II.

NURSING ASSESSMENT

A. Personal Data

For the medical case study, the group had chosen the NICU patient

Rudolph. The patient is a newborn infant delivered on the 7 th day of December

2004 at Balitucan District Hospital and was admitted at BDH on the same day.

Rudolph is the son of Mr. and Mrs. Claus. He is male, Filipino and a member of

Iglesia ni Cristo. They are presently residing at San Vicente Magalang,

Pampanga.

B. Pertinent Family History

Rudolph is the youngest among the 4 children of Mr. and Mrs. Claus.

According to Mrs. Claus, all of her children were delivered through NSD. Her

first child Chikitita was born on November 28, 1992, female, the second child

named Belen was born on January 28, 1994, female. Their third child, Luv was

born on September 16, 2002 and also a female. Their ages are 12 y/o, 10 y/o, 2

y/o respectively. According to Mrs. Claus, her 3 children were born healthy

without any complication. The family is presently residing at San Vicente

Magalang Pampanga. At present, the family is considered poor because of the

family’s monthly income of P7, 000.00 from Mr. Claus’ work as a farmer at

Bulacan. Mrs. Claus is a plain housewife. As for their living condition and

housing their house is made up of concrete, with own bathroom with septic tank

without water carriage. Their source of water is through the water pump. They use
 fluorescent as their source of lighting and their house have good ventilation as

stated by Mrs. Claus, they have one living room and two bedrooms. The family is

a member of Iglesia ni Cristo so they are not allowed to eat blood and doesn’t

engage in gambling. They don’t rely much on the curing powers of the

“herbolarios” and manghihilot.

C. Socio-Economic Status

At present, the family is considered poor because of the family’s monthly

income of P7, 000.00 from Mr. Claus’ work as a farmer at Bulacan. Mrs. Claus is

a plain housewife.

D. Personal History

During Mrs. Claus pregnancy on Rudolph, it was just on her 6 month that

she had her regular once a month check-up. During the 9 th month, she had twice a

month check-ups. According to Mrs. Claus, she does all the household chores

even though she’s pregnant because his husband is working in Bulacan. She loves

eating fruits and vegetables and she takes a bath everyday. All her children were

breastfed, however, since Rudolph was under phototherapy she had to pump milk

from her breast and transfer it to a feeding bottle. Mrs. Claus said that the duration

of her labor to Rudolph took about 8 hours. She delivered through NSD. The age

of gestation is 41 weeks and 5 days. Her LMP is February 19, 2004 and the EDC

is November 26, 2004.

 Growth and Development

Patient is in the sensory motor stage in Jean Piaget’s theory of Cognitive

Development. During this stage, infant interacts and learns about his environment

by relating his sensory experiences to their motor actions. His primary way of

interacting with the world is motor actions. His primary way of interacting with

the world is through reflexive responses such as sucking and grasping.

In Sigmund Freud’s psychosexual stage, Rudolph is in his oral stage. The

period is from early infancy to 18 months of life. In this time, the infant’s pleasure

seeking is centered on the mouth through sucking. During his hospitalization, he

was not deprived of this oral need because NPO was not ordered.

Patient is in Trust vs. Mistrust Stage in Erik Erickson’s psychosocial

stage. The child trust his primary care giver, who is his mother, since she attends

to all the needs of the baby like feeding and changing clothes.

E. History of Present Illness

Patient was born on December 7, 2004 at exactly 2:00 am with an age of

gestation of 41 weeks and 5 days. Upon delivery Rudolph’s jaundice was already

evident, so the doctor immediately ordered the infant’s confinement at BDH to

assess his condition. The doctor had ordered for different laboratory examinations

like CBC and chest x-ray for diagnostic purposes and Rudolph was subjected to

phototherapy. The CBC results revealed the presence of infection (↑ WBC), so the

doctor ordered for the administration of antibiotics. On the other hand, the chest

x-ray revealed the presence of pneumonia. Rudolph experienced dyspnea and

appeared cyanotic that day that’s why an oxygen therapy was ordered. The next

day (December 8-9 2004), Rudolph was still under phototherapy and he still has

jaundice but the yellowish discoloration was lighter compared to his initial color.

He was still on oxygen therapy. On December 10, 2004, his jaundice became

much lighter, he is still under phototherapy but the oxygen therapy was removed

for a while. However, Rudolph became dyspneic and cyanotic so the oxygen

therapy was returned. On that same day, the doctor ordered that the child be

transferred to JBLMRH due to lack of required facilities.

