Nursing Care Plan 29

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective: Hyperthermia related to Short term: within 1 hour of Independent: After all the nursing
“Mataas pa rin ang lagnat positive bacterial infection nursing intervention the  Established rapport intervention the clients body
nya hanggang ngayon”as as manifested by flushed patient’s elevated to mother to gain temp subsided within the
verbalized by the patient’s and warm to touch skin. temperature of 36.2 will trust and normal range.
mother. lessen to 37.4 degree cooperation.
Objective: Celsius.  Promote surface
Flushed skin Long term: within 3 cooling by means of
Skin is warm to touch consecutive days of nursing undressing ( heat
Temp: 38.2*C intervention, the patient’s loss by radiation and
PR: 109 body temperature will conduction)
RR: 34 return to its normal range.  Demonstrate on how
to do a proper tepid
sponge bath using
wet and dry cloth.
 Provide nutritious
diet to meet increase
metabolic demands

Dependent: Administer
antipyretic as ordered.
 Nursing Care Plan 30

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective: Acute pain related to Within 3 hours of nursing Independent: After 3 hours of nursing
“Umiiyak yan kapag meningeal infection with intervention the patient’s  Use pain rating scale intervention there is no sign
nahahawakan yung batok spasm of extensor muscle pain from 8 will reduce to 4 appropriate to its age of facial grimace and
nya saka nung may ginawa (neck, shoulder and back) as using the facial pain rating  Assess for neurologic irritability in the patient.
yung doctor nya” as manifested by positive scale. exam and vital signs
verbalized by the mother. kernig’s and brudzinski’s
sign.  Position on the side
Objective: with head gently
 Facial grimace supported in
 Irritable extension
 (+) Brudzinski’s sign
 (+)Kernigs sign  Promote rest in the
room by keeping
stimulation and the
room to minimum
 Institute respiratory
isolation

 Monitor and record

carefully intake and
output.
 Nursing Care Plan 31

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION Rationale EVALUATION

Objective: Impaired Social After 8 hours of ■ Educate parents and ■ Family members The child’s social and
 Facial grimace Interaction related to nursing intervention other visitors help fulfil the developmental
 Irritable decreased level of The child’s social to use proper infection emotional and social needs are met by family
 (+) Brudzinski’s consciousness, interaction will be control needs of the ill members
sign hospitalization, and Near normal despite Techniques. And contagious despite the child’s
(+)Kernigs sign isolation isolation. child. illness and
■ Encourage parents to ■ Parental Hospitalization.
help with involvement in the
daily activities such as child’s
feeding and care provides the
Bathing. child with a sense
of security and
emotional
wellbeing. Parents
have a sense of
control and a feeling
that they are
doing something to
enhance the
Child’s recovery.
■ Have age-appropriate ■ Providing the
games and child with toys and
Toys in the room. Play games as well as
with the sensory
Child. When the child is stimulation helps the
feeling child achieve
better, encourage A sense of well-
watching being.
television/videotape or
listening to
The radio/audiotape.
■ Arrange for hearing ■ Hearing loss is a
assessment common
prior to discharge Complication. Early
intervention is
needed to promote g

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 Nursing Care Plan 33

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION Rationale EVALUATION

Subjective: Risk for ineffective After 8 hrs. of nursing Independent: After 8 hrs. Of
“masakit ang ulo ko as cerebral Tissue interventions, the client R: Provides calming nursing
Decrease extraneous stimuli
verbalized by the perfusion related to will demonstrate stable effect, reduces Adverse interventions, the
and provide comfort
patient. cerebraledema physiological response client demonstrated
Vital signs and absence measures like back massage,
Objective: and promotes rest to stable Vital signs
of signs of intracranial quiet environment, soft voice.
Restlessness maintain or lower and absence of
pressure.
Change in motor or intracranial pressure. signs of intracranial
sensory responses pressure.
Instruct patient to avoid or
Difficulty in R: These activities
Demonstrate limit coughing, Vomiting,
swallowing increase thoracic and
behaviours/lifestyle straining at defecation,
skin discoloration intra-abdominal
changes to improve bearing down as possible.
decrease motor pressure which can
circulation.
response increase intracranial
pressure.

Elevate head and maintain R: to promote

head/neck in midline neutral circulation/venous
position drainage

Prevention:

Observe for seizure activity R: Seizure can occur as

and protect patient from
injury.
Maintain head or neck in
midline or neutral position,
support with small towel rolls side compresses the
and pillows:
Provide rest periods between
care activities and limit
duration of procedures.
Curative:
Administer supplemental
oxygen as indicated
Investigate reports of pain out
of proportion to degree of
injury:
result of cerebral
irritation, hypoxia or
increase intracranial
pressure.
R: Turning head to one
jugular veins and
inhibits cerebral venous
drainage, thereby
increasing intracranial
pressure.
R: Continual activity
can increase intracranial
pressure
R: Reduces hypoxemia.
R: May reflect
developing
compartment syndrome
Administer R: used to decrease
medications(antihypertensive, edema.
diuretics)

Rehabilitation: R: Conserves energy

Encourage quiet, restful and lower oxygen
atmosphere: demand

Limit daily activities and R: over exertion may

caution client to avoid cause dizziness
strenuous activities

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 Nursing Care Plan 36

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective Altered nutrition: less than The child’s weight will be ► Weight the child daily on The child shows normal
“Dalawang araw na sya body requirements related to stable and appropriate for age, the same scale and record on growth and development,
nagsususka” as verbalized by restricted intake; nausea, and normal serum protein, moist growth chart. nausea and vomiting
the mother. vomiting, swallowing and mucous membrane and under control, adequate
Objective: chewing difficulty. adequate urine output. ► Monitor skin turgor, daily caloric intake and
Weak in appearance mucous membrane and urine proper hydration
Irritable Nausea and vomiting output. verbalized by the S.O.
(+) Nausea and vomiting controlled.
Temp: 37.4 ► Position the infant or child
RR 40 upright after feeding.
PR 105
► Provide a flexible feeding
schedule with small feedings
of favourite foods.

► Minimise handling around

feeding times.

► Assist the child with

chewing with the child’s chin
and jaw in the nurse’s hand, if
swallowing is impaired & if so
feed by NG Tube.

► Consult dietician.

► Assess level of
consciousness before giving
liquids.

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