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ERIC V. EVANGELISTA Assessment Subjective: pa balik balike po ang lagnat po ang anak ko as verbalized by mother Objective: Temperature: 38.

3 C RR:20 Pulse:83 Lips dry and tounge white. Client appears under nourished. Nursing Diagnosis Hyperthermia related to dehydration as evidence by clients dry oral mucosa Planning After 4 hours of nursing intervention the client will maintain core temperature within normal range of 36.8 to 37.8 Nursing intervention Rationale Evaluation After 4 hours of effective nursing interventions the clients was able to maintain normal core temperature of 37.5 Goal met Latest Temp 37.3

Identify underlying To obtain factors of factors that may cause increase body alterations of body temperature. temperature. Monitored Patient To obtain get an temperature every 30 accurate body minutes. temperature and detect fever development. Monitored Patient To evaluate pulse rate and effectiveness of respiratory rate. independent nursing regimen. Provided surface To promote core cooling with tepid coding by helping sponge bath and reduce body removing extra temperature. clothing. Promoted rest and To detect further comfort providing existing discomforts bed rest. and level. Dependent intervention: Administer Paracetamol acts as Paracetamol as antipyretic and ordered by MD analgesic which helps acts with the hypothalamus to regulate body temperature.

ERIC V. EVANGELISTA Assessment Subjective: hindi po nagsasalita masyado ang aking anak at hindi masyadong naglalaro as verbalized by mother. Objective: Child appears withdrawn, and poor eye contact, and quivers when speaking. Bruises and burn marks on extremities. Nursing Diagnosis Anxiety related to situational crisis as evidence of physical abuse. Planning After 8 hours of nursing intervention the client will experience less anxiety by exhibiting normal interaction with caregiver and more eye contact. Nursing intervention Assess level of anxiety and fear in child and how it is manifested. Rationale evaluation After 8 hours of nursing intervention the client is able experience less anxiety by exhibiting normal interaction with caregiver with eye contact and is able to verbalize feelings and emotions.

Provides information about the source and level of anxiety and what might relieve it and basis to judge improvement. Provide treatment of Prevents increased injuries; avoid anxiety, and stress in treating the child as a child by discussion victim, asking too for abuse. many questions Demonstrate affection Promotes trust of staff and acceptance of the and positive behavior child even if not of the child. returned or ignored. Provide a play program with other children, praise child or reward with special treat when appropriate. Modifies negative behavior by promoting interaction with others and rewarding desired behavior: promotes self-esteem. Allow expression of Provides opportunity concerns and fears of to vent feelings, child about which reduces treatments, anxiety. environment, allow question and provide honest explanation at child's age level.

ERIC V. EVANGELISTA Refer for counseling service for the child as indicated. Reduces anxiety and supports child in dealing with abuse and negative behavior.