Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Hyperthermia Goal: After 3 The student nurse shall: After 3 days, goal is
“Napakainit ng related to disease days client’s partially met as
pakiramdam ko” process as temperature will Independent: manifested by:
as verbalized by manifested by a be within normal - Assess client’s signs and - to serve as baseline
the client. temperature of range. symptoms of infection data - Client’s
39.2 C. temperature
Objective: - Perform tepid sponge (37.4) within
T= 39.2 C bath - to decrease body normal range
(+) chills Objective: After 4 temperature after 5 days.
(+) body hours of nursing - client still
weakness intervention, - Suggest proper clothing - to promote surface demonstrates
(+) facial client’s (i.e. thin, short and lose ) cooling body weakness
grimace temperature will
be lessened as - Encourage increase in - to regulate body
manifested by a fluid intake, from 3 temperature
temperature glasses u to 5-6 glasses
lower than 39.4 per day.
C.
- t o reduce metabolic
- Encourage bed rest process

- to determine client’s
- Monitor vital signs every progress
hour
- to decrease body
Dependent: temperature
- administer antipyretic
drugs as ordered by the
physician
Subjective: Ineffective airway Goal: The student nurse shall: After 3 days, goal is
“Nahihirapan clearance related unmet as manifested
akong huminga. to retained After 3 days Independent: by:
Tsaka inuubo secretions as client’s airway
will be cleared. - Assess client’s - Indication of RR= 35 bpm
ako”, as manifested by respiratory rate, depth, respiratory distress
verbalized by the respiratory rate rhythm and sounds every and/or accumulation (+) dyspnea
client. of 30 bpm, 2 hours of secretion
dyspnea, Objective: (+) crackling sounds
difficulty of
After 24 hours - Elevate client’s head - Promotes lung (+) difficulty of
Objective: breathing and
client will: expansion breathing
non productive
RR= 30 cough. - Perform physiotherapy
- have a (+) non productive
respiratory - Expectorates and
(+) dyspnea cough
rate within liquefies secretion
- Encourage increase in
normal
(+) crackling fluid intake from 3
range
sounds glasses to 5-6 glasses a - Liquefies secretion
- be able to
day.
cough out
(+) difficulty of
phlegm
breathing - have a
Dependent:
unlabored
(+) non and normal
productive cough - Administer drug
breathing (nebulization) every 4 - Serves as
Restless hours as ordered by the bronchodilator
physician.
Medical Diagnosis: Possible Severe Viral Infection since the CBC revealed that there is an increase in WBC.