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Care plan for a ''healthy'' patient..please help ASAP!?


date of assessment: july 16, 2007.
Ms.X, 17 y.o.,1st yr college-Nursing student.
c/c: fever with unproductive cough,
admitted: july14 at 9pm... Fever was recurrent,
latest V/S temp:36.5(cold room with air conditioning facilities), RR: 16, PR:75, BP: 100/60...
meds: azithromycin 500mg i tab OD SD 9pm
Ambroxol 3mg i tab po
Cetirizine i tab OD po (allergy)
Paracetamol 500 mg i tab q4o PRN for fever
with IV infusion-NaCl .9% regulated at 15 gtt/min
lab test for typhoid fever:negative, for dengue: negative
bowel movement:regular,every other day_urination:estimated at 3x/day
before admission, 6 days of on&off fever at average temp of 37.7-38.1,took Amoxicillin,unrelieved...appetite good

mother states it may be due to school stress,low fluid intake or faulty drug intake of amoxicillin

patient is for release on july 17 am...

I'm just confused of what to put on my Nursing Care Plan since the patient is already well,plus i haven't seen any allergies on her!

It's been a while since I've done a student care plan but I would go with either:

Fever of Unknown Origin
Oral temp. q4h and prn
Drink plenty fluids
Tylenol prn for pain or fever
Take full course of antibiotics as prescribed

OR

Hyperthermia
Oral temp q4h prn
Drink plenty of fluids
Tylenol prn pain or fever
Take full course of antibiotics

Fluid volume deficit

Knowledge deficit
Teach cough and deep breathing
Get plenty of rest
See PCP as instructed
Call PCP for increased temp, chills

Did they do a urinalysis? You could also add on to the care plan if the UA showed some bacteria. Was a chest x-ray done? Good luck on the care plan.

36.5 degrees centigrade is not considered fever. So she had fever before?
Nursing care plan should be based on Nursing Process.
1- Assessment
2-Nursing Diagnosis
3-Planning
4-Intervention
5-Evaluation
A good nursing report should contain all he above in summary (e.g follow-up of her general appearance, appetite, health improvement, heat tolerance,etc) combined with reference to medical orders. You should also note the lab results.
Did you ask the patient about her mom's guess on the etiology of her daughter condition?

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