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Date/Tim

e
Nov. 30,
2015
@
6 pm

Cues
Sub.
init kayo
akonganak
nurse., as
verbalized by
the mother.
Obj.
Temp: 40c
RR:32 cpm
PR: 127 bpm
-flushed skin
-dry mucous
membranes
-muscle
rigidity
-chills
-malaise

Needs

Nursing
Diagnosis

Scientific
Basis

N
U
T
R
I
T
I
O
N
A
L
M
E
T
A
B
O
L
I
C

Hyperthermia
related to
inflammatory
process

Pyrogens
cause a rise in
body
temperature,
it also acts as
antigen
triggering
immune
system
responses.
The
hypothalamus
reacts to raise
the set point
and the body
respond by
producing
heat.

P
A
T
T
E
R
N

Source:
Fundamentals
of Nursing
-Harry &
Perry

Goals
Objectives
Criteria

Nursing
Interventions

Rationale

Evaluation
Within 4 hours of
nursing
interventions,
client was able to
report and show
manifestations
that fever was
relieved as
evidenced by:

Within 4 hours of
nursing
interventions,
client will be able
to report and
show
manifestations
that fever is
relieved as
evidenced by:

1.Establish rapport with


the client and parents.

1.Promotes cooperation in
the nursing care.

2.Monitor vital signs

2.Helps to identify the


development of the clients
VS

Verbalization of
feeling well

5.Encourage to increase
oral fluid intake up to 2
liters a day

VS within normal
range
Absence of
muscular
rigidity/chills
Absence of
flushing

3.Note presence/absence
of sweating
4.Provide tepid sponge
bath

3.Evaporation is decreased
by environmental factors
as well as body factors
producing loss of ability to
sweat

6.Promote bed rest

4.To reduce body


temperature through the
process of conduction

7.Regulate IVF as
indicated by physician

5.Water regulates body


temp.

8.Administer antipyretics
as ordered by physician
such as paracetamol

6.To promote relaxation

9.Monitor intake and


output
10. Provide high-calorie
diet such as chicken,
bread and rice

7.To replenish fluid losses


during shivering chills
8.To treat underlying
causes
9.To know the fluid
balance of the body.
10. To meet increased
metabolic demands.

Verbalization of
the client:
dili na init akong
pamati ate nurse.
VS of:
Temp= 36.7c
RR= 25 cpm
PR= 92
Absence of
muscular
rigidity/chills
Normal
complexion of
skin

Date/
Time

Goals
Cues
Needs
Nursing
Scientific
Objectives
Nursing
Rationale
Diagnosis
Basis
Criteria
Interventions
Sub.
C
Acute pain
Acute pain After 4 hours Monitor skin which are
sigeg
O
related
to
Ability
to
of nursing
Date/
Goals color/temperat usually altered
11/30/15
as
control
pain.
Time sakit ang
Cues G Needsdengue
Nursing
Scientific intervention,
Objectives ure. Nursing in acute
Rationale
@
akong
N
manifested internal/exte the patient
Administer
Diagnosis
Basis
Criteria
Interventions
9:30am
tiyan as
I
by facial
rnal
will be able to medicine as
Only the
11/30/15 verbalized
usahay T H
Joint Pain environment
At risk of experience
After span of doctor's
assess
clients client
tocan
identify
grimacing,
order.
@9:30 by magsakit
Related to to maintain
injury as a gradual
care the
muscle
riskthe
forlevel
falls
patient. I E
guarding
relief Maintain
judge
akong
A
risk
for
result
of
patient
will
be
strength,
gross
V
behavior,
comfort.
pain
personal
and distress of
tuhod ug E L
injury
environmentas evidenced
able to
and fine motor pain pain
Obj.
restlessness
hygiene.
likod
al
coordination management
to prevent
Pain
- T
and verbal
by:demonstrate Encourage
tungod
conditions normal
behaviors
ensure that should
infections
scale:8
10
P H
report of
painas verbalization
be a
atong
na
P
interacting
evidenced
by
pathway
to
Facial
E
pain felt in
scale.
of feelings
team approach
disgrasya R E
with the
lifestyle
bathroom
is that includes
grimacing
the lower
about
the pain.
ko sa
individuals
changes to Teach
unobstructed
C R
abdominal
client the client.
motoras
C
adaptive
and
reduce
risk
and properly
restlessne E
region.
divertional
defensive
factors and activities.
lighted
ss verbalized P E
by the pt. T P
resources
protect self Advise
administer
from injury. breathing
medications as
verbal
U T
I
order
report of
A
exercise.
maintain
acute pain
L O
monitor
V/Sa
N
good
hygiene
and pain scale.
guarding P
Assess the
behavior
A
patient pain
on the right T
scale and
lower
E
perception.
extremity.
R
avoid color
N
drinks.

