Patients Data Bed No.

: SNPW6 Name: Cynapzthyr Manalon Age: 54 7/12 Sex: Male CC: LBM, vomiting AGE with moderate DHN AP: Dra. Rubio

Nursing Diagnosis Diarrhea related to presence of toxins secondary to Acute Gastroenteritis as manifested by: S: Madalas dumumi ang anak ko tapos matubig pa as verbalized by the mother. O: Hyperactive bowel sounds Frequent loose liquid stools.

Objectives After 8 hours of nursing interventions, the S.O. will be able to: a) Verbalize understanding of causative factors and rationale for treatment regimen. b) Demonstrate appropriate behavior to assist with resolution of causative factors. c) Report return to a more normal stool consistency.

Nursing Interventions > Observe and record stool frequency, characteristics, amount, and precipitating factors. >Auscultate abdomen

Rationale Evaluation > Helps differentiate After 8 hours of nursing interventions, the S.O. individual disease and assess severity of episode. was be able to: a) Verbalized understanding of causative factors and rationale for treatment regimen. b) Demonstrated appropriate behavior to assist with resolution of causative factors. c) Reported return to a more normal stool consistency

>To determine for presence, location and characteristics of bowel sounds. >May help identify causative environmental factors.

>Determine recent exposure to different/ foreign environments, change in drinking water/food intake. > Identify foods and fluids that precipitate diarrhea,(e.g.,raw vegetables and fruits, whole-grain cereals, condiments, carbonated drinks, milk products) >Monitor Intake and Output. Note number, character, and amount of stools; estimate insensible fluid losses, observe for oliguria. >Observe for excessively dry skin

>Avoiding intestinal irritants promotes intestinal rest.

>Provides information about overall fluid balance, renal function, and bowel disease control, as well as guidelines for fluid replacement >Indicates excessive

and mucous membranes, decreased skin turgor, slowed capillary refill.

fluid loss/resultant dehydration

COLLABORATIVE > Administer parenteral fluids as indicated. > Maintenance of bowel rest requires alternative fluid replacement to correct losses/anemia. Determines replacement needed and effectiveness of therapy.

>Monitor laboratory studies, e.g., electrolytes (especially potassium, magnesium) and ABGs (acid-basebalance). >Administer medications as indicated: Antidiarrheal Drugs.

>Reduces fluid losses from intestines.

Patients Data Bed No.: SNPW5 Name: John Manuel Andog Age: 5 8/12 Sex: Male CC: Fever, cough, right upper quadrant pain. BPN acute bilateral nonspecific with Pneumonia AP: Dra. Cruz

Nursing Diagnosis Ineffective airway clearance related to retained secretions in nasal airway secondary to Bronchopnemonia as manifested by; S: Medyo nahihirapan huminga ang anak ko dahil sa sipon niya as manifested by the mother. O: Whitish to brownish nasal secretions Productive cough heard at times Mouth breather RR:36 bpm

Objectives After 3-4 hours of nursing intervention the patient will be able to; a) Verbalized understanding of causes and therapeutic management b) Demonstrate behaviors to improve or maintain clear airway. c) Identify potential complications and how to initiate appropriate preventive or corrective actions.

Nursing Interventions  Monitor respiration and breath sounds noting rate and sounds.

Rationale  Indicative of respiratory distress and/or accumulation of secretions.  To open or maintain airway in at rest  To take advantage of gravity decreasing pressure on the diaphragm and enhancing drainage.

 Position head appropriate for age/condition  Elevate the head of bed/change position every two hours and prn

Evaluation After 3-4 hours of nursing intervention the patient was be able to; a) Verbalized understanding of causes and therapeutic management b) Demonstrated behaviors to improve or maintain clear airway. c) Identified potential complications and how to initiate appropriate preventive or corrective actions.

 Observe for signs and symptoms of infection(change in sputum color, amount or character, fever)  Assess clients/SOs knowledge of contributing causes, treatment, plan, specific medications and therapeutic procedures.  Encourage/provide opportunities for

 To identify infectious process or promote timely intervention.

 Modalities to manage secretions and improve airflow vary according to clients diagnosis.

