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C. Nursing Managements
Problem #1: Hyperthermia
ASSESSMENT
NURSINGDIAGNOSIS
SCIENTIFICEXPLANATION
OBJECTIVE NURSINGINTERVENTI
ON
RATIONALE EXPECTEDOUTCOME
S >
O > Elevated
temperature
of 37.8 and
above
>Hyperthermi
a
>A fever
occurs when
the thermostat
resets at a
higher
temperature,
primarily in
response to an
infection. To
reach the
higher
temperature,the body
moves blood to
the warmer
interior,
increases the
metabolic rate,
Short Term:
After 4 hrs. of
nursing
intervention,
the patients
body temp.
will reduce
from 39 oC to
37 oC.
Long Term:After 24 hours
of nursing
intervention,
the patients
body temp.
will be
> Establish
rapport
> Monitor and
record vital
signs
> Assess
condition
> Determine
precipitating
factor
> To build trust
and gain
cooperation
> To obtain
baseline data
> To determine
patients
present status
> Identification
and
management of
underlying
causes are
essential to
Short Term:
After 4 hrs. of
nursing
intervention,
the patients
body temp.
shall have
been reduced
from 39 oC to
normal 37 oC.
Long Term:After 24 hours
of nursing
intervention,
the patients
body temp.
shall have
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and induces
shivering. The
"chills" that
oftenaccompany a
fever are
caused by the
movement of
blood to the
body's core,
leaving the
surface and
extremities
cold. Once the
higher
temperature is
achieved, the
shivering and
chills stop.
When the
infection has
been overcome
or drugs such
as aspirin or
maintain
within normal
range of
36.5C to37.5C.
> Assess vital
signs
> Remove
excess
clothing
> Perform TSB
> Provide
adequate rest
> Increase OFI
recovery
> Vital signs
provide moreaccurate
identification of
core
temperature
> This
decreases
warmth and
temperature
> To decrease
temp. by means
of non-
pharmacological
measure
> To conserve
energy and
avoid fatigue
been maintain
within normal
range of
36.5C to37.5C.
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acetaminophen
(Tylenol) have
been taken, the
thermostatresets to
normal and the
body's cooling
mechanisms
switch on: the
blood moves to
the surface and
sweating
occurs.
> Administer
anti-pyretic as
ordered
> To replace
liquid losses and
decreasing body
temp.
> To decrease
temp. by means
of
pharmacological
measure
Problem #2: Acute Pain
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ASSESSMENT NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATIO
N
OBJECTIVE NURSING
INTERVENTION
RATIONALE EXPECTED
OUTCOME
S >
O > Grimace
>restlessness
>irritability
> Acute pain
>W
hen Salmonella
typhi is
ingested, it
may directly
infect the
gallbladder
through the
hepatic duct or
spread to other
areas of the
body through
the
bloodstream
that can lead
to abdominalpain.
Short Term:
After 4 hours
of nursing
intervention,
the patient
will report
pain is
relieved.
Long Term:
After 24 hours
of nursing
intervention,the patient
will appear
relax and able
to sleep and
rest.
> Establish
rapport
> Monitor and
record vital sign,
note non verbal
cues
(restlessness)
> Investigate
report of pain.
> To build
trust and gain
cooperation
> To obtain
baseline data
and useful in
evaluating
verbal
comments
and
effectiveness
of
interventions
> Helpful in
assessing
need for
intervention:
may indicate
Short
Term:
After 4
hours of
nursing
intervention,
the patient
shall have
been report
pain is
relieved.
Long Term:
After 24
hours of nursing
intervention,
the patient
shall have
been appear
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> Provide a quiet
environment and
reduce stressful
stimuli.
> Place in
position of
comfort.
> Assist
with/provide
diversional
activities,
relaxation
technique.
developing
complications
> Promotesrest
> May
decrease
associated
discomfort
> Helps with
pain
management
by redirecting
attention.
relax and
able to sleep
and rest.
