ASSESSMENT DIAGNISIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Hyperthermia related Short term: within 1 hour of Established rapport to to gain trust and cooperation After all the nursing
“Mataas pa rin ang lagnatnya to positive bacterial infection nursing intervention the mother. intervention the clients body
hanggang ngayon” as as manifested by flushed and  patient’s elevated temp subsided within the
verbalized by the patient’s warm to touch skin temperature of 36.2 will Promote surface cooling by means of undressing (heat normal range
mother. lessen to 37.4 degree Celsius. loss by radiation and
Objective: Long term: conduction)
Flushed skin, Skin is warm to  within 8hrs. of nursing
touch Temp: 38.2 C, PR: 109 intervention, the patient’s Demonstrate on how to do a to decrease body temperature
RR: 34  body temperature will return proper tepid sponge bath
to its normal range using wet and dry cloth.
diet to meet increase
Provide nutritious metabolic demands

Subjective: Ineffective airway clearance Short term: within 1 hour of Assess airway for patency Maintaining patent airway is After all the nursing
“inuubo at sinisipon posiya” r/t Excessive secretions nursing intervention Patient always the first priority, intervention Patient maintain
will maintain clear, open especially in cases like clear, open airways as
airways as evidence by trauma, acute neurological evidence by normal breath
normal breath sounds, normal decompensation, or cardiac sounds, normal rate and depth
rate and depth of respirations, arrest. of respirations, and ability to
and ability to effectively effectively cough up
cough up secretions after Auscultate lungs for presence Abnormal breath sounds can secretions after treatments
treatments and deep breaths. of normal or adventitious be heard as fluid and mucus and deep breaths.
Long term: breath sounds accumulate. This may
 within 8hrs. of nursing indicate ineffective airway
intervention Patient will clearance.
maintain clear, open airways
as evidence by normal breath
sounds, normal rate and depth Note presence of sputum; Unusual appearance of
of respirations, and ability to evaluate its quality, color, secretions may be a result of
effectively cough up amount, odor, and infection, bronchitis, chronic
secretions after treatments consistency. smoking, or other condition.
and deep breaths. A discolored sputum is a sign
of infection; an odor may be
present. Dehydration may be
present if patient has labored
breathing with thick,
tenacious secretions that
increase airway resistance.

Upright position limits

 abdominal contents from
pushing upward and
inhibiting lung expansion.
Position the patient upright if This position promotes better
tolerated. Regularly check the lung expansion and improved
patient’s position to prevent air exchange.
sliding down in bed.

Hydration facilitates easy

elimination of secretions.

Instruct the patient’s mother

to Increase fluid intake The most convenient way to
remove most secretions is
coughing. So it is necessary
Instruct the patient’s mother to assist the patient during
the proper ways of coughing this activity. Deep breathing,
and breathing on the other hand, promotes
oxygenation before controlled
coughing.