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Nursing Care Plan

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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

Dependent: Administer antipyretic as ordered.

Nursing Care Plan


ASSESSMENT Subjective: Umiiyak yan kapag nahahawakan yung batok nya saka nung may ginawa yung doctor nya as verbalized by the mother. DIAGNOSIS Acute pain related to meningeal infection with spasm of extensor muscle (neck, shoulder and back) as manifested by positive kernigs and brudzinskis sign. Objective: Facial grimace Irritable (+) Brudzinskis sign (+)Kernigs sign Promote rest in the room by keeping stimulation and the room to minimum Institute respiratory isolation Monitor and record carefully intake and output. Position on the side with head gently supported in extension PLANNING Within 3 hours of nursing intervention the patients pain from 8 will reduce to 4 using the facial pain rating scale. INTERVENTION Independent: Use pain rating scale appropriate to its age Assess for neurologic exam and vital signs

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EVALUATION After 3 hours of nursing intervention there is no sign of facial grimace and irritability in the patient.

Nursing Care Plan


ASSESSMENT Objective: Facial grimace Irritable (+) Brudzinskis sign (+)Kernigs sign DIAGNOSIS Impaired Social Interaction related to decreased level of consciousness, hospitalization, and isolation PLANNING After 8 hours of nursing intervention The childs social interaction will be Near normal despite isolation. Encourage parents to help with daily activities such as feeding and Bathing. INTERVENTION Educate parents and other visitors to use proper infection control Techniques. Rationale Family members help fulfil the emotional and social needs of the ill And contagious child. Parental involvement in the childs care provides the child with a sense of security and emotional wellbeing. Parents have a sense of control and a feeling that they are doing something to enhance the Childs recovery. Have age-appropriate Providing the

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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.

Hearing loss is a common Complication. Early intervention is needed to promote g

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Nursing Care Plan


ASSESSMENT Subjective: masakit ang ulo ko as verbalized by the patient. Objective: Restlessness Change in motor or sensory responses Difficulty in swallowing skin discoloration decrease motor response Demonstrate behaviours/lifestyle changes to improve circulation. DIAGNOSIS Risk for ineffective cerebral Tissue perfusion related to cerebraledema PLANNING After 8 hrs. of nursing interventions, the client will demonstrate stable Vital signs and absence of signs of intracranial pressure. Instruct patient to avoid or limit coughing, Vomiting, straining at defecation, bearing down as possible. R: These activities increase thoracic and intra-abdominal pressure which can increase intracranial pressure. Elevate head and maintain head/neck in midline neutral position Prevention: Observe for seizure activity R: Seizure can occur as INTERVENTION Independent: Decrease extraneous stimuli and provide comfort measures like back massage, quiet environment, soft voice. R: Provides calming effect, reduces Adverse physiological response and promotes rest to maintain or lower intracranial pressure. Rationale

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EVALUATION After 8 hrs. Of nursing interventions, the client demonstrated stable Vital signs and absence of signs of intracranial pressure.

R: to promote circulation/venous drainage

and protect patient from injury.

result of cerebral irritation, hypoxia or increase intracranial pressure.

Maintain head or neck in midline or neutral position, R: Turning head to one

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

medications(antihypertensive, edema. diuretics)

Rehabilitation: Encourage quiet, restful atmosphere:

R: Conserves energy and lower oxygen demand

Limit daily activities and caution client to avoid strenuous activities

R: over exertion may cause dizziness

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Nursing Care Plan


ASSESSMENT Subjective Dalawang araw na sya nagsususka as verbalized by the mother. Objective: Weak in appearance Irritable (+) Nausea and vomiting Temp: 37.4 RR 40 PR 105 Provide a flexible feeding schedule with small feedings of favourite foods. Minimise handling around feeding times. Assist the child with chewing with the childs chin and jaw in the nurses hand, if swallowing is impaired & if so Nausea and vomiting controlled. Position the infant or child upright after feeding. DIAGNOSIS Altered nutrition: less than body requirements related to restricted intake; nausea, and vomiting, swallowing and chewing difficulty. PLANNING The childs weight will be stable and appropriate for age, normal serum protein, moist mucous membrane and adequate urine output. Monitor skin turgor, mucous membrane and urine output. INTERVENTION Weight the child daily on the same scale and record on growth chart. EVALUATION

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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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