Assessment Subjective: Nilalagnat po ang anak ko. Pabalik-balik po ang kanyang lagnat. Mataas po yung lagnat niya sa gabi.

As verbalized by the mother. Objective: - TEMP: 38.7 C - Skin is warm to touch and s reddish - (+) body weakness

Nursing Diagnosis Hyperthermia r/t inflammatory response manifested by high body temperature and elevated WBC levels in the blood.

Scientific Rationale Street foods, flood waters, tap water. Salmonella Typhi Enter the G.I tract Invasion of intestinal epithelium through Peyers Patches Organism travels to lymph nodes multiplication of microorganisms enters the blood stream infectious process Fever

Planning Short Term Goal: After 30 minutes of rendering nursing care, the patients body temperature will fall with the normal range of 37.5 *C

Intervention Independent: - Establish Rapport - Perform tepid sponge bath

Rationale - To gain trust from parents - To promote heat loss by evaporation and conduction to lower body temperature - Due to high body temperature there is an increase in metabolic rate and diaphoresis associated with fever causing loss of body fluids

Evaluation Short term goal: Met. After 30 mins of nursing intervention the patients body temperature is within normal range

- Assess fluid loss and facilitate oral fluid intake or administer IV fluids to accomplish fluid replacement Dependent: - Administer Paracetamol as ordered by the physician

- Paracetamol produces antipyresis by inhibiting the hypothalamic heatregulating center. - Administer - This is an antiChloramphenicol infective drug that can be used to treat acute salmonella typhi infection. It inhibits bacterial protein synthesis; bacteriostatic

Assessment Subjective: Nagsusuka at nagtatae ang anak ko. As verbalized by the mother. Objective: - Body weakness - Pale skin - Skin Turgor: moderately slow return of sin when pinched. - Dry lips

Nursing Diagnosis Fluid volume deficit related to excessive losses through normal routes (frequent diarrhea and vomiting) as evidenced by low skin turgor, body weakness and dry lips.

Scientific Rationale Environment, unsterilized bottles,hygiene ingestion of E.Coli Invasion of gastric mucosa proliferation of bacteria in the intestines toxins produced by pathogens cause watery stool irritation of the gastric lining causing vomiting increased fluid loss dehydration

Planning Short Term Goal: After 8 hours of nursing interventions the patient will demonstrate decreased frequency in vomiting and normal hydration. Long term goal: After 2 days of nursing care the patient will demonstrate no vomiting and normal hydration as evidenced by moist lips, and normal skin turgor

Intervention Rationale Independent: - Monitor Intake - Provides and Output. information about Note overall fluid number,charact balance,renal er, and amount function, and of stools;. bowel disease Measure urie control, as well specific gravity; asguidelines for observe for fluid replacement. oliguria - Observe for - Indicates excessive excessively dry fluid skin and mucous loss/dehydration membrames, decreased skin turgor. - Promote bed - To regain strength rest and alleviate body weakness Dependent: - Administer - Inhibits tha action Ranitidine as of H2 receptor ordered by the sites located physician primarily in the gastric lining of the stomach resulting in inhibition of gastric acid secretion

Evaluation Short term goal: Partially met: After 8 hours of nursing interventions, the patient still vomited by less frequent, still had dry lips and body weakness