03/10/2022 Focus: hyperthermia D: “3 araw ng nilalagnat si

baby” as verbalized by the

mother. received with
temperature of 38.2C , patient
was irritable, flushed skin, Skin
was warm to touch. RR of 35
CPM-------------------------------J.M
A: asssessed thermoregulatory
status. Accurately measured
and documented client’s
temperature. Administered
paracetamol as ordered.
Instructed the mother to loosen
the patients clothing. Educated
the mother about the
importance of adequate fluid
intake.-----------------------------J.M
R: temperature went down
from 38.2C to 37.2C-----------J.M

Focus: ineffective breathing D: upon admission, the patient

pattern the patient showed nasal
flaring, use of accessory
muscles to breath, and
presence of crackles upon
auscultating the patient. RR of
35 CPM. SPO2 of 86%---------J.M
A: assessed respiratory rate.
Observed breathing patterns.
Auscultated for breath sounds.
Assisted in changing position
from supine to semi Fowler.
Administered salbutamol as
ordered. O2 inhalation given via
face mask regulated at 1-2 LPM.
R: patient shows improvement.
RR of 28 CPM and SPO2 0f
98%.no abnormal breath
sounds and chest sound noted.-
j.m

D:upon admission. The patient

Focus:Impaired Gas exchange showed presence of nasal
flaring, use of accessory
muscles to breath, the patient
was irritable. SPO2 of 86% . PR
of 155bpm -----------------------J.M
A: monitored vital signs
specially Respiratory rate.
Monitored oxygen saturation.
Assessed capillary refill.
Assisted in repositioning to
patient to semi fowler.
Administered O2 at 1-2 LPM as
ordered. Administered
salbutamol as ordered.
Educated the mother about
complications of the disease
and when to call a physician -
j.m
D: patient showed
improvement. SPO2 98% and
displayed relief and ease of
breathing.------------------------j.m