Assessment

Nursing Diagnosis Hyperthermia related to inflammatory process/ hyper metabolic state as evidenced by an increase in body temperature, warm skin

Scientific Explanation Due to the presence of an infectious agents, stimulation of the monocytes triggers the release of the pyrogenic cytokines that stimulate anterior hypothalamus which results in elevated thermoregulatory set point that leads to an increased heat conservation (Vasoconstriction) increased heat production which results to Fever.

Planning

Intervention

Rationale

Expected Outcome Short term:

SMainit ang katawan ng baby ko:- as verbalized by the client

Short-term: After 4 hrs of nursing intervention the patient will maintain normal core temperature as evidenced by vital signs within normal limits

Independent 1. Monitor infant s condition. 1. To determine the need for intervention and the effectiveness of therapy. 2. To have a baseline data

OThe patient manifested the following: - Temperature above normal level (38 oC) - Skin warm to touch - appears weak - flushed skin

The patient shall maintain normal core temperature as evidenced by normal vital signs

2. Monitor Vital signs

3. Provide TSB

3. Helps in lowering down the temperature

Interdependent 4. Ensure that all equipment used for infant is sterile, scrupulously clean. Do not share equipment with other infants 4. this would prevent the spread of pathogens to the infant from equipment

Dependent 5. Administer Anti-pyretics as ordered INTERVENTION Establish Rapport 1. Monitor and record 2. vital signs Note RR, use of 3. accessory muscles & pursed lip breathing Evaluate clients cough/gag reflex and 4. swallowing ability Auscultate breath sounds, note areas of 5. decreased/adventitiou s breath sounds Elevate head of bed and encourage frequent position 6. changes. 5. aids in lowering down temperature RATIONALE EVALUATION To gain pts trust SHORT TERM: To obtain baseline After 3-4 hours of data NI, pt. shall have To evaluate demonstrated degree of improve airway compromise clearance as evidenced by To determine reduction of ability to protect congestion with own airway breath sounds To ascertain clear and RR status and note improve progress or complications

ASSESSMENT Subjective: (none)

DIAGNOSIS Ineffective airway clearance Objective: r/t accumulation Weak & restless of tracheobronchial secretions Irritable (+)nasal flaring and (+) use of accessory muscles With DOB and (+) wheezes (+)Tachypnea and (+)Tachycardia With changes in rate, rhythm and depth of breathing

PLANNING SHORT TERM: After 3-4 hours of NI, pt.s SO will be able to demonstrate improve airway clearance as evidenced by reduction of congestion with breath sounds clear and RR improve LONG TERM: After 2-3 days of NI, pt. will be able to establish and maintain airway patency.

1. 2. 3.

4.

5.

6.

-v/s taken as follows:

7. Keep back dry and

loosen clothing

To promote maximal inspiration, enhance expectoration of secretions in order to improve ventilation 7. To promote comfort and

T-37.7 P- 130 Rr- 45

8. Instruct the SO to

increase clients oral fluid intake to at least 2000 ml/day within level of cardiac tolerance. 9. Encourage deep breathing exercises and coughing exercises 10. Encourage adequate rest and limit activities to within client tolerance.

adequate ventilation 8. To help liquefy the secretions

9. For drainage of

secretions
10. Rest will prevent

fatigue and decrease oxygen demands for metabolic demands

11. To promote

11. Fix bed linens 12. Give expectorants and

bronchodilators as ordered. 13. Administer oxygen therapy and other medications as ordered.

comfort 12. To further mobilize secretions

13. To clear airway

14. Keep environment

allergen-free

when secretions are blocking the airway indicated to increase oxygen saturation. 14. To reduce irritant

effects on airway

Assessment Subjective: walang gana dumede ang anak ko as verbalized by the patient. Objective: - increase body temperature -flushed skin -increased respiratory rate -v/s taken as follows: T-37.7 P- 130 Rr- 45

Diagnosis Risk for further infection related to compromised immune system

Inference Sepsis is a symptomatic bacteremia, with or without organ dysfunction.

Planning

Intervention Independent: -provide isolation and monitor visitors as indicated

rationale

evaluation Within 8 hours of nursing intervention the patient was was achieve timely healing and free from infection. Goal met.

Within 8 hours of nursing interventions, the patient will achieve timely may result in a healing and sustained free from febrile further response that infection may be associated with organ dysfunction. multiplications of bacteria in the bloodstream that results in an overwhelming

-Body substance isolation (BSI) should be used for all infections patients. Reverse isolation restrict on of visitors may be needed to protect the immunosuppessed patient. -reduces risk of cross contamination because gloves may have noticeable defects get form or damaged during uses.

-wash hands before or after each care activity, even gloves are used.

infection.

-limit use of -prevents spread invasive device of infection via or procedure airborne droplets as possible. -inspect wounds or site of invasive devices, paying particular attention to parenteral lives. -maintain sterile technique when changing dressings, suctioning or providing site care

-may provide clue to portal entry, type of primary infecting organisms, as well as early identification secondary to infection.

-provide tepid sponge bath and avoid using of alcohol.

-prevents introduction of bacteria, reducing risk of nososcomial

infection. -observe for chills and profuse diaphoresis

-monitor of signs of deterioration of condition or failure to improve in therapy

-used to reduce fever

Collaborative: -obtain specimens of urine, blood, sputum, wound as indicated for gram stain, and sensitivity.

-chills often precede temperature spikes in presence of generalized infection.

-administer antibiotics as prescribed

-may reflect inappropriate

antibiotic therapy or overgrowth of secondary infections.

-identification of portal of entry and organism causing the septicemia is crucial in effective trwatment.

-to prevent further spread of infection.