DIAGNOSTIC DATE ORDERED INDICATION OR RESULT 1st., 2nd 3rd NORMAL VALUES ANALYSIS AND
LABORATORY DATE RESULT PURPOSE (UNITS USED IN INTERPRETATION
PROCEDURES THE HOSPITAL) OF RESULTS
Urinalysis 12-7-04 To determine urine COLOR: Yellow Pale Yellow to Amber The result is normal.
12-7-04 complications and
possible abnormal
components (e.g. TRANSPARENCY:
CHON, glucose, blood, Turbid Clear Turbid urine results
pus) or infection. from precipitation of
crystals due to rapid
cooling of urine.
Occasionally, it may be
due to presence of RBC,
WBC.

pH: 6 5-6 The result is within the

normal value.

ALBUMIN: (-) (-) The result is normal

SUGAR: (-) (-) It is within the normal

value.
 BACTERIA: Few (-) There is presence of
infection.

PUS CELLS:
15- 26/hpf 0-2/hpf The result is above the
normal value. This
indicates infection.

RBC: 0-3 0-1 The result is above the

normal value. An
increase in RBC o
occurs as a physiologic
response to altitude or
as a compensatory
response to a pathologic
condition such as
hypoxia.

DIAGNOSTIC DATE ORDERED INDICATION OR RESULT 1st., 2nd 3rd NORMAL VALUES ANALYSIS AND
LABORATORY DATE RESULT PURPOSE (UNITS USED IN THE INTERPRETATION
PROCEDURES HOSPITAL) OF RESULTS
Hematology

Hemoglobin 12-7-04 To determine oxygen 19.4 mg. in % 12-16 The result is above the
12-7-04 carrying capacity of the normal value. It
blood. It evaluates the indicates an increase in
hemoglobin content of the % of RBC in the
erythrocytes. blood. It also indicates
Hemoconcentration and
may cause
polycythemia.

12-10-04 27.5 mg in % The result is above the

12-10-04 normal value. It
indicates an increase in
the % of RBC in the
blood. It also indicates
Hemoconcentration and
may cause
polycythemia
Hematocrit 12-7-04 To determine 37-47 The result is above the
12-7-04 percentage of RBC cells 68 normal value. It
in the plasma. indicates an increase in
the % of RBC in the
blood.

12-10-04 78 The result is above the

12-10-04 normal value. It
indicates an increase in
the % of RBC in the
blood.

WBC 12-7-04 To determine infection 27, 800 5,000-10,000 mm3 The result is above the
12-7-04 or inflammation normal value. It
indicates the presence of
infection.
 12-10-2004 19,400 The result is above the
12-10-2004 normal value. It
indicates the presence of
infection.

Lymphocytes 12-7-04 Produces antibodies, 57 30-70% The result is within the

12-7-04 responsible for allergic normal value.
reactions

12-10-04 42 The result is within the

12-10-04 normal value.

Eosinophils 12-7-04 These cells act as 0.2 0.01-0.04% The result is within the
12-7-04 phagocytes and are normal value.
active in allergic
reactions.
Platelet Count 12-7-04 To evaluate platelet 166,000 150,000-350,000 The result is within the
12-7-04 production to diagnose normal value.
and monitor severe
thrombocytosis or
thrombocytopenia.
To confirm visual
estimate of platelet
number and
morphology from a
stained blood film.

12-10-2004 73,000 The result is below the

12-10-2004 normal value. This
indicates of
disseminated infection.

Polys 12-07-04 To determine infection 62 60-70% It is within normal value

(polymorphonuclear 12-07-04 or inflammation
cells)
12-10-04 67 60-70 It is within normal
12-10-04 values
 12-7-04 It provides the Pneumonia Left lumen Normal Lung Fields Considered Neonatal
Chest X-ray 12-7-04 information about the lung pulmonary hyper Pneumonia.
location and extent of aeration.
pneumonia.
Nursing Responsibilities:

Hematology:

- Identify the patient’s name

- Explain the procedures of the test to be done.

- Inform the mother that the test is used to detect and screen abnormal condition of

the blood.

- Tell the mother that the medical technician will perform a venipuncture and

collect the blood sample.

- Apply a pressure after the insertion, to control bleeding.

- Make sure that there will be no bleeding before and removing the pressure.

- Attach laboratory results to patient’s chart.

