Assessment

Nursing Diagnosis Hyperthermia related to inflammatory process/ hyper metabolic state as evidenced by an increase in body temperature, warm skin

Scientific Explanation Due to the presence of an infectious agents, stimulation of the monocytes triggers the release of the pyrogenic cytokines that stimulate anterior hypothalamus which results in elevated thermoregulatory set point that leads to an increased heat conservation (Vasoconstriction) increased heat production which results to Fever.

Planning

Intervention

Rationale

Expected Outcome Short term:

SMainit ang katawan ng baby ko:- as verbalized by the client

Short-term: After 4 hrs of nursing intervention the patient will maintain normal core temperature as evidenced by vital signs within normal limits

Independent 1. Monitor infant s condition. 1. To determine the need for intervention and the effectiveness of therapy. 2. To have a baseline data

OThe patient manifested the following: - Temperature above normal level (38 oC) - Skin warm to touch - appears weak - flushed skin

The patient shall maintain normal core temperature as evidenced by normal vital signs

2. Monitor Vital signs

3. Provide TSB

3. Helps in lowering down the temperature

Interdependent 4. Ensure that all equipment used for infant is sterile, scrupulously clean. Do not share equipment with other infants Dependent 5. Administer Anti-pyretics as ordered 5. aids in lowering down temperature 4. this would prevent the spread of pathogens to the infant from equipment

ASSESSMENT Subjective: (none) Objective: Weak & restless Irritable (+)nasal flaring and (+) use of accessory muscles With DOB and (+) wheezes (+)Tachypnea and (+)Tachycardia With changes in rate, rhythm and depth of breathing Vital signs (RR 54; HR 104;

DIAGNOSIS Ineffective airway clearance r/t accumulation of tracheobronchial secretions

PLANNING SHORT TERM: After 3-4 hours of NI, pt.s SO will be able to demonstrate improve airway clearance as evidenced by reduction of congestion with breath sounds clear and RR improve LONG TERM: After 2-3 days of NI, pt. will be able to establish and maintain airway patency.

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INTERVENTION Establish Rapport Monitor and record vital signs Note RR, use of accessory muscles & pursed lip breathing Evaluate clients cough/gag reflex and swallowing ability Auscultate breath sounds, note areas of decreased/adventitious breath sounds Elevate head of bed and encourage frequent position changes.

RATIONALE 1. To gain pts trust 2. To obtain baseline data 3. To evaluate degree of compromise 4. To determine ability to protect own airway 5. To ascertain status and note progress or complications 6. To promote maximal inspiration, enhance expectoration of secretions in order to improve ventilation 7. To promote comfort and adequate ventilation 8. To help liquefy the secretions

EVALUATION SHORT TERM: After 3-4 hours of NI, pt. shall have demonstrated improve airway clearance as evidenced by reduction of congestion with breath sounds clear and RR improve

7. Keep back dry and loosen clothing

8. Instruct the SO to increase clients oral fluid intake to at least 2000 ml/day within level of cardiac tolerance. 9. Encourage deep breathing exercises and coughing exercises

9. For drainage of secretions

10. Encourage adequate rest and limit activities to within client tolerance.

10. Rest will prevent fatigue and decrease oxygen demands for metabolic demands 11. To promote comfort 12. To further mobilize secretions 13. To clear airway when secretions are blocking the airway indicated to increase oxygen saturation. 14. To reduce irritant effects on airway

11. Fix bed linens 12. Give expectorants and bronchodilators as ordered. 13. Administer oxygen therapy and other medications as ordered.

14. Keep environment allergen-free