Cues/ Diagnosis Analysis Objectives Intervention Rationale Evaluation

Clues s
38degrees Hyperthermia Hyperthermia After 15 mins 1.Monitor VS -hypotension, Patient has
Celsius related to is an increase of nursing dysrythmia and temperature
presence of of the body intervention: hyperventilation within normal
Diagnosed bacterial temperature -Patient will might be level
with renal infection above the have a lower present
abscess manifested by normal range temperature together with Patient does
increase in caused by the reading hyperthermia not have renal
WBC- 25.1 x WBC effect of the 2. Monitor Intake - to check for failure and/ or
109/L inflammation After an hour and output symptoms of signs of shock
process that is of nursing renal failure and
reacting to the intervention: shock
infection -Patient will 3.Promote surface -to promote
present have no cooling by heat loss
recurrent undressing, or through
episodes of giving a Tepid convection,
increase in sponge bath conduction and
temperature evaporation
4. Maintain -to reduce
bedrest metabolic
demands
5. advise mother to -to promote
give adequate fluid circulating
to patient volume and
tissue perfusion
6.administer -to promote
replacement fluid circulating
and electrolyte as volume and
ordered tissue perfusion
7. administer -To reduce fever
antipyretics as through
ordered pharmacological
means
Cues/ Diagnosis Analysis Objectives Intervention Rationale Evaluation
Clues s
Mother Effective Effective After nursing 1.)Recommend -to see Patient’s
verbalized” breastfeeding breastfeeding intervention: monitoring number adequate mother is able
ayos naman related with is when -Patient’s of patient’s wet hydration to continue
ung pagpapa mother mother-infant mother be able diaper proper
breastfeed understanding exhibits to continue 2.) Review -to help breastfeeding
ko of proper proficiency breastfeeding techniques for sustain until 2nd year of
breastfeeding and with proper expression and breastfeeding age
process satisfaction technique until storage of breast techniques
with patient is 2 milk
breastfeeding years of age 3.) Explain changes -Growth spurts
process in feeding needs require
increased
intake
4.)Recommend -some
avoidance of medication are
specific known to
medications and decrease milk
alcohol supply
5.) Educate father -Enlisting
about benefits of supportis
breastfeeding associated
 with higher
ratio if
successful
breastfeeding
activity
6.)Note incorrect -to be able to
myths correct this
mythology
Cues/ Diagnosis Analysis Objectives Intervention Rationale Evaluation
Clues s
Has Risk for Risk for After nursing 1.)Monitor lab -to identify Patient is not
intermittent imbalanced imbalanced intervention: values potential demonstrating
fever body body Patient would internal any sign of
temperature temperature is not have any causes of febrile episodes
Diagnosed related to due to failure of future febrile temperature
with renal presence of the body to episodes imbalance
abscess infection control 2.)Assess -to determine
without temperature nutritional status metabolism
urosepsis within normal effect on body
range due to the temp.
effect of 3.)Limit clothing -to prevent
theinflammation overheating
process that is and promote
reacting to the heat loss
infection 4.) Monitor core -to assess
present body temp. temperature
more
accurately
5.) Maintain core -to be able to
temp. within keep patient
clients normal homeostasis
Cues/ Clues Diagnosis Analysis Objectives Intervention Rationale Evaluation
s
Post Impaired skin Impaired skin After 6 hours of 1.) Inspect skin on - to promote Patient is free
percutaneous integrity integrity is nursing a daily basis proper from
Nephrostomy related to a due to the Intervention: assessment complication in
tube insertion break in the break of the Patient will and timely his skin
skin of the epidermis show no signs intervention integrity
patient and dermis in of infection, 2.) Avoid use of -Promote
surgery to pain, or any plastic material moisture that
insert an complication in potentiates
object lesion sight. skin
foreign to the breakdown
body After 3.) Provide -to aid in skin
hospitalization: optimum nutrition and tissue
Patient will healing
display timely 4.) Review -to maintain
healing of skin importance of skin proper skin
without and measures functioning
complication 5.)Discuss to - to promote
parents the timely
importance of intervention
early detection of
skin changes
Cues/ Diagnosis Analysis Objectives Intervention Rationale Evaluation
Clues s
Prescribed Risk for Risk for After nursing 1.) stress proper - first line Patient is free
with infection infection is interventions: hand hygiene by all defense against from other
Gentamycin related to increase risk The patient will caregivers health care infection
and suppressed for being not have any associated
Ceftriaxone immunity of invaded by additional infections
the body pathogenic infection 2.) Educate - to prevent
organism relatives in cross
caused by a infection control contamination
suppression in procedures
the immunity 3.)Instruct parents - to maintain
of the patient to do patient’s hygiene of the
that is caused mouth care patient
by undergoing 4.)Maintain - to avoid
an antibiotic adequate urinary stasis
therapy which hydration
kills the normal 5.) Provide regular -reduce risk of
flora of the urinary catheter ascending
body care urinary tract
infection