NAME: P.

T Diagnosis: Bronchial Asthma in Acute Excerbation

Age: 2 ½ year old Attending Physician: Dr. A.P
Gender: Female

CUES NURSING OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS

SUBJECTIVE DATA: Hyperthermia GENERAL OBJECTIVES: INDEPENDENT: After 30 minutes of

“Ginaeagnat man related to To facilitate the nursing intervention,
imaw ko gabi-i nga infection as maintenance of regulatory  Introduce ourselves  A therapeutic way to Goals met as evidence
gindaea namon imaw manifested by mechanism and function to the client and build trust in working by :
sa ospital bale 4 increased body significant others relationship. body temperature
adlaw eon.” as temperature, SPECIFIC OBJECTIVES: subsided to 37.2⁰C/ax
verbalized by the tachypnea and After 30 minutes of nursing  Monitor vital signs  To have a baseline
mother. warm flushed skin intervention the patient specifically data.
will be able to: temperature
OBJECTIVE DATA:
Decrease body
 T: 38.5°C/ax temperature from 39⁰C to  Provide tepid
37.4⁰C sponge bath  To increase heat loss
 Flushy skin
through conduction
 Warm to
touch  Apply cold compress
 Sweating  It could help in
reducing hyperthermia
through evaporation
 Encourage the
mother to have an  To replace fluid loss
adequate fluid due to perspiration
intake

 To reduce metabolic
 Instruct the mother demands and oxygen
consumption
to maintain bed rest
 for the client
 Schedule activity
 To maximized rest
and assessments periods.

 Reassess  To determine the

temperature every effectiveness of the
intervention done.
15 minutes

DEPENDENT:
 Antipyretic acts on the
 Administer hypothalamus,
Paracetamol 83mg reducing
IVTT prn for fever hyperthermia.
q4h per doctor’s
order.

 Administer IV fluids  to replenish fluid loss

 Administer
cefuroxime 215mg  to treat infection
IVTT q8h and
clarythromycin
d5mg/5ml bid as
ordered by the
physician.

COLLABORATIVE:
 to rule out presence of
 CBC exam an infection