Generic Name Brand name Classification Generic name: Paracetamol Brand name: Aeknil Classification: para aminophenol derivative,

, nonnarcotic analgesic, antipyretic.

Indication Frequency Dosage Route Indication: mild pain or fever Frequency: PRN Temp 37.8C PRN Temp 38.5 C Dosage:100 mg/mL amp (IV)

Mechanism of action Inhibits thesynthesis of prostaglandin s that may serve as mediators of pain and fever primarily In the CNS. Has no significant anti inflammatory property or GI toxicity.

Side Effect/ Adverse Reaction Side effects: hives, rash, short breath adverse reaction: Hematologic: Hemolytic anemia, neutropenia, leucopenia, pancytopenia, thrombocytopenia Hepatic: Liver damage, jaundice Metabolic: Hyploglycemic Skin: rash, urticatria

Special Considerations Special consideration: Nursing Responsibilities: Assess patient patients pain or temperature before and during therapy. Be alert of adverse reactionsand drug interactions. Tell patient not to use drug for marked fever (39.5C), fever persisting longer than 3 days, or recurrent fever unless directed by prescriber. Warn patient that high doses or unsupervised long - term use can cause hepatic damage.

Cues

Diagnosis

Background Knowledge Hypothalamus is the thermoregulation center of a human body presence of infection trigger of the fever, called a pyrogen release of prostaglandin E2 (PGE2). PGE2 then in turn acts on the hypothalamus causing heatcreating effects increase heat conservation and production resulting increase body temperature hyperthermia. Reference: Luckmann, Joan and Sorensen,

Planning

Intervention

Rationale

Expected Outcome Short Term: After the nursing intervention, the patients temp shall decrease from 37.7to 37.5 C.

Objective Temp: 37.7 C >warm to touch

Hyperthermia related to illness AEB an elevated body temperature secondary to acute tonsillopharyngitis

.Short Term: After 8 hours shift, the patients temperature will decrease from 37.7to 37.5 C.

>Establish rapport.

>Enhances sense of trust and nurse client relationship >To asses if there is any irregularities. >To ensure that the patient is receiving the right amount of IVF that aids in hydration.

>Monitor vital signs. >Monitor and regulate IVF.

Long Term: Within a week of nursing intervention the patient will maintain his temperature within the normal range. >Discuss pts perceptions/fearful feelings. Listen to the pts concerns.

>Promotes atmosphere of caring and permits explanation/correction of misperception. >To reduce metabolic demands/oxygen consumption.

Long Term: Within a week of intervention, the patient shall be free from fever.

>Promote bed rest, encourage relaxation skills and diversional activities. >Provide TSB as needed

>Heat is loss by evaporation and conduction.

>Administer Paracetamol PRN.

>Paracetamol are classified as analgesics and antipyretic which acts on

Karen. MS-Nursing 4th. ed

the hypothalamus to regulate normal body temperature.

>Encourage to increase OFI.

>To prevent from dehydration.

>Advise (-)DCF

>To monitor signs of bleeding that may be present in stool or urine.

Cues

Diagnosis

Background Knowledge Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway. Reference: NANDA Edit.11 p.77

Planning

Intervention

Rationale

Evaluation

Subjective inuubo pa din paminsan minsan, as verbalized by the patients mother Objective: > inability to cough effectively >(+) cough

Ineffective airway clearance r/t presence of secretion in the tracheobronchial tree.

Short Term: At the end of an 8 hours shift the pt will maintain airway patency and be able to expectorate/clear the secretions. Long term: Within a week of nursing intervention the pt will be free from cough and maintain airway clearance.

>Establish rapport.

>Enhances sense of trust and nurse client relationship >To asses if there are any irregularities and obtain baseline data.

>Monitor vital signs.

Short Term: After 8 hours of nursing intervention the patient shall have maintain airway patency and be able to expectorate/clear the secretions. Long Term: Within the week of nursing intervention, the patient shall be free from cough and maintain airway clearance.

>Monitor and regulate IVF.

>To ensure that the patient is receiving the right amount of IVF that aids in hydration.

> Monitor child for feeding intolerance.

>To assess if there is a presence of compromise airway. > To prevent further irritants that may aggravate coughing. > To promote wellness.

>Keep environment allergen free.

>Provide adequate rest. >Position head appropriate for age/condition. >To open or maintain open airway in at-rest individual.

>Encourage to increase OFI.

>Hydration can help liquefy viscous secretions and improve clearance.

Cues

Diagnosis

Background Knowledge Increased susceptibility to falling that may cause physical harm.

Planning

Intervention

Rationale

Evaluation

Risk for fall

Short Term: After 8 hours shift, the patients mother will understand the risk factors that can contribute to fall.

>Establish rapport.

>Enhances sense of trust and nurse client relationship >To asses if there is any irregularities. >To ensure that the patient is receiving the right amount of IVF that aids in hydration. >Reduces stress and excess stimulation, promoting rest >To monitor the movements of the child. >To prevent the child from falling.

Short Term: After the 8 hour shift the patients mother shall have understand the risk factors that can contribute to fall

>Monitor vital signs.

Reference: NANDA Edit.11 p.291

>Monitor and regulate IVF. Long Term: Within the week of nursing intervention the pts mother will demonstrate behaviors, lifestyle changes to reduce risk factor and protect the pt from injury.

>Provide a calm and quiet environment

Long Term: Within a week of intervention, the patients mother shall have demonstrated behaviors, lifestyle changes to reduce risk factor and protect the pt from injury.

>Discuss the need for supervision

>Maintain side rails.

Cues

Diagnosis

Background Knowledge Tonsillopharyngitis is acute infection of the pharynx or palatine tonsils or both. Due to infection inflammation would occur, thus several signs and symptoms will also be experience by the patient. One of which is dysphagia. Or difficulty swallowing. Patient may find it difficult to swallow food especially those hard ones. The patient may also experience loss of taste. Thus result to poor intake of foods making the patient at risk for imbalanced nutrition.

Planning

Intervention

Rationale

Expected Outcome Short Term: within 8 hours of nursing intervention the patient shall be able to increase her food and milk intake

Risk for imbalanced nutrition less than body requirements related to decreased swallowing appetite secondary to ATP

Short Term: within 8 hours of nursing intervention the patient will be able to increase her food and milk intake

>Establish rapport.

>Enhances sense of trust and nurse client relationship >To asses if there is any irregularities. >To ensure that the patient is receiving the right amount of IVF that aids in hydration. >to know other factors that can influence or affect ingestion of foods. >soft foods may not be hard to swallow.

>Monitor vital signs.

Long Term: Within a week of nursing intervention the patient will be able to maintain stable weight and be free from any signs of malnutrition.

>Monitor and regulate IVF.

>Assess patients ability to chew, swallow, and taste foods >Encourage patients mother to let the patient eat soft diet foods or eat small amount of foods frequently Weigh the patient on a daily basis. >Provide a calm and quiet environment

Long Term: Within a week of nursing intervention the patient shall be able to maintain stable weight and be free from any signs of malnutrition.

>to know if patient has been gaining or loosing weight.

>Discuss/implement effective ageappropriate bedtime rituals.

>Reduces stress and excess stimulation, promoting rest