 To prevents or reduces fatigue.

rest; limit activities to level of respiratory tolerance  Keep environment free from allergen (dust, smoke)  Allergens may aggravate patients condition.  Hydration ca liquefy viscous secretions and improve secretion clearance.

 Encourage increase fluid intake of alteast 8 glasses a day within cardiac tolerance Collaborative  Administer analgesics

 To improve cough when pain is inhibiting effort  Expectorants/ bronchodilators helps in relaxing smooth muscle airway and expel sputum.

 Give expectorants/ bronchodilator as ordered

Patients Data Bed No.: SNPW7 Name: Zenovia Davila Age: 1 11/12 Sex: Female CC: On and off fever R/O UTI partially DHF vs. Kawasaki AP: Dra. Rubio

Nursing Diagnosis Hyperthermia related to infectious process secondary to Kawasaki Disease as manifested by: S: Pabalik balik ang lagnat ng anak ko as verbalized by the mother. O: Tempt- 37.8 C Flushed skin, warm to touch Reddish conjunctiva Weak in appearance Loss of appetite

Objectives After 8 hours of effective nursing intervention, the patients temperature decreased as evidence by: a) Demonstrated temperature within normal range, from37.8C to 36.5C-37.5C b) Skin is cool to touch and less flushness

Nursing Interventions  Monitor core temperature q 1 .

Rationale  Temperature of 38.941.1C suggest acute infectious disease process.  Evaporation is decreased by environmental factors of high humidity and high ambient temperature as well as body factors producing loss of ability to sweat.  To support circulating volume and tissue perfusion.  To reduce metabolic demands/oxygen consumption.  Heat is loss by evaporation and conduction.  Heat is loss by convection, radiation and conduction.  To promote wellness

Evaluation After 8 hours of effective nursing intervention, the patients temperature decreased as evidence by: c) Demonstrated temperature within normal range, from37.8C to 36.5C37.5C d) Skin is cool to touch and less flushness After 8 hours of effective nursing intervention, the mother was able to:

 Note presence or absence of sweating as body attempts to increase heat loss by evaporation.

 Increase oral fluid intake. After 8 hours of effective nursing intervention, the mother will be able to:  Promote bed rest. a) Identify underlying cause/contributi ng factors and importance of treatment, as well as signs/sympto ms requiring further interven tions. b) Verbalize understanding of specific interventions

 Provide TSB as needed

 Promote surface cooling, loosen clothing and cool environment  Review specific risk factors/causes, signs and symptoms with the interventions required

a) Identified underlying cause/contrib uting factors and importance of treatment, as well as signs/sym ptoms requiring further interv entions. b) Verbalized

to prevent hyperthermia c) Demonstrate behaviors to monitor and promote normo-thermia.

 Discuss importance of adequate fluid intake and protein diet Collaborative:  Administer medications as indicated to treat underlying cause, such as:-Paracetamol  Administer replacement fluids and electrolytes to support circulating volume and tissue perfusion

 To prevent dehydration

understandin g of specific interventions to prevent hyperthermia c) Demonstrated behaviors to monitor and promote normothermia.

 To treat underlying causes

 To support circulating volume and tissue perfusion

Patients Data Bed No.: SNPW8 Name: Alberto Ortega Age: 4 1/12 Sex: Male CC: LBM, abdominal pain, vomiting Acute UTI AP: Dra. Arias

Nursing Diagnosis Imbalance nutrition less than body requirements related to nausea and vomiting as manifested by: S: Apat na beses ng sumuka ang anak ko simula noong isang araw as verbalized by the mother. O: Hyperactive bowel sounds. Pale conjunctiva and mucus membrane. Poor appetite

Objectives After 3-4 hours of nursing intervention, the S.O. will be able to: a) Verbalize understanding of causative factors when known and necessary interventions. b) Demonstrate behaviors/ techniques to nourish or increase patients appetite.

Nursing Interventions  Auscultate bowel sounds, noting absence or hyperactive sounds.

Rationale  Inflammation or irritation of the intestine may be accompanied by intestinal hyperactivity, diminished water absorption and diarrhea.  Reduces gastric stimulation and vomiting response.  Might increase abdominal cramping.

