Serum-sicknes Nursing Care Plan.docx

Serum Sickness Cues

Nursing Diagnosis

Subjective: “Nagpuon ining kalintura ko kang tigturukan ako kang bulong”

Acute Pain related to inflammation of joints and skin eruptions, possibly evidenced by verbal reports, guarding or distraction behaviors and self-focus.

Objective: BP: 130/90 PR: 92 RR: 22 Temp: 40.1°c

Background knowledge Unpleasant sensory and emotional experience arising from actual potential tissue damage described in terms of such damage; sudden or slow onset of any intensity from mild to severe with anticipated or predictable end and a duration of less than 6 months

Desired Outcomes Verbalize sense of control to response to acute situation and positive outlook for the future

Nursing Interventions Apply warm compress to painful joints

Rationale

Evaluation

Warmth can help increase circulation to the joints and promote pain relief.

After all of the nursing interventions rendered, patient reported relief.

Non-pharmacologic measures lower body temperature and promote comfort. Sponging reduces body temperature by increasing evaporation from skin.

At the end of the shift, after all the nursing interventions rendered, the patient was able to obtain a temperature of 38°c. Patient experiences normal fluid balance as evidenced by the equal intake and output.

Observed rashes and hives Hyperthermia related to medication as evidenced by the increased body temperature of 40.1°c and the verbal complaint of “Nagpuon man sana ining kalintura ko kang tigturukan ako kang bulong”

Body temperature elevated above normal range

For the patient to demonstrate normal body temperature and will not show any associated complications. To maintain balance of intake and output within normal range

Tepid Sponge Bath (TSB) performed. Vital signs monitored every two hours Encouraged patient to drink plenty of water placed in a measured bottle. Administer Antipyretic drug as ordered .

To obtain an accurate core temperature. Because insensible fluid loss increases

Serum Sickness by 10% for every 1°cincrease in temperature, patient must increase fluid intake to prevent dehydration. Antipyretics act on hypothalamus to regulate temperature. Impaired skin integrity

Altered epidermis or dermis

Verbalize feelings of increased selfesteem and ability to manage situations

-Assess blood supply and sensation of skin surfaces and affected areas on a regular basis

-Encourage early ambulation or mobilization

To provide comparative baseline opportunity for timely intervention when problems are noted. -Promotes circulation and reduces risks associated with immobility.

Display timely healing of skin lesions without complications.