Urinalysis:

1. Identify the patient’s name

2. Explain to the mother that this test aids in the diagnosis of renal or urinary tract

disease and helps evaluates the overall body function.

3. Notify the laboratory of the medications that patient is taking that may affect

laboratory results, they may need to be restricted.

4. Attach laboratory result to the patient’s chart/

Chest X-ray

- Explained to the SO that the procedure is used in evaluating the lungs and the

heart.

- Inform the SO to remove clothing to the waist of the patient.

- Tell the SO that this test will take only few minutes and is painless.

- Tell the SO that X-ray is needed to follow the status of the body’s condition.
MEDICAL DATE ORDERED GENERAL INDICATIONS/PURPOSES CLIENTS INITIAL CLIENTS
MANAGEMENT DATE DESCRIPTION REACTION TO RESPONSE TO
/TREATMENT PERFORMED TREATMENT TREATMENT
DATE CHANGED
D10w 500 cc x 7-8 DO: 12-7-04 Hypertonic solution - To expand the Patient’s initial Patient maintained
ugtts/min DP: 12-7-04 (505 mosm/L); osmotic intravascular reaction was not seen hydration status.
DC: 12-8-04 diuretic; provides free compartments. but according to his
H2O and 340 cal/liter - Use as route for mother the patient
but no electrolytes. administration of cried upon insertion of
medications. the IV needle.
- Reduces risk for
D10w 500 cc x 9-10 DO: 12-8-04 edema and regulates
ugtts/min DP: 12-8-04 urine output.
DC: 12-9-04 - To prevent
dehydration.
D10w 500 cc x 11-12 DO: 12-9-04
ugtts/min DP: 12-9-04
DC:
O2 inhalation at 1.5 DO: 12-7-04 Administration of - To relieve difficulty Patient’s initial Patient did not
LPM DP: 12-7-04 oxygen via nasal of breathing/dyspnea. reaction was not seen experience dyspnea
DC: 12-9-04 cannula, which are - Used when a client but according to the and cyanosis.
inserted in both has a severe SO patient’s dyspnea
nostrils. The other end extensional or resting was relieved and Patient did not
O2 inhalation at 1.5 DO: 12-9-04 connected to O2 supply hypoxemia. cyanosis disappeared. experience dyspnea
LPM DP: 12-9-04 with H2O chamber for and cyanosis.
humidification. Patient was relieved
It consists of rubber or from dyspnea and
plastic tube that cyanosis disappeared.
extends around the
face, with 0.6-1.3 cm
curved prongs.
Hep-Lock Insertion DO: 12-7-04 For direct Used as a route for direct Patient’s initial Patient’s response was
DP: 12-7-04 administration of IV administration of IV reaction was not seen not seen.
DC: 12-7-04 medications. Does not medications, without using but according to the
need the use of IVF. IVF. mother, the patient
cried upon insertion.
Phototherapy DO: 12-7-04 Phototherapy is the Neonatal jaundice has been Patient’s initial Patients jaundice
DP: 12-7-04 clinical approach to treated with phototherapy. reaction was not seen. decreases from very
DC: treating various Phototherapy causes bright yellow to lighter
ailments with the use photoisomerisation of yellowish
of light. bilirubin into a H2O soluble discoloration.
form which can be excreted
by the kidney. It effectively
decreased the SBR in
jaundiced newborn infants
and decreases need for blood
transfusion.
Nursing Responsibilities: (IVF Administration)

- Check order for solution in physician’s order sheet. Explain the procedure to

family and patient.

- Check the solution. Verify type, volume and expiration date.

- Wash hands thoroughly

- Maintain the sterility of the end of tubing, hold it over a waste basket or sink and

open the flow clamp. Leave the clamp open until solution flow through the entire

length of tubing.

- Hang the solution with administration set on the stand.

- Assist physician during venipuncture.

- Release tourniquet and start flow of solution.

- Check for either free flow or infiltration. If there is free flow, adjust rate of the

flow. If there is infiltration, assist for reinsertion.

- Anchored with hypoallergenic tape or splint when necessary.

- Ensure proper calibration of the bottle and regulate the infusion following the

prescribed note.

- Observe client from time to time to determine response to therapy.

- Check IV insertion site for phlebitis.

- Check IV tubing for pressure of air.

- Check the integrity of infusion

- Monitor IV flow rate

Nursing Responsibilities (O2 therapy)

- Check for doctor’s order.