Evaluation After 3-4 hours of nursing intervention, the S.O. will be able to: a) Verbalized understanding of causative factors when known and necessary interventions. b) Demonstrated behaviors/ techniques to nourish or increase patients appetite.

 Eliminate smells from the environment.  Avoid foods that might cause or exacerbate abdominal cramping like caffeinated beverages, chocolate, orange juice.  Measure abdominal girth.

 Provides quantitative evidence of changes in gastric or intestinal distention.  Hypovolemia, fluid shifts and nutritional deficits contribute to poor skin turgor, edematous tissue.

 Observe skin or mucous membrane for dryness, and turgor. Note peripheral edema and sacral edema.  Assess abdomen frequently for return to softness,

 Indicates return of normal bowel function and ability

appearance of normal bowel sounds, and passage of flatus.  Weigh daily.

to resume oral intake.

 Initial losses or gains reflect changes in hydration.  To enhance food satisfaction and stimulate appetite

 Use flavoring agents and good food presentation

 Collaborative  Monitor BUN, protein, prealbumin or albumin, glucose, nitrogen balance as indicated.  Advance diet as tolerated.  Reflects organ function and nutritional status and needs.

 Careful progression of diet when intake is resumed reduces risk of gastric irritation

Patients Data Bed No.: SNPW6 Name: Hannah Grace Angara Age: 5 11/12 Sex: Female CC: Fever, t/c SVI, t/c acute bronchitis AP: Dr. Abuel

Nursing Diagnosis Ineffective airway clearance related to retained secretions in nasal airway secondary to Bronchopnemonia as manifested by; S: Tatlong araw ng sinisipon ang anak ko as manifested by the mother. O: Whitish to brownish nasal secretions Productive cough heard at times Mouth breather RR:38 bpm

Objectives After 3-4 hours of nursing intervention the patient will be able to; d) Verbalized understanding of causes and therapeutic management e) Demonstrate behaviors to improve or maintain clear airway. f) Identify potential complications and how to initiate appropriate preventive or corrective actions.

Nursing Interventions  Monitor respiration and breath sounds noting rate and sounds.

Rationale  Indicative of respiratory distress and/or accumulation of secretions.  To open or maintain airway in at rest  To take advantage of gravity decreasing pressure on the diaphragm and enhancing drainage.

 Position head appropriate for age/condition  Elevate the head of bed/change position every two hours and prn

Evaluation After 3-4 hours of nursing intervention the patient was be able to; d) Verbalized understanding of causes and therapeutic management e) Demonstrated behaviors to improve or maintain clear airway. f) Identified potential complications and how to initiate appropriate preventive or corrective actions.

 Observe for signs and symptoms of infection(change in sputum color, amount or character, fever)  Assess clients/SOs knowledge of contributing causes, treatment, plan, specific medications and therapeutic procedures.  Encourage/provide opportunities for

 To identify infectious process or promote timely intervention.

 Modalities to manage secretions and improve airflow vary according to clients diagnosis.

 To prevents or reduces fatigue.

rest; limit activities to level of respiratory tolerance  Keep environment free from allergen (dust, smoke)  Allergens may aggravate patients condition.  Hydration ca liquefy viscous secretions and improve secretion clearance.

 Encourage increase fluid intake of alteast 8 glasses a day within cardiac tolerance Collaborative  Administer analgesics

 To improve cough when pain is inhibiting effort  Expectorants/ bronchodilators helps in relaxing smooth muscle airway and expel sputum.

 Give expectorants/ bronchodilator as ordered

Patients Data Bed No.: SNPW8 Name: Kate Kathrin Solis Age: 8 mons and 28 days Sex: Female CC: Vomiting, fever, convulsion BFC, BPN acute AP: Dra. Arias

Nursing Diagnosis Imbalance nutrition less than body requirements related to nausea and vomiting as manifested by: S: Tatlong beses ng nagsuka ang anak ko simula kahapon as verbalized by the mother. O: Hyperactive bowel sounds. Pale conjunctiva and mucus membrane. Poor appetite

Objectives After 3-4 hours of nursing intervention, the S.O. will be able to: c) Verbalize understanding of causative factors when known and necessary interventions. d) Demonstrate behaviors/ techniques to nourish or increase patients appetite.

