Assessment Subjective Cues: Nilalagnat ang anak ko mainit po siya, as the patients mother verbalized.

Objective Cues Weakness Flush skin Warm to touch Pale Febrile 38.9C Loss of appetite

Diagnosis Hyperthermia related to infection.

Planning Short term goal After an hour of nursing intervention, the clients temperature will subside from 38.9C-38.0C.

Intervention Provide surface cooling such as TSB and removing of extra clothing. Encouraged increase fluid intake. Provide bed rest. Administer Paracetamol 5ml p.oas ordered by the physician.

Rationale To promote core cooling by helping reduce body temperature. To prevent dehydration because increase in body temperature causes fluid loss such as sweating. To detect further existing discomfort and promote rest. Paracetamol are classified as analgesics and antipyretic which acts on the Hypothalamus to regulate normal body temperature. Patient condition improved

Evaluation After an hour of nursing intervention, the patient will decrease the normal body temperature as evidenced by 36 C.

Assessment Subjective Objective pale in appearance dyspnea (+) use of accessory muscles when breathing (+) productive cough RR= 2 4 cpm

Diagnosis Ineffective Airway Clearance r/t secretions in the bronchi

Planning Short Term Goal After 4 hours of nursing intervention, airway patency will be maintained, secretions will be readily expectorated and there will be signs of reduction in congestion.

Intervention Independent Vital signs monitored and recorded. Proper positioning

Rationale This is for baseline comparison.

Proper positioning helps in draining secretions. Prescribed meds such as bronchodilators helps in aiding effective airway clearance. Nebulization helps in liquefying secretions for better and faster expectorating the secretions.

Dependent Administered prescribed medications.

Evaluation After 4 hours of nursing intervention, the goal is met through maintenance of airway patency and reduction in congestion.

Provided supplemental humidification via use of nebulizer.

Assessment SUBJECTIVE: Nanghihina ako., as verbalized by the patient OBJECTIVE: Pale skin Fatigue Weakness Restlessness Irritability Greater need for sleep and rest Cold hands

Diagnosis Activity intolerance related to body weakness.

Planning Short term: After 3 hours of nursing interventions the patient will: -regain strength & increase in activity tolerance including activities of daily living Long term: After 2 days of nursing interventions, the patient: is free from weakness and risk for complications has been prevented.

Intervention Independent: Assess V/S of the pt. Assess patients ability to perform normal task or Activities of daily living. Note changes in balance/ gait disturbance, muscle Weakness. Encourage client to do whatever possible such as sitting, walking. Identify or implement energy saving technique like sitting While doing a task.

Rationale to be able to detect any danger signs that may occur and to be able to monitor the status of the pt. Influences choice of interventions or needed assistance. May indicate neurological changes associated with vitamin B12 deficiency, affecting patient safety or risk of injury. to be able to maintain her ROM and to promote good circulation Encourages patient to do as much as possible, while conserving limited energy and Preventing fatigue.

Evaluation Short term: After the 3-4 nursing intervention, the pt. was able to reveal an increase in activity tolerance, demonstrated a reduction in physiological signs of intolerance and laboratory values within normal range. Long Term: After 2 days of nursing interventions, the patient was not observed to have weakness and risk for complication has been prevented. Goal met.

Assessment Subjective N/A Objective Difficulty of breathing Tachypnea (increased respiratory rate) Use of accessory muscles to breath Nasal flaring Presence of adventitious sound when auscultation such as wheezing. Ineffective coughing. Increase mucus production (present in the mouth).

Diagnosis Ineffective breathing pattern related to increased mucus production in the lungs secondary to pneumonia.

Planning Short term: After 3 to 4 hours of nursing interventions, the patient will demonstrate relief from difficulty of breathing and will maintain a respiratory rate in normal ranges. Long Term: After 5 to 8 hours of nursing interventions, the patient will demonstrate effective breathing pattern and patent airway.

Intervention Independent: Proper Positioning Monitor vital signs specially respiration every 15 to 30 minutes. Administer oxygen supply or artificial ventilator to client. Monitor patient for pallor and cyanosis. Asses need for airway insertion. Note chest movement, watching for symmetry, use of accessory muscles. Auscultate breath sounds, noting areas of decreased/absent ventilation.

Rationale To improve airway breathing by positioning. To help or support patient in breathing. to improve patients comfort. To improve breathing by dilating the airway pathway or medications that dilates bronchus.

Evaluation Short term: After 3 to 4 hours of nursing interventions, the patient demonstrated relieve from difficulty of breathing and maintained a respiratory rate within normal ranges. Long term: After 5 to 8 hours of nursing interventions, the patient demonstrated effective breathing pattern and have a patent airway

Assessment Subjective: Konti konti lang ang iniinum nyang gats iyak sya ng iyak. Verbalized by the mother of patient. Objective: Refuse to intake milk. Irritable

Diagnosis Risk for imbalance nutrition less than body requirements related to decrease intake.

Planning With in 1 hour of nursing intervention the client SO will be able to identify intervention to maintain clients optimal nutritional status.

Intervention Document patients weight. Provide small frequent feeding.

Provide oral care.

Rationale Evaluate the clients nutritional status. This will enhance intake even with a poor appetite. Sputum can be foul tasting and decrease appetite.

Evaluation After 1 hour of nursing intervention the client SO was able to identify instructions to maintain clients optimal status.

Assessment Subjective: Dumudugo ang ilong nganak ko, as the patients mother verbalized. Objective Cues:

Diagnosis At risk of bleeding r/t to altered clotting factor .

Planning After an hour of nursing intervention, the client will be able to demonstrate behaviors that reduce the risk for bleeding.

Intervention Assess for signs of GI bleeding.

Rationale The GI tract is the most usual source of bleeding of its mucosal fragility To prevent other complications

Observe color and consistency of stools or vomits. Focus for presence of bleeding from one or rmore sites.

Evaluation After the nursing intervention the risk of having bleeding is avoided.

Weakness

Irritability

To prevent risk for hemorrhage

Restlessness Pale Inhibit of taking aspirin containing products Monito r Hb and Hctand clotting factors Increase fluid intake Indicators of anemia, active bleeding or impending complication

Febrile- 38.9C

To prevent dehydration

Place patient on a bed rest

To detect further existing discomfort Patient condition improved