- Identify the patient

- Be sure that you are giving the right amount/regulation.

- Regulate O2 level as ordered.

- Make sure that humidifier is functioning well to prevent drying of mucous

membrane.

- Always check for the potency of the cannula.

- Check for the H2O level in the chamber.

Nursing Responsibilities (Hep-Lock)

- Check for the potency of the Hep-Lock and check for the presence of

inflammation at the injection site.

- In administration, introduce plain NSS first, then the medication. Then flush it

again with NSS.

Nursing Requirements (Phototherapy)

- Cover the infant’s eyes with mask to prevent retinal damage.

- Make sure that eye mask is not displaced because it can cause nasal obstruction.
December 10, 2004

S> O

O> Received patient lying on bed with intact eye bandage with yellowish discoloration of

skin with dry wrinkled rough and peeling of skin, (+) wheezes on both lung fields upon

auscultation.

> v/s are as follows:

T- 36.1C

P- 125 bpm

R- 54 cpm

A> Impaired gas exchange R/T ventilation perfusion imbalance 2° to pneumonia.

P> p 5 of N.1, patient will demonstrate improved ventilation and adequate oxygenation of

tissues AEB absence of cyanosis and (-) wheezes on both lung field upon auscultation.

I > Established rapport

> Monitored v/s

> Noted respiratory rate and depth: note areas of cyanosis such as nail beds and lips.

> Monitored infant for feeding tolerance, abdominal distention that may compromise

airway.

> Kept on moderate back rest.

> Assessed breath sounds and air movement to a certain status and note progress.

> Instructed S.O. on proper positioning of baby during breastfeeding to prevent

aspiration.
 > Referred patient accordingly.

> Administered O2 therapy as ordered.

> Carried out doctor’s order.

E> Goal partially met AEB absence of cyanosis, still (+) wheezes on both lung fields

upon auscultation.
December 10, 2004

S> O

O> Received patient lying on bed with intact eye bandage with yellowish discoloration of

skin with dry wrinkled rough and peeling of skin, (+) wheezes on both lung fields upon

auscultation.

> v/s are as follows:

T- 36.1C

P- 125 bpm

R- 54 cpm

>with increase hemoglobin (27.5) and hematocrit (78)

A> Impaired tissue perfusion R/T hypervolemia 2° to pneumonia.

P> p 5 of N.1, patient will demonstrate improved tissue perfusion and adequate

oxygenation of tissues AEB absence of cyanosis and (-) wheezes on both lung field upon

auscultation.

I > Established rapport

> Monitored v/s

> Noted respiratory rate and depth: note areas of cyanosis such as nail beds and lips.

> Monitored infant for feeding tolerance, abdominal distention that may compromise

airway.

> Kept on moderate back rest.

> Assessed breath sounds and air movement to a certain status and note progress.
 > Instructed S.O. on proper positioning of baby during breastfeeding to prevent

aspiration.

> Referred patient accordingly.

> Administered O2 therapy as ordered.

> Carried out doctor’s order.

E> Goal partially met AEB absence of cyanosis, (-) DOB, still (+) wheezes on both lung

fields upon auscultation.

