Make a Nursing Care Plan using

Make a Nursing Care Plan using the nursing processapplied 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 medicatedwith lagundi herbal capsule w/c afforded temporaryrelief.

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

           Few hours PTA, symptoms persisted accompanied with body malaise andan episode of minimal gum bleeding w/c prompted the patient toconsult a private physician. He was advised for admission hencetransferred 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, anictericsclera, dry lips, (+) nasal discharge, (-) tonsillopharyngealcongestion, (-) cervicolymphadenopathy

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

Adynamic precordium, normal rate, regular rhythm, nomurmur, grossly normal extremities, (-) cyanosis, (-) edema

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



Assessment Nursing diagnosis GOal Planning Intervention Rationale Evaluation


Patient says that ” I was having low grade fever associated withcough and colds. I self medicated with lagundi herbal capsule ,which gave me temporary relief. But now i have fever, accompaniedwith body malaise and an episode of minimal gum bleeding. amfeeling pain over my throat also.”


  • 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 bodytemperature.
  • 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 byincreased body temperature of 38.5˚C

Patient maintains normal body temperaturerange 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 thephysician
  • Assessed the body temeperature of the patient, T=38.5˚C
  • Identified the triggering factors.Patient had elevated bodytemperature 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 bythe physician
  • To assess the patients condition.
  • Identifying the triggering factors will helps to manage thesituation effectively.
  • Vitals MONITORING WILL PROVIDE A clear picture about thepatients condition.
  • Monitoring th fluid intake will give information regarding thefluid status of the client.he patient who is significantlydehydrated is no longer able to sweat, which is necessary forevaporative cooling and to reduce the body temperature.
  • Raising the side rails will provide comfort and preventsfalls.
  • Administering the antipyretics and other prescribed medicationshelps to reduce temperature and bleeding.
Patient maintained a normal bodytemperature range below 37.5 c as evidenced by hourly temperaturemonitoring

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