7/30/2019 Ncp for Parent and Child
1/3
ERIC V. EVANGELISTA
Assessment Nursing Diagnosis Planning Nursing intervention
Rationale Evaluation
Subjective:
pa balik balike po ang
lagnat po ang anak koas verbalized bymother
Objective:
Temperature: 38.3 CRR:20
Pulse:83Lips dry and tounge
white.
Client appears under
nourished.
Hyperthermia related
to dehydration as
evidence by clientsdry oral mucosa
After 4 hours of
nursing intervention
the client willmaintain coretemperature within
normal range of 36.8
to 37.8
Identify underlying
factors that may cause
alterations of bodytemperature.
Monitored Patient
temperature every 30minutes.
Monitored Patient
pulse rate and
respiratory rate.
Provided surface
cooling with tepidsponge bath and
removing extra
clothing.Promoted rest and
comfort providingbed rest.
Dependentintervention:Administer
Paracetamol asordered by MD
To obtain factors of
increase body
temperature.
To obtain get an
accurate bodytemperature and
detect feverdevelopment.
To evaluate
effectiveness of
independent nursingregimen.To promote core
coding by helpingreduce body
temperature.
To detect further
existing discomfortsand level.
Paracetamol acts as
antipyretic andanalgesic which helps
acts with thehypothalamus to
regulate body
temperature.
After 4 hours of
effective nursing
interventions theclients was able tomaintain normal core
temperature of 37.5
Goal metLatest Temp 37.3
7/30/2019 Ncp for Parent and Child
2/3
ERIC V. EVANGELISTA
Assessment Nursing Diagnosis Planning Nursing intervention
Rationale evaluation
Subjective:
hindi po nagsasalita
masyado ang akinganak at hindimasyadong naglalaro
as verbalized by
mother.Objective:
Child appearswithdrawn, and poor
eye contact, and
quivers when
speaking.Bruises and burnmarks on extremities.
Anxiety related to
situational crisis as
evidence of physicalabuse.
After 8 hours of
nursing intervention
the client willexperience lessanxiety by exhibiting
normal interaction
with caregiver andmore eye contact.
Assess level of
anxiety and fear in
child and how it ismanifested.
Provide treatment ofinjuries; avoid
treating the child as avictim, asking too
many questions
Demonstrate affectionand acceptance of thechild even if not
returned or ignored.
Provide a play
program with otherchildren, praise child
or reward with specialtreat when
appropriate.
Allow expression of
concerns and fears ofchild about
treatments,environment, allow
question and provide
honest explanation atchild's age level.
Provides information
about the source and
level of anxiety andwhat might relieve itand basis to judge
improvement.
Prevents increasedanxiety, and stress in
child by discussionfor abuse.
Promotes trust of staffand positive behaviorof the child.
Modifies negative
behavior bypromoting interaction
with others andrewarding desired
behavior: promotesself-esteem.Provides opportunity
to vent feelings,which reduces
anxiety.
After 8 hours of
nursing intervention
the client is ableexperience lessanxiety by exhibiting
normal interaction
with caregiver witheye contact and is
able to verbalizefeelings and
emotions.