Problem #3: Diarrhea
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ASSESSMENT NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATIO
N
OBJECTIVE NURSING
INTERVENTIO
N
RATIONALE EXPECTED
OUTCOME
S >
O >
Hyperactive
bowel sounds.
> Diarrhea r/t
enteric
infection.
> It may result
from a variety
of factors,
including
intestinal
absorption
disorders,
increased
secretion of
fluid by the
intestinal
mucosa and
hypermotility
of the
intestines.Diarrhea may
also result
form infectious
processes such
as parasites.
Short Term:
After 4 hours
of nursing
intervention,
the patient
will verbalize
understanding
of health
teachings
given.
Long Term:
After 24 hours
of nursingintervention,
the patient
will decrease
frequency of
defecation.
> Establish
rapport
> Monitor and
record vital
signs
> Obtain a
fecal analysis
> Assess
hydration
status
> To build
trust and gain
cooperation
> To obtain
baseline data
> To identify
the causative
organism
> To prevent
dehydration
and
electrolyteimbalance
> To replace
fluid loss
Short Term:
After 4 hours
of nursing
intervention,
the patient
shall have
been verbalize
understanding
of health
teachings
given.
Long Term:
After 24 hours
of nursingintervention,
the patient
shall have
been
decrease the
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> Encourage
increase OFI
> Teachpatients SO the
importance of
perianal
hygiene after
each bowel
movement
> Auscultate
abdomen
> Restrict solid
food intake as
indicated
> Hygiene
controls
perianal skinexcoriation
and minimizes
risk of spread
of infectious
diarrhea
> To note
presence,
location, and
characteristics
of bowel
sounds
> To allow for
bowel rest/
reduced
intestinal
workload
> To avoid
frequency of
defecation.
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> Provide for
changes in
dietary
> Promote the
use of
relaxation
technique
> Give
medications as
ordered
> Review
causative
factors and
foods/
substances
that
precipitatediarrhea
> To decrease
stress/ anxiety
> To treat
infectious
process,
decrease
gastric
motility, and/
or absorb
water
> To prevent
recurrence
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appropriate
interventions
> Review foodpreparation,
emphasizing
adequate
cooking time
and proper
refrigeration/
storage
> To prevent
bacterial
growth/contamination
Problem #4: Self-care Deficit: Hygiene
ASSESSMENT NURSING SCIENTIFIC OBJECTIVE NURSING RATIONALE EXPECTED
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DIAGNOSIS EXPLANATIO
N
INTERVENTIO
N
OUTCOME
S > Hindi siya
naghuhugas
ng kamay pag
kumakain as
verbalized by
the SO.
O >
> Self-care
Deficit r/t to
weakness.
>Salmon
ella typhi are
spread by
contaminated
food, drink, or
water.
Following
ingestion, the
bacteria
spread from
the intestine
via the
bloodstream to
the intestinal
lymph nodes,
liver, and
spleen via theblood where
they multiply
and this can
cause malaise.
Short Term:
After 4 hrs of
nursing
intervention,
the patient
will perform
self-care
activities
within level of
own ability.
Long Term:
After 2 days of
nursingintervention,
the patient
will
demonstrate
lifestyle
> Establish
rapport
> Monitor and
record vital
signs
> Promote S.O
participation in
problem
identification
and decision
making
.> Providecommunication
among those
who are
involved in
caring for the
> To build
trust and gain
cooperation
> To obtain
baseline data
> Enhance
commitment
to plan
optimizing
outcomes
> Enhances
coordinationand continuity
of care
Short Term:
After 4 hrs of
nursing
intervention,
the patient
shall have
been perform
self-care
activities
within level of
own ability.
