ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS & RATIONALE EVALUATION

Subj: Hyperthermia r/t increase Goal: Independent: Criteria:

Nanghihina ako tsaka wala
akong ganang kumain as
verbalized
Obj:
Increase in body temperature
(37.7 C) temporal
BP is 120/80 mmHg
RR is 38 bpm
PR is 113 bpm
Confusion
Skin warm to touch
in metabolic rate due to At the end of 6 hrs, the
illness patients temperature will
decrease into 37.2 C or less
Dependent:
Administer antipyretics as ordered
Performed head to toe At the end of 6 hrs,
assessmentTo assess for any the patients
complications & general temperature is now
condition <37.2 C
Monitored VS & lab results
(CBC) To monitor any signs
of progressive infection
Encourage the patient to take
medications as prescribed to
reduce increased temp
Encourage significant others to
monitor temperature & report
any signs of increased temp
Encourage client proper
hygiene to lessen the
transmission of microorganisms
Observe proper medical
asespis to decrease the risk of
more infection
Educate the patient on the
following medication to be
given to be able to know the
purpose & increase compliance

Collaborative:
Monitoring of lab results
Proper nutrition to meet the increasing
metabolic needs
NURSING CARE PLAN
ASSESSMENT
Subj:
Dahan-dahan lang ako
gumalaw kasi madali akong
mapagod at nahihiran akong
huminga. Nahihilo rin ako. as
verbalized
Obj:
Patient manifests confusion,
restless & irritability
Clubbing of fingers & toes
Has pale & dry skin
RR is 38 bpm
PR is 113 bpm
BP is 120/80 mmHg
O2 sat is 92%
Decreased breath sounds on left
side lung upon auscultation
Has nasal flaring
Increased breathing depth
Dull upon percussion on left side
lung
Abn ABGs (hypoxia,
hypercapnia)
DIAGNOSIS PLANNING
Impaired gas exchange Goal:
r/t alveolar-capillary At the end of 6 hrs, the
membrane changes due patient will be able to
to pleural effusion & participate in treatment
regimen (DBE & use of
pulmonary mass
oxygen) within the level of
ability/situation
INTERVENTIONS & RATIONALE EVALUATION
Independent: Criteria:
Assess respiratory & mental At the end of 6 hrs,
status & level of energy of the the patient is now
client to monitor any able to participate in
respiratory changes treatment regimen
Monitor VS (cardiac (DBE & use of
rhythm) to note signs of oxygen) within the
oxygenation changes level of
Applied aseptic techniques ability/situation
(washing of hands, wearing of
masks)decrease the risk of
infection
Encourage to elevate head of
bed & position properly to
facilitate respiration
Maintain adequate input &
output to avoid fluid
overload
Encourage to do DBE to
increase comfort & maximize
the areas of the lungs for
proper lung expansion &
perfusion
Encourage adequate rest &
limit activities within clients
tolerance & promote calming
environment reduce oxygen
needs & consumption
Health teaching on maintaining
a good hygiene (wound
dressing/basic hygiene) for
them to be informed that it
helps to reduce the risk of
infection
Dependent:
Provide oxygen as ordered

Collaborative:
Collaborate to medtech for monitoring
of CBC & pulmonary studies