Objective data On P/E the patient is very week. Pink palpebral conjuctiva, anicteric sclera, dry lips, (+) nasal discharge, (-) tonsillopharyngeal congestion, (-) cervicolymphadenopathy Vitals are not stable. patient had elevated body temperature. BP: 100/70 mmHg                                      RR: 22 cpm CR: 82 bpm                                                        T: 38.5˚C Chest is clear and no abnormalities found.	Hyperthermia related to infectious process as evidenced by increased body temperature of 38.5˚C	Patient maintains normal body temperature range below 37.5 C	Assess the body temeperature of the patient. Identify the triggering factors. Monitor the Heart rate, BP and SPO2 Monitor fluid intake and output Eliminate excess clothings and coverings Encourage ample fluid intake by mouth. Raise the side rails of the bed. Administer antipyretics and other medications prescribed by the physician	Assessed the body temeperature of the patient, T=38.5˚C Identified the triggering factors.Patient had elevated body temperature and nasal discharge. Monitored the Heart rate, BP and SPO2. BP: 100/70 mmHg                                      RR: 22 cpm CR: 82 bpm                                                        T: 38.5˚C Monitored fluid intake and output. Drinking adequately Eliminated excess clothings and coverings Encouraged ample fluid intake by mouth. Raised the side rails of the bed. Administered antipyretics and other medications prescribed by the physician	To assess the patients condition. Identifying the triggering factors will helps to manage the situation effectively. Vitals MONITORING WILL PROVIDE A clear picture about the patients condition. Monitoring th fluid intake will give information regarding the fluid status of the client.he patient who is significantly dehydrated is no longer able to sweat, which is necessary for evaporative cooling and to reduce the body temperature. Raising the side rails will provide comfort and prevents falls. Administering the antipyretics and other prescribed medications helps to reduce temperature and bleeding.	Patient maintained a normal body temperature range below 37.5 c as evidenced by hourly temperature monitoring