i.

Nursing Management

Date/Tim Cues Nursing Goal and Interventio Rationale EVALUATIO

e Diagnosis Objective ns N
s
03/14/21 SUBJECTIVE Hypertherm After 8 Independent: Goal met.
DATA:”Mga ia related to hours of -Establish -To gain patient’s After 8
limang araw presence of nursing rapport. trust and hours of
bago ako na dengue interventio cooperation. nursing
confine dito virus in n, the pt. intervention,
nagkaroon patient’s will be able -Monitor -Monitoring is the pt. has
ako ng body to patient’s vital necessary in able to
pabalik-balik causing demonstra signs. order to trace the demonstrate
na lagnat release of te behavior sudden changes behavior
madalas pyrogens as that thus effective that reduces
paghapon.” evidenced reduces care is render. high
as by fever high temperature
verbalized. with a temperatur -Encourage -To replace fluids as evidenced
temperatur e as patient to loss thus by the
Objective: e of 38.4° evidenced drink plenty preventing decrease of

89
 C. by the of 1500- dehydration. temperature
 fever decrease 2000cc/ day from 38.4° C
of (as to 37.5° C.
 body temperatur tolerated).
malais e from -Providing a
e 38.4° C to -Instruct the sense of comfort
37.5° C. patient to and easy thin
 warm
wear clothing clothing absorbs
to
that is thin sweat and does
touch
and easy to not stimulate an
absorb increase body
sweat. temperature.

T: 38.4° C
-It helps to
BP: 100/65
-Observation prevent
mmHg
of intake and dehydration and
RR: 21 cpm
output. to know the
PR: 96 bpm
balance of fluids
and electrolytes

90
 in the body.

- Perform - Considered to
TSB. be one of the
cooling
treatments. This
method is
recommended for
febrile pt.;
effective in
relieving high
temperature and
helpful in
alleviating pain
and discomfort.
- Discuss
importance
of adequate -To lower the
fluid intake temperature
particularly of the pt.

91
 to the
significant
other.

Dependent:

-Administer
IVF. -Replacement is
essential for
patients with a
high body
temperature
particular drug to
lower the patient
body
-Administer temperature.
paracetamol
as ordered.
-It acts as
antipyretics

92
 thereby it used to
decrease fever by
inhibiting the
central action of
hypothalamus
which is the
thermoregulation
. By
hypothalamic
Collaborative action, it would
: lead to sweating
and vasodilation.
-Refer to the
physician if
the
temperature -To monitor
still higher to patient’s
normal condition.
range.

93
 -Endorse the
patient’s
case to the -To maintain
nurse on the patient's dign
duty. ity throughout
treatment and
care and this
may include
making
suggestions in
the treatment
plan of patients,
in collaboration
with other health
professionals.

94
 I R E
na V
t t A
ei L
r o U
vn A
ea T
nl I
t e O
i N
o
Date/Tim Cues Nursing Goal and Intervention Rationale EVALUATIO
n
e Diagnosis Objectives s N
s
03/14/21 Subjective: Ineffective After 8 Independent: After 8 hours
I G
“Wala akong tissue hours of of Nursing
n- o
lakas.” As perfusion nursing -Establish -To gain patient’s intervention,
dT a
verbalized. related to intervention
 rapport. trust and the client will
eo l
insufficient , the pt. will cooperation. be able to
p
Objective: knowledge be able
 to demonstrate
eg m
 Pale of disease demonstrat a -Monitor
e and -Serves as a basis increase
n
skin process or e increase i trecord vital for any alteration perfusion as
d
 T: aggravatin perfusion asn .sign. in system function. evidenced by
e
38.4° g factors evidenced normal skin
n
p A
t
a f
:
95 t t
-
i e
E
e r
s
n
 C as by normal color, T of
 BP: evidenced skin color, T -Provide -To inform and 37.5°C, and
100/6 by pale of 37.5°C, health help pt. BP of 100/65
5 skin, T of and BP of teaching understand her mmHg.
mmHg 38.4°C, 100/65 about Dengue health condition.
and BP of mmHg. Fever.
100/65
mmHg. -To improve
-Elevate the circulation and
head of the increase venous
bed to about return.
10°.

-Helps in
-Assess skin identifying problem
color. as changes may
indicate circulation
problem. Thus,
prompt treatment
and prevention is

96
 address.

-Enough rest is
-Advice pt. to needed to
have enough conserve energy.
rest.

Dependent:
-Sufficient fluid
-Check for intake maintains
optimal fluid adequate filling
balance and pressures and
administer IV optimizes cardiac
fluids as output needed for
ordered. tissue perfusion.

-Improves blood
- Administer circulation that can

97
 medications increase tissue
as ordered. perfusion.

-To maintain
- Hook O2 myocardial
support via perfusion.
nasal cannula
x 3 LPM as
indicated.

Collaborative:
-To monitor
- Refer to the patient’s condition.
physician if
the blood
pressure is
still lower to
normal range. -To maintain

98
 the patient's dignit
-Endorse the y throughout
patient’s case treatment and care
to the nurse and this may
on duty. include making
suggestions in the
treatment plan
of patients, in
collaboration with
other health
professionals.

99