FEVER ASSESSMENT Subjective: init kaayo akoa lawas dong as verbalized by the patient.

DIAGNOSIS
Hyperthemia related to exposure to environment with increased temperature; inappropriate clothing

PLANNING After 8 hours of nursing intervention, the patient will be

able to resume and maintain normal body temperature.

INFERENCE
Hyperthermia or commonly known as fever is present when the body temperature is higher than 37C which can be measured orally, but 37.7C if measured per rectum. It occurs when the body is invaded by some bacteria, viruses, or parasites. Sometimes the occurrence of fever may also be due to non- infectious factors like injury, heat stroke or dehydration.

INTERVENTION - Assess and monitor

clients temperature and note for presence of chills/ profuse diaphoresis; also note for degree and pattern of occurrence.

RATIONALE -- Temperature 38.9C

EVALUATION Goal Met

Objective: - Flushed skin with body temperature of 38.1C per axilla - Respiratory rate of :
21 breaths per minute

to 41C may suggest The patient has acute infectious been able to resume disease process. A and maintain normal sustained fever may be body temperature. due to pneumonia or typhoid fever while a remittent fever may be due to pulmonary infections; and an intermittent fever may be caused by sepsis. -Room temperature may be accustomed to near normal body temperature and blankets and linens may be adjusted as indicated to regulate temperature of client. - It could help in reducing hyperthermia; avoid using alcohol and iced water which may even produce chills and increase clients temperature.

- Pulse rate of: 89 beats per minute - Muscle rigidity; chills

- Adjust and monitor environmental factors like room temperature and bed linens as indicated

- Apply tipid sponge bath.

- Encourage client to increase fluid intake. - Raise the side rails at all times.

-- Water regulates
body temperature. - To ensure clients safety even without the presence of seizure activity.

Collaborative: - Provide high caloric diet or as indicated by the physician. - Start intravenous normal saline solutions or as indicated. - Administer antipyretics as prescribed by the physician, utilizing the 10 Rs in giving medication. -To meet the metabolic demand of client.

-To replenish fluid

losses during shivering chills. - Antipyretics acts on the hypothalamus, reducing hyperthermia.

DIARRHEA ASSESSMENT Subjective: cge ra xa kalibang dong. Basa ra ba jud as verbalized by patients mother. DIAGNOSIS Diarrhea related to
Lactose intolerance

PLANNING After 8 hours of nursing intervention, patient will be able to re-established and maintain normal bowel functioning.

INFERENCE
Diarrhea may result from a variety of factors, including intestinal absorption disorders, increased secretion of fluid by the intestinal mucosa, and hypermotility of the intestine. Problems associated with diarrhea, which may be acute or chronic, include fluid and electrolyte imbalance and altered skin integrity. Diarrhea can be lifethreatening. Diarrhea may result from infectious (viral, bacterial, or parasitic) processes, primary bowel diseases (such as Crohn's disease), drug therapies (e.g., antibiotics), increased osmotic loads (e.g., tube feedings), radiation, or increased intestinal motility such

INTERVENTION Independent: -observe and record frequency, amount, time and characteristic of stool

RATIONALE

-to determine the causative factor and need additional hydration replacement

EVALUATION Goal Met After 8 hours of nursing intervention, the goal is partially met as evidenced by reduction in frequency of passing of stool to 3 from previous of 5.

Objective: -passed loose watery stools for 5 times already -frequent flatulence -skin warm and moist

-restrict food as indicated

-maybe food or these food can cause more irritation to stomach -stress can trigger frequent passing of stools.

-provide a quite and stimulating environment Collaborative: -administer anti diarrheal agents/antibiotic as indicated.

-these agents could help halt. Diarrhea and the progression of this condition dehydration.

as irritable bowel disease. Treatment is based on addressing the cause of the diarrhea, replacing fluids and electrolytes, providing nutrition (if diarrhea is prolonged and/or severe), and maintaining skin integrity. Health care workers and other caregivers must take precautions (e.g., diligent handwashing between patients) to avoid spreading diarrhea from person to person, including self.

RISK FOR INFECTION ASESSMENT Subjective: Nipula lagi ang kilid sa akoa samad as verbalized by patient. DIAGNOSIS Risk for infection related to wound site. PLANNING After 8 hours of nursing intervention, the patient will be able timely wound healing, free of signs of infection and inflammation. INTERVENTION
Independent:

RATIONALE

EVALUATION Goal not met Because it takes time to heal wound healing.

-Stress and model proper

hand-washing technique to client and caregivers. - Maintain aseptic technique with any procedures. Provide routine site care/wound care, as appropriate.

- Reduces risk of crosscontamination/bacterial colonization.

Objective: -Redness at wound site -temperature of 38.0 c -swelling at wound site

-Prevents entry of bacteria,

reducing risk of nosocomial infections.

-Inspect dressings and wound; note characteristics of drainage.

-Early detection of
developing infection provides opportunity for timely intervention and prevention of more serious complications.

-Encourage frequent position changes and being out of bed or ambulation, as tolerated.

- Limits stasis of body

fluids, promotes optimal functioning of organ systems and GI tract.

Monitor vital signs.

-Temperature elevation
and tachycardia may

reflect developing sepsis. Collaborative:

- Obtain drainage
specimens, if indicated.

Grams stain, culture, and sensitivity testing is useful in identifying causative organism and choice of therapy.

- Administer antibiotics, as indicated.

Wide-spectrum antibiotics may be used prophylactically, or antibiotic therapy may be geared toward specific organisms.