CUES/ NURSING RATIONALE GOALS & INTERVENTIONS EVALUATION

NEEDS DIAGNOSIS OBJECTIVES

Subjective Data: Risk for fluid Typhoid fever, also Short Term: Independent Short Term:
“tatlong araw ng imbalance: Less known as At the end of the 8 -Monitor VS Goal partially Met.
nilalagnat ang anak than body Salmonella typhi or hours shift patient -Monitor I and O Patient ingested 3
ko. Nung martes, requirement r/t loss commonly just would be able to -Regulated IVF glasses of water at
sobrang taas at of appetite and typhoid, is a ingest 4-5 glasses -Keep the area the end of the 8
umabot ng 38.9. increased common worldwide of water. clean and dry. hours shift.
Pinapainom ko frequency of bowel illness, transmitted -Carefully dress
naman siya ng movement by the ingestion of Long Term: wound Long Term:
Tempra pero secondary to food or water At the end of 2 -Stimulate Goal partially Met.
bumababa lang disease process. contaminated with weeks or until circulation to Patient showcase
hanggang 38 yung the feces of an patient is surrounding area increase in appetite
lagnat niya. infected person. discharged patient -Encourage mother by eating ¾ cup of
Pinunasan ko rin The bacteria then would be able to to give increase different food and
siya kaso ganun pa perforate through showcase increase intake of fluid and drinking 4 glasses
din” as verbalized the intestinal wall in appetite by nutritious foods. of water at most at
by the patient’s and are ingesting food of at the end 2 weeks of
mother. phagocytosed by least 1 cup and Dependent nursing
Objective Data: macrophages. It is would be able gain -Administer intervention.
-(+) Hyperthermia; caused by the weight to at least paracetamol via IV.
temperature: bacterium 13.5 kg. -Administer
37.8°C Salmonella typhi antibiotics via IV.
-(+) rhinorrhea The organism is a
-(+) productive Gram-negative Collaborative
cough short bacillus that is -Provide optimum
-(+) diarrhea motile due to its nutrition
-(+) anorexia peritrichous flagella.
-decreased in The bacterium
activity grows best at
-(+) chills 37 °C/99 °F –
-(+) Weight loss human body
from 14.5 kg to 13 temperature. And
kg therefore affects the
-Physicians gastrointestinal
Diagnoses: system the most.
Typhoid Fever Causing either
diarrhea or
constipation and
loss of appetite.

Reference:
Wikipedia.com