Assessment

Diagnosis

Subjective
Parang mainit
ang katawan
nya as
verbalized by
mother
Objective:
With flushed
face
Skin warm to
touch
Pale and weak
in appearance
temperature=
39 C
RR= 46
breaths/min
HR= 96

Alteration in Body
temperature;
hyperthermia;
related to presence
of pyogenic
microorganisms in
the
thermoregulating
center of the brain.

Planning

After 5 hours
nursing
intervention,
temperature
will decrease or
return to normal
range.

Intervention

Assess for the

possible
contributing
factors.
Monitor vital
signs
Render
continuous
tepid
spongebath and
teach
significant
others on
proper
provision.
Provide
adequate
ventilation.
Remove overly
constricting or
thick clothing.
Maintain a quiet
and restful
environment.
Regulate IV
fluids properly.
Administer
antipyretics as
ordered.

Evaluation
After 5 hours of
nursing
interventions,
temperature
returned to
normal range.
T 37.2c

Assessment

Diagnosis

Subjective
Baka bumalik
yung
kumbulsyon
niya as
verbalized by
grandmother

Risk for injury

related to seizure
episodes secondary
to disease condition

Objective
(+) Convulsions

Planning

At the end of
nursing
intervention,
grandmother
mother will
understand and
demonstrate
ways on how to
manage patient
when seizure
occurs

Intervention

Monitor Patient
vital signs.
Remove
unnecessary
articles on
patients bed.
Provide oxygen
to patient.
Place patient on
side lying
position to
avoid
aspiration.
Do not put
anything on
patient's mouth
when there is a
seizure attack.
Do not restrain
patient.
Provide a quiet

Evaluation

After 5 hours of
nursing
interventions,
the
grandmother
mother
understand and
demonstrate
ways on how to
manage patient
when seizure
occurs

Assessment

Diagnosis

Objective
Patient have
physical contact
with his relatives
through kissing and
sometimes
coughing without
aseptic technique

Risk for Infection

related to presence
of pathogenic
microorganism in
the cerebrospinal
fluid as evidenced
by lab result.

Planning

At the end of
Nursing
Intervention,
Significant
others will
demonstrate
ways and
means to
prevent spread
of infection.

non stimulating
environment
and dim the
lights.
Teach
significant
others on
management of
patient with
seizure.

Intervention

Assess familys
level of
understanding
of patients
current
condition.
Demonstrate
proper hand
washing
technique to

Evaluation

At the end of
Nursing
Intervention,
Significant
others
demonstrated
ways and
means to
prevent spread
of infection.

relatives and
stress out its
importance.
Instruct
significant
others to wear
protective gears
such as face
mask.
Isolate patient
as quickly as
possible.
Minimize room
visits as much
as possible.
Discard any
articles or body
secretions from
the patient in
the proper
waste disposal
bin.
Acquire
prophylaxis by
taking
prescribed
medications or
vaccination.
.

Assessment

Diagnosis

SUBJECTIVE:
Masakit ang
ulo ko as
verbalized by
patient
Objective:
Pain scale:
9/10
With facial
grimace
Irritable
Restless
With high
pitched cry
BP: 120/70
mmHg

Alteration in
comfort, pain
related to
meningeal irritation
secondary to
disease condition.

Planning

At the end of
nursing
intervention,
pain level
experienced will
be decreased or
alleviated.

Intervention

Assess patients
pain scale.
Place patient on
a comfortable
position. Be
careful not to
flex the
patients neck
when turning or
positioning her.
Allow the child
to assume a
comfortable
position.
(mostly
opisthotonic
position
wherein the
neck and head
is
hyperextended
to relieve
discomfort.)
Provide rest
periods to
facilitate
comfort, sleep,
and relaxation.
Keep the lights
dim and

Evaluation

At the end of
Nursing
Intervention,
pain has been
decreased as
verbalized by
the patient
Nabawasan ng
kaunti sakit ng
ulo ko

maintain quiet
environment.
Provide pain
medication as
ordered and
check
effectiveness of
medication
given.