Evaluation
After 4 hours of nursing
intervention the patient
was able toEvaluation
experience
gradual relief of pain as
evidenced by no
After span
of care the
abdominal
cramp.
patient will be able to
demonstrate behaviors as
evidenced by lifestyle
changes to reduce risk
factors and protect self
from injury

Date/Time

11/30/15
@
11:48am

Cues

Subj:
Kapoyanko
usahaymagli
hok gusto
langnako
mag higda
as verbalized
by client.
Obj:
-lack of
energy
-warm skin
to touch
-limited
ROM
-irritability
- dozing
-drowsy
-droopy eyes
-flushed skin
-poor
concentratio
n
-T 39.1
RR 32
PR 127

Needs
A
C
T
I
V
I
T
Y
E
X
E
R
C
I
S
E
P
A
T
T
E
R
N

Nursing
Diagnosis
Fatigue r/t
increased
metabolic
rate
secondary
to dengue
virus
infection
Source:
American
Journal of
Clinical
Nutrition

Scientific
Basis
Both bacterial
and viral
infections can
increase the
metabolic rate
of the body
which
decreases the
energy levels
of the body
which then
leads to
tiredness or
fatigue.

Goals
Objectives
Criteria
After/within 8hrs
span of care client
able to develop
good progress
such as:
- increased energy
and enhance self
esteem.
-improvement of
all activities daily
living (ADLs)
-avoid client into
discomfort
environment.
-client able to
expresses his
feelings.
-client able do a
simple task to
provide own
needs.

Nursing
Interventions

Rationale

-established rapport
to the client.
-assess vital sing.
-enhances
commitment to
promoting optimal
outcomes.
-encourage nutritious
food to promote
energy.
-assess the patient
ability to performed
activities of daily
living(ADLs).
-promotes sense of
control and improves
self-esteem.
-teach client
strategies for energy
conservation.
-encourage to drink
fluids.
-provide a sound and
comfortable
environment
conducive for resting.
-fatigue can be
consequences of and
exacerbated by sleep
deprivation.
-avoid drinks
containing caffeine.

-to gain cooperation and


alleviate anxiety.
-for easily monitor any
changes vital sing.
-encourage the patient
to promote goal for
good outcome
-encourage eating
nutritious food high in
energy such as honey,
apple, orange, sweet
potato.
-enhance that patient
will plan all daily
activity
-assist client to identify
appropriate coping
behaviors.
-energy conservation is
to preserve more energy
to response our body
needs
-drinking in high in
electrolyte can
promotes more energy
-providing comfortable
environment increase
resting period
-determine presences
degree of sleep
disturbances
-drinking more caffeine

Evaluation

Partially goal
met

- Verbalizes
increased energy
and improved
well-being.
-moderately
improved during
activity level
-maintain the
peaceful
environment in
client.
-communication
in client can
improved her
feeling /situation.
-showing the
ability to
development
simple activity.

-provide diversional
activities like open
and jovial
communication.
-encourage the client
to get adequate sleep.
-certain meds
including prescription
esp. beta adrenergic
blockers and over the
counter drug herbal
supplements are
known to cause
exacerbate fatigue.
-monitor for
depression as a
possible contribution
for fatigue.
-determine the client
physical limitations.
-observe the
environment for
discomfort during
activities.
-limit the number and
disturbance by
visitors if they
want/need.
-ask client to rate
fatigue from 1 to 10.
-some studies fatigue
often in females than
male also the stage of
adolescences and the
condition.

can affect resting period


-jovial communication
elevate stress and
promotes good
perception
-sleep and adequate rest
can improve the client
status
- review the
medications for side
effects may cause
fatigue
-depression also trigger,
so alter the client
perception.
-client must know their
limitations in the daily
activities to prevent
more complication.
-check the place before
doing the activities that
can harm to client.
-visitors are to many
also disturbed our
client during rest and
sleep pattern.
-scale the fatigue in our
client to determine
within normal range.
-age , gender ,and
development stage can
affect fatigue.

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