Nursing Interventions  Auscultate bowel sounds, noting absence or hyperactive sounds.

Rationale  Inflammation or irritation of the intestine may be accompanied by intestinal hyperactivity, diminished water absorption and diarrhea.  Reduces gastric stimulation and vomiting response.  Might increase abdominal cramping.

Evaluation After 3-4 hours of nursing intervention, the S.O. will be able to: c) Verbalized understanding of causative factors when known and necessary interventions. d) Demonstrated behaviors/ techniques to nourish or increase patients appetite.

 Eliminate smells from the environment.  Avoid foods that might cause or exacerbate abdominal cramping like caffeinated beverages, chocolate, orange juice.  Measure abdominal girth.

 Provides quantitative evidence of changes in gastric or intestinal distention.  Hypovolemia, fluid shifts and nutritional deficits contribute to poor skin turgor, edematous tissue.

 Observe skin or mucous membrane for dryness, and turgor. Note peripheral edema and sacral edema.  Assess abdomen frequently for return to softness,

 Indicates return of normal bowel function and ability

appearance of normal bowel sounds, and passage of flatus.  Weigh daily.

to resume oral intake.

 Initial losses or gains reflect changes in hydration.  To enhance food satisfaction and stimulate appetite

 Use flavoring agents and good food presentation

 Collaborative  Monitor BUN, protein, prealbumin or albumin, glucose, nitrogen balance as indicated.  Advance diet as tolerated.  Reflects organ function and nutritional status and needs.

 Careful progression of diet when intake is resumed reduces risk of gastric irritation

Patients Data Bed No.: 110A Name: Alyssa Bajada Age: 8 10/12 Sex: Female CC: Fever, abdominal pain, DFS AP: Dra. Rubio

Nursing Diagnosis Hyperthermia related to infectious process secondary to Kawasaki Disease as manifested by: S: Mainit at nilalamig ang anak ko as verbalized by the mother. O: Tempt- 37.7 C Flushed skin, warm to touch Reddish conjunctiva Weak in appearance Loss of appetite

Objectives After 8 hours of effective nursing intervention, the patients temperature decreased as evidence by: e) Demonstrated temperature within normal range, from37.8C to 36.5C-37.5C f) Skin is cool to touch and less flushness

Nursing Interventions  Monitor core temperature q 1 .

Rationale  Temperature of 38.941.1C suggest acute infectious disease process.  Evaporation is decreased by environmental factors of high humidity and high ambient temperature as well as body factors producing loss of ability to sweat.  To support circulating volume and tissue perfusion.  To reduce metabolic demands/oxygen consumption.  Heat is loss by evaporation and conduction.  Heat is loss by convection, radiation and conduction.  To promote wellness

Evaluation After 8 hours of effective nursing intervention, the patients temperature decreased as evidence by: g) Demonstrated temperature within normal range, from37.8C to 36.5C37.5C h) Skin is cool to touch and less flushness After 8 hours of effective nursing intervention, the mother was able to:

 Note presence or absence of sweating as body attempts to increase heat loss by evaporation.

 Increase oral fluid intake. After 8 hours of effective nursing intervention, the mother will be able to:  Promote bed rest. d) Identify underlying cause/contributi ng factors and importance of treatment, as well as signs/sympto ms requiring further interven tions. e) Verbalize understanding of specific interventions

 Provide TSB as needed

 Promote surface cooling, loosen clothing and cool environment  Review specific risk factors/causes, signs and symptoms with the interventions required

d) Identified underlying cause/contrib uting factors and importance of treatment, as well as signs/sym ptoms requiring further interv entions. e) Verbalized

to prevent hyperthermia f) Demonstrate behaviors to monitor and promote normo-thermia.

 Discuss importance of adequate fluid intake and protein diet Collaborative:  Administer medications as indicated to treat underlying cause, such as:-Paracetamol  Administer replacement fluids and electrolytes to support circulating volume and tissue perfusion

 To prevent dehydration

understandin g of specific interventions to prevent hyperthermia f) Demonstrated behaviors to monitor and promote normothermia.

 To treat underlying causes

 To support circulating volume and tissue perfusion