Cabriga, Lady Diane

BSN-III

ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION

Subjective: Altered body After 30 mins. Of Independent: - Enhances heat loss After 30 mins on
“Pabalik- balik po yung temperature related to nursing intervention by evaporation and effective nursing
lagnat niya” as diseases process as the client will maintain - Provide tepid sponge bath conduction intervention the client
verbalized by the SO evidenced by core temperature - Assess fluid loss and facilitate - Increases metabolic was able to maintain
temperature of within normal range of oral intake. rate and core temperature of
patient is 38.8 C 37.0 C from 38.8 - Promote bed rest diaphoresis. 37.0 C
Objective: - Provide cool circulating air - Reduces body heat
- Warm to touch using a fan production.
- Flushed skin - Assist patient in changing into - Dissipates heat by
- Temp = 38.8 C dry clothing convection
- Increase RR = 31 - Provide oral hygiene - Increases comfort
- Monitor vital signs. - Prevents herpetic
Dependent: lesions of the mouth
- Maintain IV fluids as ordered - Notes progresses
by the physician. and changes
- Administer anti-pyretic as condition
ordered. - Prevents
- Administered antibiotic as dehydration
ordered - Reduces fever
Collaborative: - Treats underlying
- Monitor hematologic test and cause
other pertinent lab records. - Indicates presence
- Discuss condition of the patient of infection and
with others members of the dehydration
health care team. - Ensures continuous
intervention.
ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION
Subjective: Activity intolerance related The patient will be able to - Monitor the patients - This helps in The patient was able to
“mataas ang presyon ko, to the disease process tolerate easy exercises vital signs especially getting the base tolerate exercises by the
nanghihina pati ako”. As evidenced by the patient and will be able to know the blood pressure information of time they left the hospital
verbalized by the patient. verbalizing that they get what exercises they able every two hours. how the patient
tired easily when performing to do by the time they - encourage patient to is performing.
relatively easy tasks. leave the hospital decrease intake of - May indicate
caffeine, cola and cyanide toxicity
Objective: chocolates from increasing
- Weakness - Monitor for sudden intracranial
- Pale in color onset of chest pain. pressure
- skin cool to touch - May indicate
- BP= 140/90 - Teach the patient dissecting aortic
relatively easy aneurysm.
exercises like - So that they
stretching, walking. stopover
- Refer the patient to straining their
a physiotherapist so heart with heavy
that they can exercises.
continue to teach - So that they give
the patient on what them more
exercises they are assistance with
able to do without the exercises.
overstressing the - These drugs
heart reduce the work
Dependent: load of the heart.
- Administer - This reduces the
medications that anxiety of the
reduce the patient so
hypertension as reduces the
prescribed by a stress.
medical doctor.
- Reassure the patient
that they would
improve.