ASSESSSMENT NURSING SCIENTIFIC GOAL INTERVENTIONS RATIONALE EXPECTED
(CUES) DIAGNOSIS EXPLANATION OUTCOME
S>O Ineffective airway Ineffective airway - Establish To gain patients trust
O> Patient may clearance related to clearance is the SHORT TERM: rapport and cooperation. SHORT TERM:
manifest: retained secretions inability to clear After 5 hours of - Monitor To obtain baseline data. After 5 hours of
- Changes in in the secretions on nursing VS nursing
rate depth tracheobronchial respiratory tract to intervention, - Assess To note for tachypnea, intervention,
of tree secondary to maintain clear patient’s SO will rate/depth shallow respirations, patient’s SO will
respiration pneumonia. airway. Pneumonia verbalize of and asymmetric chest verbalize
s. is an inflammatory understanding of respirations movement which are understanding of
- Abnormal process in lung the causes of and chest frequently present the causes of
breath parenchyma usually ineffective airway movement because of discomfort ineffective airway
sounds associated with a clearance and of moving chest wall clearance and
(wheezes, marked increase in identify therapeutic and or fluid in lung. identify therapeutic
crackles) interstitial and management, management,
- Dyspnea alveolar fluid. The potential - Auscultate To assess decreased potential
- Cyanosis inflammatory complications and lung fields, airflow that occurs in complications and
- Cough, process leads to initiate appropriate noting areas consolidated with initiate appropriate
effective or tissue edema and preventive and areas of fluid. Bronchial breath preventive and
ineffective; formation of corrective actions decreased/a sounds can also occur in corrective actions
with or exudates when this to maintain patent bsent consolidated areas, to maintain patent
without occurs in the lungs, airway. airflow and crackles, bronchi, and airway.
sputum narrowing and adventitiou wheezes are heard in
production. potential LONG TERM: s breath inspiration and or LONG TERM:
obstruction of the After 1 week of sounds expiration in response to After 1 week of
bronchial passages nursing (crackles, fluid accumulation, nursing
and alveoli is a intervention, wheezes) thick secretions and intervention,
possible result. patient will display airway spasm or patient will display
Assessments patent airway with obstruction. patent airway with
findings that breath sounds - Elevate To lower diaphragm, breath sounds
support this nursing clearing; absence patients promote chest clearing; absence
diagnosis with of dyspnea, head expansion, aeration of of dyspnea,
pneumonia include cyanosis. through lung segments cyanosis.
adventitious breathe moderate mobilization of
sounds tachypnea high back secretions.
and cyanosis. rest.
- Suction as To mechanically clear
 indicated airway from secretions
(adventitio that block the flow of
us breath air.
sounds,
desaturatio
n related to
airway
secretions)
- Istruct SO To liquefy secretions
to increase
patient’s
fluid intake
- Perform To loosen secretions
bronchial
tappings
- Instruct SO To help encourage SO
about the to initiate appropriate
causative preventive and
factors of corrective actions to
ineffective maintain airway.
airway
clearance
it’s
potential
complicatio
ns and
therapeutic
regimen.
ASSESSMENTS NURSING SCIENTIFIC GOAL INTERVENTIONS RATIONALE EXPECTED
(CUES) DIAGNOSIS EXPLANATION OUTCOME

S> O Impaired gas Impaired gas SHORT TERM: > Establish rapport To gain patients trust SHORT TERM:
D> Patient may exchange related to exchange is a state and cooperation. After 5 hours of
manifest: altered oxygen where in there is After 5 hours of > Monitor VS To get baseline data nursing
-cyanosis; abnormal supply; effects of excess or deficit nursing >Maintain patent To enhance lung intervention
skin color (pale, endotoxins on the oxygenation and/or intervention airway by elevating expansion, respiratory patients SO will
dusky) respiratory center carbon dioxide patients SO will patients head. effort, verbalize
-abnormal rate, in the medulla elimination sepsis is verbalize >Monitor To assess for rapid or understanding of
rhythm, depth of secondary to sepsis. a syndrome understanding of respiratory rate and shallow respirations that the causative
breathing. characterized by the causative depth. occur because of factors and
-nasal flaring clinical signs and factors and hypoxemia, stress and demonstrate
-tachycardia symptoms of severe demonstrate circulating endotoxins. appropriate
-abnormal breath infection that may appropriate Hypoventilation and interventions to
sounds (wheezes, progress to interventions to dyspnea reflect improve ventilation
crackles) septicemia and improve ineffective and maintain
septic shock. This is ventilation and compensatory adequate
caused by rapidly maintain adequate mechanisms and are oxygenation
multiplying oxygenation indication that
microorganisms or ventilatory support is LONG TERM:
their toxins. The needed. After 1 week of
microorganisms and LONG TERM: >Auscultate breath To note for respiratory nursing
toxins that flow in After 1 week of sounds. NOTE distress and presence of intervention,
the blood penetrate nursing crackles, wheezes, adventitious sounds patient will
the respiratory tract intervention, areas of which are indicators of demonstrate
where inflammation patient will decreased/absent of pulmonary improved
develops. This leads demonstrate ventilation. congestion/interstitial ventilation and
to colonization of improved edema, atelectasis. adequate
lungs and ventilation and >Note for presence To assess for inadequate oxygenation and
subsequent adequate of cyanosis. systemic absence of
infection. Inflamed oxygenation and oxygenation/hypoxemia. symptoms of
and fluid filled absence of >Put patient to To promote lung respiratory distress
alveolar sacs cannot symptoms of fowler’s position expansion as evidenced by
exchange oxygen respiratory distress ]
and carbon dioxide as evidenced by
effectively. These absence of >Administer To correct hypoxemia
endotoxins produce dyspnea; (-) supplemental with failing respiratory absence of
by microorganisms cyanosis and clear oxygen via effort or progressing dyspnea; (-)
present in the blood breath sounds. appropriate route as acidosis. cyanosis and clear
can also lodge in ordered. breath sounds.
the brain affecting
the respiratory
center in medulla
resulting to altered
oxygen supply.
 ASSESSMENT NURSING SCIENTIFIC GOAL NURSING RATIONALE EXPECTED
(CUES) DIAGNOSIS EXPLANATION INTERVENTIONS OUTCOME

