Professional Documents
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ASSESSMENT Subjective: Mataas pa rin ang lagnat nya hanggang ngayonas verbalized by the patients mother. Objective: Flushed skin Skin is warm to touch Temp: 38.2*C PR: 109 RR: 34
DIAGNOSIS Hyperthermia related to positive bacterial infection as manifested by flushed and warm to touch skin.
PLANNING
INTERVENTION
EVALUATION After all the nursing intervention the clients body temp subsided within the normal range.
Short term: within 1 hour of Independent: nursing intervention the patients elevated temperature of 36.2 will lessen to 37.4 degree Celsius. Long term: within 3 consecutive days of nursing intervention, the patients body temperature will return to its normal range. Established rapport to mother to gain trust and cooperation. Promote surface cooling by means of undressing ( heat loss by radiation and conduction) Demonstrate on how to do a proper tepid sponge bath using wet and dry cloth. Provide nutritious diet to meet increase metabolic demands
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EVALUATION After 3 hours of nursing intervention there is no sign of facial grimace and irritability in the patient.
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EVALUATION The childs social and developmental needs are met by family members despite the childs illness and Hospitalization.
games and Toys in the room. Play with the Child. When the child is feeling better, encourage watching television/videotape or listening to The radio/audiotape. Arrange for hearing assessment prior to discharge
child with toys and games as well as sensory stimulation helps the child achieve A sense of wellbeing.
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EVALUATION After 8 hrs. Of nursing interventions, the client demonstrated stable Vital signs and absence of signs of intracranial pressure.
support with small towel rolls side compresses the and pillows: Provide rest periods between care activities and limit duration of procedures. jugular veins and inhibits cerebral venous drainage, thereby increasing intracranial pressure.
R: Continual activity can increase intracranial Curative: Administer supplemental oxygen as indicated pressure
R: Reduces hypoxemia. Investigate reports of pain out of proportion to degree of injury: R: May reflect developing compartment syndrome
Administer
R: used to decrease
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The child shows normal growth and development, nausea and vomiting under control, adequate daily caloric intake and proper hydration verbalized by the S.O.
feed by NG Tube. Consult dietician. Assess level of consciousness before giving liquids.
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