ROSILLA, LEANDRO
ASSESSMENT
AGE: 5 yrs old
DIAGNOSIS ANALYSIS
DIAGNOSIS: DHF III
GOALS INTERVENTION RATIONALE EVALUATIO N
Subjective data: Hyperthermia maiinit siya tsaka related to ayaw illness magpahawak as verbalized by the mother of the patient. Objective data: Temperatur e over 38.6 C Loss of appetite Shivering Warm to touch Flushe skin
Hyperthermia is an elevated body temperature due to failed thermoregulatio n. Hyperthermia occurs when the body produces or absorbs more heat than it can dissipate. When the elevated body temperatures are sufficiently high, hyperthermia is a medical emergency and requires immediate treatment to prevent disability The heatregulating mechanisms of the body eventually become overwhelmed and unable to effectively deal with the heat, causing the body
After 30 minutes of nursing intervention the patient will be able to maintain core temperature within normal range from 38.6 C to 37 C
Independent: 1. Encourag e fluids when indicated. 1. to reduce fever
2. Assess
temperatu re every 30 minutes.
2. to prevent dehydartio n
After 30 minutes of nursing intervention the child exhibit core temperature within normal range from 38.6 C to 37C. Goals met
3. Promote Comfort 4. Promote wellness Dependent: 5. administer anti pyretic drug as ordered
3. to assess if the temperatu re become normal after giving medicatio n
4. to allow
patient to rest 5. reducing fever aids in reducing insensible loss.
temperature to climb uncontrollably
ASSESSMENT Subjective data: masakit yung daliri ko, parang napilayan,panglawa ng araw na to pain in the right thumb Objective data: tempreratur e 36.6 C respiratory rate: 24 contusion hematoma pain scale of 5
DIAGNOSIS Acute pain related to injuring agent
ANALYSIS Pain is an uncomfortable feeling that tells you something may be wrong in your body. It is a very personal response that is both physical and emotional. Pain may occur suddenly or come about slowly. It may range from mild to severe. You are the best judge of your own pain.
GOALS After 8 hours of nursing intervention the client is able to verbalized relieved of pain
INTERVENTION 1. Note patients perception and, along with behavioral and physiologica l responses 2. Accept patients description of pain
RATIONALE
1. To
determine patients attitude towards pain and use of specific pain medication. 2. Pain is a subjective experience and cannot be felt by others.
EVALUATIO N After 8 hours of nursing intervention the patient verbalized relief from pain after giving prescribed medications and all needs are met
3. Apply cold compress
3. to reduce pain
4. Encourage use of relaxation exercise 5. Administer analgesic as indicated to maximal dosage 6. Promote wellness and swelling or injury to soft tissue. 4. to relieve anxiety due to pain 5. to maintain acceptable level of pain/ to relieve pain.
6. to encourage adequate rest period to prevent fatigue.
TERCENA, ARJUR
ASSESSMENT
Age; 6 months old
DIAGNOSIS
Diagnosis: Pneumonia
GOALS INTERVENTION RATIONALE EVALUATION
Subjective data: nahihirapan siyang huminga, tapos me sipon pa siya Objective data: cough with sputum production use of accessory muscle restlessness nasal secretion respiratory rate: 44 bpm
Ineffective airway clearance related to mucus from respiratory tract
After 30 minutes of nursing intervention the child will b e able to exhibit adequate ventilation.
Independent: 1. Place child in upright position (semi fowlers to high fowlers). Reposition child frequently 1. An upright position facilitates breathing and promotes optimal lung expansion. Frequent repositioning prevents pooling and stasis of secretions. 2. anxiety increase the childs demand for oxygen 3. Increased respiratory rate lead to an increase in sensible loss during exhalation and can lead to dehydration. Therefore increase fluid is necessary. 4. Input and output is a reliable indicator of fluid balance. Fluid loss can result in dehydration, leading to decreased renal function and ability to eliminate waste.
After 30minutes of nursing intervention The child was able to exhibit adequate ventilation. Goals met.
2. Assist child and parents with measures to relax. 3. Increased fluid intake
4. Monitor input and output.