Long Term:
After 2 days of
nursing
intervention,the patient
shall have
been
demonstrate
lifestyle
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changes to
meet self-care
needs.
client
> Assess
abilities andlevel of deficit
> Avoid doing
things for
patient that the
patient can do
for self,
providing
assistance as
necessary
> Aids in
anticipating/
planning formeeting
individual
needs
> To maintain
pts self-
esteem and
promote
recovery
changes to
meet self-care
needs.
Problem #5: Readiness for enhanced fluid balance
ASSESSMENT NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATIO
OBJECTIVE NURSING
INTERVENTIO
RATIONALE EXPECTED
OUTCOME
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N N
S > Umiinom
na siya ngaun
as verbalized
by the SO.
O >
> Readiness
for enhanced
fluid balance.
> The S.O is
willing to put
interventions
into action and
at the same
time, the
patient
demonstrated
willingness or
readiness for
enhanced fluid
balance as
evidenced by
increasing
fluid intake.
Short Term:
After 4 hours
of nursing
intervention,
the S.O will
demonstrate
behaviors to
monitor fluid
balance of the
patient.
Long Term:
After 2 days of
nursing
intervention,
the patient willmaintain fluid
volume at a
functional
level as
indicated by
> Establish
rapport
> Monitor and
record vital
signs
> Monitor I/O
as
appropriately,
being aware of
insensible
loses and
hidden
sources of
intake
> Encourage
regular oral
intake
> To build
trust and gain
cooperation
> To obtain
baseline data
> To ensure
accurate
picture of fluid
status
> To maximize
intake and
maintain fluid
balance
Short Term:
After 4 hours
of nursing
intervention,
the S.O shall
have been
demonstrate
behaviors to
monitor fluid
balance of the
patient.
Long Term:
After 2 days of
nursing
intervention,
the patientshall have
been maintain
fluid volume at
a functional
level as
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adequate
urinary output.
> Recommend
restrictions of caffeine
> Instruct S.O
how to
measure and
record I/O if
needed for
home
management
> Prevents
untoward
diuretic effectand possible
dehydration
> Provides
means of
monitoring
status and
adjusting
therapy to
meet changing
needs
indicated by
adequate
urinary output.
VI. Clients Daily Progress
DAYS ADMISSION (26) April 27, 2010 April 28,
2010
April 29,
2010
April 30,
2010*Nursing
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Problems:
1. Hyperthermia
2. Acute Pain
3. Diarrhea
4. Self Care Deficit
(Hygiene)
5. Readiness for
enhance fluid
balance
Vital Signs:
T: (C)
PR: (bpm)
RR: (cpm)BP: (mmHg)
36.6
75
2470/40
35.8
80
20100/70
37.9
98
3090/60
38.2
80
2790/60
35.8
96
2180/60
Dx. Lab
Procedures:
*Urinalysis
Color: Yellow
Clarity: Slightly
Turbid
Specific Gravity:
1.025
PH: 5.0Protein: Trace
Glucose: Negative
RBC: 2-3/ hpf
WBC: 0-3/hpf
Epithelial cells:
few
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*CBC
*Typhidot Test
*Chest PAL
*HbsAg Screening
Mucus Threads:
many
Amorphous: few
Bacteria: few
Casts: Hyaline
cast- 0-2/pf
Hgb: 123
Hct: 0.37
Platelet Count: 210
Positive
Findings:
Bilateral ill- defined infrahilar densities
with paratracheal and hilar nodularities
are noted. Heart is not enlarged.
Diaphragm and bony thorax are
unremarkable.
Impression:
Consider bilateral PPTB. Clinical/ PPD
correlated are suggested.
Non- reactive
127
0.38
230
123
0.37
238
133
0.40
300
Medical
Managements:
IVFs: D5 0.3 Nacl
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1L x FD 150 cc
then 22-23
gtts/minDrugs:
Paracetamol:Ranitidine:
Ampicillin:
Chloramphenicol:
Diet:
DAT except Dark
colored foods
** There was no
prescribed activity
or exercise for the
patient .