A four old girl was treated because of jigh fever with chills ,coughing,shorthness of

breath and weakness. The assesment result is that BP 100/60 mmHg, P : 110 beats per minute
, temperature :39,5 C ,the respiration : 45 breaths per minute ,there was ronchi breathing , Hb
: 10 gr% , Erythrocyte sedimentation rate ( ESR) : 50 mm/h , leucocytes : 20,000 mm3 .
A. DATA ANALYSYS
No
1.

2.

3.

Date
May

Data (as evidenced by )

SD : -

04, 2014

OD : BP : 100/60 mmHg , T : 39,50c

07.45 am

,leucocytes : 20,000 mm3, high

May

fever with chills.

SD :-

04, 2014

OD : T : 39,50c,ESR : 50 mm/h , p :

07.45 am
May

110 x/mnt, weakness.

SD :-

04, 2014

OD:Coughing,shortness of

07.45 am

breath,ronchi breathing,R:45 x/mnt

Problem
Hyperthermia

proces )

Intolerance

General

activity

weaknees

Ineffective

Execive mucus

airway clearance

B. PRIORITY ISSUES
1. Ineffective airway clearance related to execive mucus.
2. Hypertermia related to ilness (infection proces).
3. Intolerance activity related to general weaknees

C. PLANNING

Etiology
Illnes ( infection

Date
May

Diagnosis labels
1. Ineffective

NOC
After the nusrsing

NIC
Airway Suctioning (3160)

04, 2014

airway

implementations for

1. Determine the need

08.00 am

clearance

1X24 hours the client

for oral and/or

related to

will achieve :

tracheal suctioning.

execive mucus

Respiratory status :

2. Auscultate breath

airway patency (0410) as

sound before and

evidenced by :

after suctioning.

UOTCOME TARGET

3. Inform the patient

RATING :

and family about

INDICATORS:

suctioning.

Respiratory rate and

4. Aspirate the

Ability to clear secretions

nasopharynx with a

maintain at level 1

bulb syringe or

increase to level 4.

suction device, as

Level 1 severe
deviation from

5. Use universal

normal range

precautions gloves,

Level 2 subtantial

goggles, and mask,

deviation from

as appropriate.

normal range

appropriate.

6. Insert a nasal airway

Level 3 moderate

to facilitate

deviation from

nasotracheal

normal range

suctioning, as

Level 4 mild

appropriate.

deviation from
normal range..

7. Instruct the patient to

take several deep
breaths before
nasotracheal
suctioning and use
supplemental
oxygen, as
appropriate.
8. Use sterile

disposable
equipment for each
tracheal suction
procedure.
9. Select a suction
catheter that is one
hal
10. Insrtruct the patient
to take slow, deep
breaths during
insertion of the
suction catheter via
the nasotracheal
route.
May

2. Hyperthermia

After the nusrsing

Fever treatment (3740)

04, 2014

related to Illnes

implementations for

1.monitor temperature as

08.00 am

(infection

2X24 hours the client

frequntly as is appropriate

proces ).

will achieve :

2.monitor

Vital sign (0802) as

WBC,hb,hematocrit value

evidenced by :

3.monitor blood

OUTCOME TARGET

pressure,pulse and

RATING :

respiration,as appropriate

INDICATOR :

4.monitor for insensible

Body Temperature

fluid loss

maintain at level 1

5.monitor skin color and

increase to leve 4.

temperature

Level 1 severe

6.monitor intake and output

deviation from

7.monitor for seizure

normal range

activity

Level 2 subtantial

8.adminisator IV fluid as

deviation from

appropriate

normal range

9.administer oxygen as

Level 3 moderate

appropriate

deviation from

10.administer medications

normal range

to treat the cause of fever.

Level 4 mild
deviation from

May

3. Intolerance

normal range..
After the nusrsing

04, 2014

activity related

implementations for

08.20 am

to general

2X24 hours the client

weaknees

will achieve :

Energy Management (0180)

1. Determine patient
physical limitations
2. Determine patient

Activity Tolerance

significant others

(0005) as evidenced by :

perception of causes

OUTCOME TARGET

of fatique

RATING

3. Encourage

INDICATORS :

verbalization of

Oxygen saturation with

feelings about

activity, pulserate and

limitations

respiratory rate wiyh

activity maintain at level
1 increase to level 4

5. Determine what and

how much activity is

compromised

required to build

Level 2

endurance
6. Monitor nutritional

compromised

intake to ensure

Level 3

adequate energy

moderately

resources

compromised

fatique

Level 1 severely

subtantially

4. Determine causes of

Level 4 mildly
compromised.

7. Consult with
dietition about wave
to increase intake of
high energy foods
8. Monitor patient for
evidence of excess
physical and
emotional fatique

9. Monitor
cardiorespiratory
response to activity
10. Monitor / record
patient sleep pattern
and number of sleep
hours.

Purwokerto, 13 June 2014

Ns. Rahmaya Nova H, S.Kep., M.Sc, AIFM