C.

Nursing Managements

Problem #1: Hyperthermia

ASSESSMEN NURSING SCIENTIFIC OBJECTIVE NURSING RATIONALE EXPECTED

T DIAGNOSIS EXPLANATION INTERVENTI OUTCOME
ON

S> Ø >Hyperthermi >A fever Short Term: > Establish > To build trust Short Term:
a occurs when After 4 hrs. of rapport and gain After 4 hrs. of
O> Elevated the thermostat nursing cooperation nursing
temperature resets at a intervention, intervention,
of 37.8 and higher the patient’s > Monitor and > To obtain the patient’s
above temperature, body temp. record vital baseline data body temp.
primarily in will reduce signs shall have
response to an from 39 oC to been reduced
infection. To 37 oC. > Assess > To determine from 39 oC to
reach the condition patient’s normal 37 oC.
higher present status
temperature, Long Term: Long Term:
the body After 24 hours > Determine > Identification After 24 hours
moves blood to of nursing precipitating and of nursing
the warmer intervention, factor management of intervention,
interior, the patient’s underlying the patient’s
increases the body temp. causes are body temp.
metabolic rate, will be essential to shall have
and induces maintain recovery been maintain
shivering. The within normal within normal
"chills" that range of > Assess vital > Vital signs range of
often 36.5ºC to signs provide more 36.5ºC to
accompany a 37.5ºC. accurate 37.5ºC.
fever are identification of
caused by the core
movement of temperature
blood to the
body's core, > Remove > This
leaving the excess decreases
surface and clothing warmth and
extremities temperature
cold. Once the > Perform TSB
higher > To decrease
temperature is temp. by means
achieved, the of non-
shivering and pharmacological
chills stop. measure
When the > Provide
infection has adequate rest > To conserve
been overcome energy and
or drugs such avoid fatigue
as aspirin or > Increase OFI
 acetaminophen > To replace
(Tylenol) have liquid losses and
been taken, the decreasing body
thermostat temp.
resets to > Administer
normal and the anti-pyretic as > To decrease
body's cooling ordered temp. by means
mechanisms of
switch on: the pharmacological
blood moves to measure
the surface and
sweating
occurs.

Problem #2: Acute Pain

ASSESSMENT NURSING SCIENTIFIC OBJECTIVE NURSING RATIONALE EXPECTED
DIAGNOSIS EXPLANATIO INTERVENTION OUTCOME
N
>W
S> Ø > Acute pain hen Salmonella Short Term: > Establish > To build Short
typhi is After 4 hours rapport trust and gain Term:
O> Grimace ingested, it of nursing cooperation After 4
>restlessness may directly intervention, hours of
>irritability infect the the patient > To obtain nursing
gallbladder will report > Monitor and baseline data intervention,
through the pain is record vital sign, and useful in the patient
hepatic duct or relieved. note non verbal evaluating shall have
spread to other cues verbal been report
areas of the (restlessness) comments pain is
body through and relieved.
the Long Term: effectiveness
bloodstream After 24 hours of Long Term:
that can lead of nursing interventions After 24
to abdominal intervention, hours of
pain. the patient > Helpful in nursing
will appear assessing intervention,
relax and able > Investigate need for the patient
to sleep and report of pain. intervention: shall have
rest. may indicate been appear
 developing relax and
complications able to sleep
and rest.
> Promotes
rest
> Provide a quiet
environment and
reduce stressful
stimuli. > May
decrease
> Place in associated
position of discomfort
comfort.
> Helps with
pain
management
> Assist by redirecting
with/provide attention.
diversional
activities,
relaxation
technique.

Problem #3: Diarrhea

ASSESSMENT NURSING SCIENTIFIC OBJECTIVE NURSING RATIONALE EXPECTED
DIAGNOSIS EXPLANATIO INTERVENTIO OUTCOME
N N

S> Ø > Diarrhea r/t > It may result Short Term: > Establish > To build Short Term:
enteric from a variety After 4 hours rapport trust and gain After 4 hours
O> infection. of factors, of nursing cooperation of nursing
Hyperactive including intervention, intervention,
bowel sounds. intestinal the patient > Monitor and > To obtain the patient
absorption will verbalize record vital baseline data shall have
disorders, understanding signs been verbalize
increased of health > To identify understanding
secretion of teachings > Obtain a the causative of health
fluid by the given. fecal analysis organism teachings
intestinal given.
mucosa and > To prevent
hypermotility Long Term: > Assess dehydration Long Term:
of the After 24 hours hydration and After 24 hours
intestines. of nursing status electrolyte of nursing
Diarrhea may intervention, imbalance intervention,
also result the patient the patient
form infectious will decrease shall have
processes such frequency of > To replace been
as parasites. defecation. fluid loss decrease the
> Encourage frequency of
increase OFI > Hygiene defecation.
controls
> Teach perianal skin
patient’s SO the excoriation
importance of and minimizes
perianal risk of spread
hygiene after of infectious
each bowel diarrhea
movement
> To note
presence,
> Auscultate location, and
abdomen characteristics
of bowel
sounds

> To allow for

bowel rest/
> Restrict solid reduced
food intake as intestinal
indicated workload

> To avoid
 foods/
> Provide for substances
changes in that
dietary precipitate
diarrhea

> To decrease
stress/ anxiety
> Promote the
use of
relaxation > To treat
technique infectious
process,
> Give decrease
medications as gastric
ordered motility, and/
or absorb
water

