CUES DIAGNOSIS RATIONALE PLANNING NURSING RATIONALE EVALUATION

INTERVENTIONS
Subjective: P – Alteration in presence of Short Term: Independent: Short Term:
“Sobrang init ng thermoregulation microorganisms After 2-3 hours of  Monitor vital  For baseline After 2 hours of nrsg.
katawan niya kaya (Hyperthermia) nrsg. intervention, signs especially data and to intervention, the
nga daw siya the relative will be temperature and monitor progress relative is able to know
nagkarashes E – related to release of pyrogen able to know and RR and understand the
sabi ni doctor. Ang bacterial invasion in from leukocytes understand the causative factors that
init na naman niya the lungs secondary causative factors that  Loosen  To promote causes increased body
ngayon oh” as the to causes increased clothing heat loss temperature and the
mother of Baby Lee bronchopneumonia sensed by body temperature patient’s temperature is
verbalized Hypothalamus and the patient’s  To provide decreased from 38.4oC
S – as manifested by temperature will be comfort to the to 37.4oC, decrease
 Provide TSB
Objectives: Skin is warm to decreased from patient and irritability, and
 Skin is touch, Flushed skin, resetting the 38.4oC to 37.9oC, will increase heat loss diminished abdominal
warm to touch Irritable, body’s thermostat decrease irritability, through rash
 Flushed Uncomfortable, to febrile level and diminished conduction
skin Maculo-papular rash abdominal rash  GOAL FULLY
 Irritable in the abdominal MET
area, WBC = 112, epinephrine & Long Term:  To replace
 Uncomfort  Encourage to fluid loss
able Plt = 280, norepinephrine is After 1-2 days of Long Term:
Segmenters= 0.80, increased; nrsg. intervention, increase fluid
 Maculo- After 1 day of nrsg.
v/s: T = 38.4oC, vasoconstriction the patient’s body intake
papular rash in intervention, the
CR = 112bpm, occurs temperature will  To promote patient’s body
the abdominal  Encourage wellness
PR=110, become normal, temperature is now
area adequate rest and
RR = 25bpm, shows comfort and normal T=37.3oC,
BP = 100/60mmHg Increase in body the abdominal rash limit activities shows comfort and the
Inference:  To confirm
temperature will be absent abdominal rash is
 WBC = 11.2  Review all presence of diminished
(NV= 5.0 – 10.0 laboratory data infection
x 10^9/L)  GOAL
 Platelet = 280 PARTIALLY MET
(NV = 150 – 400 x Dependent:  To decrease
10^9/L)  Administer the level of fever
 Segmenters = antipyretics as
0.80 (NV= 0.55- Reference: ordered
0.70) Luckmann, Joan  An increase
and Sorensen,  Administer O2 in body temp is an
 Vital signs: Karen. Medical- inhalation increase in BMR
T = 38.4oC Surgical and O2 demand
CR = 112bpm Nursing: A
PR = 110bpm Psychophysiolo
RR = 25bpm gic Approach.
BP = 100/60mmHg 4th ed.