S>O Ineffective tissue Ineffective tissue SHORT TERM: >Establish rapport To gain patients trust SHORT TERM:
O> Patient may perfusion related to perfusion is After 5 hours of and cooperation. After 5 hours of
manifest: reduction of arterial decrease in oxygen nursing >Monitor VS To have baseline data nursing
-dyspnea or venous blood resulting in the intervention, and note far any intervention,
-cyanosis flow: selective failure to nourish patient’s SO will alterations. patient’s SO will
-altered respiratory vasoconstriction, the tissues at the verbalize >Maintain bed rest; To decrease myocardial verbalize
rate outside of vascular occlusion capillary level. understanding of Assist with care workload and oxygen understanding of
acceptable (initial damage, The feature condition, therapy activities. consumption, condition, therapy
parameters. microemboli) common to all types regimen, side maximizing regimen, side
- chest retraction of pneumonia is an effects of effectiveness of tissue effects of
-nasal flaring. inflammatory medications and perfusion. medications and
-poor capillary refill pulmonary response when to contact >Monitor heart rate, To assess for when to contact
-pale mucous to the offending healthcare rhythm. NOTE tachycardia that occurs healthcare
membrane organism or agent. provider. dysrhythmias. because of sympathetic provider.
The defense nervous system
mechanisms of the stimulation secondary to
lungs lose LONG TERM: stress response and to LONG TERM:
effectiveness and After 1 week of compensate for After 1 week of
allow organisms to nursing hypervolemia and nursing
penetrate the sterile intervention patient hypotension. Cardiac intervention patient
lower respiratory will display dysrhythmias can occur will display
tract, where adequate perfusion as result of hypoxia or adequate perfusion
inflammation as evidenced by low flow perfusion rate. as evidenced by
develops. stable VS, absence >Note quality and To assess pulse that may stable VS, absence
Disruption of of dyspnea and strength of become weak/thready of dyspnea and
mechanical cyanosis. peripheral pulses. because of sustained cyanosis.
defenses and ciliary hypotension, decreased
motility leads to cardiac output and
colonization of peripheral
lungs and vasoconstriction if the
subsequent shock state progresses.
infection. Inflamed >Assess respiratory To note for increased
and fluid filled rate, depth and respirations that occur in
alveolar sacs cannot quality. Note onset response to direct
exchange oxygen of severe dyspnea. effects of endotoxins on
and carbon dioxide the respiratory center in
effectively. the brain, as well as
Alveolar exudates developing hypoxia,
tend to consolidate. stress and fever
So it is increasingly respiration can become
difficult to shallow as respiratory
expectorate. insufficiency develops,
Bacterial creating risk of acute
pneumonia may be respiratory failure.
associated with
significant >Assess skin for To assess for
ventilation- changes in color compensatory
perfusion mismatch temperature, mechanisms of
as the infection moisture. vasodilatation that result
grows. in warm, dry, pink skin,
this is characteristic of
hyperfusion in
hyperdynamic phase of
early septic shock.

>Instruct SO of To help SO learn the

causative factors, initial interventions for
therapeutic regimen, ineffective tissue
side effects of perfusion.
medications and
when to contact
health care provider.

>Administer To maximize oxygen

supplemental available for cellular
oxygen as ordered. uptake.
 ASSESSMENT NURSING SCIENTIFIC GOAL NURSING RATIONALE EXPECTED
(CUES) DIAGNOSIS EXPLATION INTERVENTIONS OUTCOME

