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CUES Subject: - An akon anak kay mapasupaso gad hiya tas maluya it iya lawas yana, as vferbalized by the

mother - Diri gud hiya nakaka-ka-on hin tuhay, tuman la it iya nakakaon...nagkukuri man gud hiya pag hinga, as verbalized by the mother Objectifve: - Febrile; 39C temperature (36.5-37.2C) - Moist skin - Tachypnea; RR=52cpm (2040cpm)

NURSING DIAGNOSIS Altered body temperature related to bacterial invasion in the lungs as manifested by body temperature higher than normal

SCIENTIFIC RATIONALE Bacterial microorganisms (e.g. pulmonary pathogens) enter the airway. These bacteria/ viruses infects the lung/s resulting to inflammation in the lungs and causes the signs and symptoms of pneumonia (e.g. temperature may be greater than 37.5C), tachypnea, coughs with greenish secretions. SOURCE: http://nursingcrib.com /wpcontent/uploads/case study/NCPpneumonia. pdf

OBJECTIVE After 2 hours of nursing intervention, the childs temperature will decrease from 39C to normal range (36.537.2C).

INTERVENTION Independent: - Monitor patients temperature every hour. Encourage patient to take rest. Encourage patient to increase fluid intake. Encourage the patients guardian to do tepid sponge bath. If patient is lying on bed, frequent changing position and linen. Frequently change patients clothing. If patient feels cold provide blanket. -

RATIONALE To determine if the patients temperature is above the normal range. Allows the patient to recuperate physical strength. To maintain hydration status and increase fluid intake helps lessen febrility. Sponge bath with warm water evaporates off his skin, thus cooling off the patient. This may help to reduce discomfort. Because of increased in sweating. To conserve body heat or to reduce heat loss.

EVALUATION

Dependent: Acetaminophen elixir 120mg every 4 hours PRN for temperature

>101F, as ordered by the physician Ampicillin 100mg/kg/day in divided doses every 6 hours.