Question

1. Case Study: You are asked to provide background information on your chosen    

client. A fictional name is to be used. Basic information like: age, gender, occupation, place of residence, marital status, diagnosis, allergies, health status, hospitalizations, visits to the emergency department is to be included.

You will then describe your client’s current condition.

2. Signs and symptoms: Include all the complaints your client has expressed and your findings. Remember to identify the data as subjective or objective. Be as detailed as possible.

3. Appropriate nursing diagnosis: You must choose a relevant nursing diagnosis from the proper resources.

4. Client outcomes: For this section, you will need to formulate one short term goal

and one long term goal.

5. Nursing interventions: You will need to come up with at least 5 relevant nursing actions and a brief explanation for each.

6. Evaluation: You will need to evaluate the effectiveness of your nursing interventions and whether or not the client goals have been met.

7. Can answer questions: You are expected to answer questions that your fellow students ask about your care plan.

Answer 1

Identification Data

• Name – Baby Ben Jackson
• Age – 2 years 6 months
• Gender - Male
• Occupation - Nil
• Place of residence - Florida
• Marital Status – Not Applicable
• Diagnosis – Acute Pharyngitis
• Allergies – There is no history of any allergies.
• Health Status – Healthy toddler without any specific medical or surgical history.
• Hospitalizations – There is no history of hospitalization
• Reason for visit to emergency department: High fever above 100⁰ F.

Assessment

Subjective Data:

Mother of Baby Ben says that, “Ben had fever since yesterday and was given Babygesic drops 0.6ml as prescribed previously. But again started with fever after 2 hours, and the same continues till now even with sponging of the body.”

Objective Data:

• Baby Ben has fever of 100⁰ F
• Redness and congestion of throat
• Mild cough and running nose
• Chest is clear bilaterally and normal breath sounds
• Poor food intake

Nursing Diagnosis

Hyperthermia related to infection process as manifested by increased body temperature, redness and congestion of throat.

Client Outcome

Short Term Goal:

To reduce the temperature to normal.

Long term Goal:

To reduce the temperature to normal and to educate the parents regarding the care to be taken.

Nursing Interventions

• Monitor vital signs on hourly basis

Rationale: To get the baseline data and to plan the care accordingly, also to identify the effectiveness of the care provided.

• Give tepid sponging of the body except chest region

To prevent the elevation of temperature. Chest region must be excluded to avoid unnecessary exposure to cold and thus to prevent complications.

• Promote fluid intake and monitor the intake and output

To prevent dehydration and to promote hydration status which will help in the thermoregulation.

• Administer medications as prescribed

To reduce the temperature of the body by blocking synthesis of prostaglandins that act in hypothalamus.

• Promote bed rest.

Bed rest promotes the recovery faster.

Evaluation

Child's condition is improved as manifested by reduced body temperature of 98.8⁰ F.