S>O Hyperthermia Hyperthermia is a SHORT TERM: >Establish rapport To gain patient’s trust SHORT TERM:
O> Patient may related to direct state in which an After 5° of nursing and cooperation. After 5° of nursing
manifest: effect of circulating individual’s intervention, intervention the
-increased in body endotoxins on the temperature id patient will >Monitor VS To get baseline data. patient will
temperature higher hypothalamus, above normal due demonstrate demonstrate
than normal range. altering to infections temperature within >Monitor patient To note increased in temperature within
-flushed skin; warm temperature process occurring in normal range. temperature (degree temperature which is normal range.
to touch. regulation the circulating and pattern) indicative of acute
-increased secondary to sepsis. blood, the LONG TERM: infectious process LONG TERM:
respiratory rate, endotoxins reached After 1 week of (38.9C-41.1C) Fever After 1 week of
tachycardia the brain affecting nursing pattern may aid in nursing
the intervention patient diagnosis such as intervention,
thermoregulatory will experience no sustained or continuous patient will
center of the brain associated fever curves lasting experience no
which is the complications. more than 24 suggest associated
hypothalamus and pneumococcal complications.
because of pneumonia, scarlet or
inflammatory typhoid fever.
process, chemical
mediators are >Perform TSB; To reduce fever. Use of
released such as avoid use of alcohol. alcohol may cause
kinins, histamines chills, actually elevating
that alter body temperature, it is also
temperature. drying to skin.
>Administer
antipyretics as Use to reduce fever by
ordered. its central action or the
hypothalamus.
 ASSESSMENT NURSING SCIENTIFIC GOAL NURSING RATIONALE EXPECTED
(CUES) DIAGNOSIS EXPLANATION INTERVENTIONS OUTCOME

S> O Nutrition: Nutrition: SHORT TERM: >Establish rapport To gain patient’s trust SHORT TERM:
O> Patient may Imbalanced, less Imbalanced, less After 5° of nursing and cooperation. After 5° of nursing
manifest: than body than a body intervention, intervention,
-loss of weight with requirements requirement occurs patient’s SO will >Monitor VS To get baseline data patient SO will
inadequate food related to increased when intake of verbalize verbalize
intake. metabolic needs nutrients is understanding of >Assess patient’s To evaluate patient’s understanding of
-pale conjunctiva secondary to insufficient to meet causative factors nutritional status general nutritional state causative factors
and mucous infectious process. metabolic needs. and necessary (height and weight) and to obtain baseline and necessary
membranes. Due to interventions to weight. interventions to
-decreased inflammatory maintain maintain
subcutaneous process causing appropriate weight. >Instruct SO to To monitor effective of appropriate weight.
fat/muscle mass. depleted energy weigh the infant efforts regaining desired
reserves, periods of LONG TERM: weekly. body weight. LONG TERM:
dyspnea and After 2 weeks of After 2 weeks of
impairment of nursing >Provide SO with To emphasize the nursing
oxygen and carbon intervention. information importance of well- intervention,
dioxide transport Patient will regarding individual balanced nutritious patient will
leave little oxygen demonstrate nutritional needs. intake. demonstrate
to meet metabolic progressive weight progressive weight
needs, The signs gain towards goal. >Recommend/ To help SO understand gain towards goal.
and symptoms of Support the importance of
infection makes hospitalization and immediate referral to the
feeding difficult. instruct SO to seek nearest hospital.
medical assistance
in severe
malnutrition/life
threatening
situation.
CONCLUSION

Life to most of us is a giant jigsaw puzzle. We sometimes have complications,

like sometimes the pieces don’t fit or we have a hard time finding the right one to

complete the puzzle.

We sometimes think our petty problems are big and are worth crying over, like

money, material things and our love life, we tend to ever see real problems, like a mother

praying, asking God to let no harm come into her child. Crying because she’s worried

that if she falls asleep or leaves her baby for even a minute, she’ll wake up or return just

to hold a lifeless angel in her arms. Yes I have to admit, we are living in a world that has

forgotten to appreciate the simple things in life. We tend to fight start wars over small

things, we worry more about how we look and how to spend money on worthless things

like gambling, shopping, rather than thinking of how we can use the money to help those

in need. We have learned so much from this case study, not just to appreciate life, but to

also appreciate what we already have in it. Seeing the mother cry over her baby made us

realized we don’t need to look like popstars, we don’t need to have the latest phones,

clothes or cars.

For the people who are lucky enough to have a good life, they should be happy

with what they have, with what God gave them. We don’t have search for something

better or greater. We are lucky enough to have loving parents, brothers and sisters who

love us so much and friends who stick besides us when were down and need that shoulder

to lean on. Don’t take life for granted especially when you almost have it all. Your love
life can wait, and I’m sure that special someone’s waiting out there somewhere, it is in

God’s plan for all of us.