> To prevent
recurrence
> Review
causative
factors and
 appropriate
interventions > To prevent
bacterial
> Review food growth/
preparation, contamination
emphasizing
adequate
cooking time
and proper
refrigeration/
storage

Problem #4: Self-care Deficit: Hygiene

ASSESSMENT NURSING SCIENTIFIC OBJECTIVE NURSING RATIONALE EXPECTED

 DIAGNOSIS EXPLANATIO INTERVENTIO OUTCOME
N N
>Salmon
S> “Hindi siya > Self-care ella typhi are Short Term: > Establish > To build Short Term:
naghuhugas Deficit r/t to spread by After 4 hrs of rapport trust and gain After 4 hrs of
ng kamay pag weakness. contaminated nursing cooperation nursing
kumakain” as food, drink, or intervention, intervention,
verbalized by water. the patient > Monitor and > To obtain the patient
the SO. Following will perform record vital baseline data shall have
ingestion, the self-care signs been perform
O> Ø bacteria activities self-care
spread from within level of > Promote S.O > Enhance activities
the intestine own ability. participation in commitment within level of
via the problem to plan own ability.
bloodstream to identification optimizing
the intestinal and decision outcomes Long Term:
lymph nodes, Long Term: making After 2 days of
liver, and After 2 days of > Enhances nursing
spleen via the nursing .> Provide coordination intervention,
blood where intervention, communication and continuity the patient
they multiply the patient among those of care shall have
and this can will who are been
cause malaise. demonstrate involved in demonstrate
lifestyle caring for the lifestyle
 changes to client changes to
meet self-care > Aids in meet self-care
needs. > Assess anticipating/ needs.
abilities and planning for
level of deficit meeting
individual
needs

> To maintain
> Avoid doing pt’s self-
things for esteem and
patient that the promote
patient can do recovery
for self,
providing
assistance as
necessary

Problem #5: Readiness for enhanced fluid balance

ASSESSMENT NURSING SCIENTIFIC OBJECTIVE NURSING RATIONALE EXPECTED

DIAGNOSIS EXPLANATIO INTERVENTIO OUTCOME
 N N

S> “Umiinom > Readiness > The S.O is Short Term: > Establish > To build Short Term:
na siya ngaun” for enhanced willing to put After 4 hours rapport trust and gain After 4 hours
as verbalized fluid balance. interventions of nursing cooperation of nursing
by the SO. into action and intervention, intervention,
at the same the S.O will > Monitor and > To obtain the S.O shall
O> Ø time, the demonstrate record vital baseline data have been
patient behaviors to signs demonstrate
demonstrated monitor fluid behaviors to
willingness or balance of the > Monitor I/O > To ensure monitor fluid
readiness for patient. as accurate balance of the
enhanced fluid appropriately, picture of fluid patient.
balance as being aware of status
evidenced by Long Term: insensible Long Term:
increasing After 2 days of loses and After 2 days of
fluid intake. nursing hidden nursing
intervention, sources of intervention,
the patient will intake the patient
maintain fluid shall have
volume at a > To maximize been maintain
functional > Encourage intake and fluid volume at
level as regular oral maintain fluid a functional
indicated by intake balance level as
 adequate indicated by
urinary output. > Prevents adequate
> Recommend untoward urinary output.
restrictions of diuretic effect
caffeine and possible
dehydration

> Provides
> Instruct S.O means of
how to monitoring
measure and status and
record I/O if adjusting
needed for therapy to
home meet changing
management needs

VI. Client’s Daily Progress

DAYS ADMISSION (26) April 27, 2010 April 28, April 29, April 30,
2010 2010 2010
*Nursing
Problems: •
1. Hyperthermia • •
2. Acute Pain • • •
3. Diarrhea • • •
4. Self Care Deficit
(Hygiene) • • •
5. Readiness for
enhance fluid
balance
Vital Signs:
T: (◦C) 36.6 35.8 37.9 38.2 35.8
PR: (bpm) 75 80 98 80 96
RR: (cpm) 24 20 30 27 21
BP: (mmHg) 70/40 100/70 90/60 90/60 80/60
Dx. Lab
Procedures: Color: Yellow
*Urinalysis Clarity: Slightly
Turbid
Specific Gravity:
1.025
PH: 5.0
Protein: Trace
Glucose: Negative
RBC: 2-3/ hpf
WBC: 0-3/hpf
Epithelial cells:
few
 Mucus Threads:
many
Amorphous: few
Bacteria: few
Casts: Hyaline
cast- 0-2/pf
Hgb: 123 127 123 133
*CBC Hct: 0.37 0.38 0.37 0.40
Platelet Count: 210 230 238 300

Positive
*Typhidot Test
Findings:
*Chest PAL Bilateral ill- defined infrahilar densities
with paratracheal and hilar nodularities
are noted. Heart is not enlarged.
Diaphragm and bony thorax are
unremarkable.
Impression:
Consider bilateral PPTB. Clinical/ PPD
correlated are suggested.

Non- reactive
*HbsAg Screening
Medical
Managements:
IVFs: D5 0.3 Nacl • • • • •
1L x FD 150 cc
then 22-23
gtts/min
Drugs:
Paracetamol: • •
Ranitidine: • • • • •
Ampicillin: • • • • •
Chloramphenicol: • • •

Diet:
DAT except Dark • • • • •
colored foods
** There was no
prescribed activity
or exercise for the
patient.