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1.Actual Problem: Hyperthermia r/t infectious process secondary to fever.

ASSESSMENT Subjective: "Mas-maskawak."( I feel cold)As verbalized by the patient. Objective: Flushed skin,warm to touch. Restlessness Vital signs taken as follows: T:40 C- febrile CR:135-tachycardia RR:35- tachypnea Nursing Diagnosis: Hyperthermia r/t infectious process secondary to fever.

EXPLANATION OF THE PROBLEM Infectious agents(pyrogens) stimulates monocytes then monocytes releases pyrogenic cytokines that stimulates the anterior hypothalamus which results in the elevation of thermoregulatory set point that leads to increased heat conservation which causes vasoconstriction and change of behaviour it also leads to increase of heat production that causes involuntary muscular contractions result in fever.

OBJECTIVE STO: After 30 minutes of nursing intervention, the mother will report improvement with regards to the condition of the patient as manifested by: >Temperature will decrease from 40C to 37.5-37C > Absence of flushed skin will be noted >Cardiac rate will decrease from 135 to 120 beats per minute >Respiratory rate will decrease from 35 to 30 breaths per minutes LTO: After 24 hours of nursing intervention, the mother will report improvement with regards to the patients condition as

NURSING INTERVENTION Diagnosis: Monitored vital signs.

RATIONALE

EVALUATION STO: Goal partially met: After 30 minutes of nursing intervention, the mother reported improvement with regards to the condition of the patient as manifested by: >Temperature decreases from 40C to 37.5-37C > Absence of flushed skin is noted >Cardiac rate decreases from 135 to 120 beats per minute >Respiratory rate decreases from 35 to 30 breathes per minute

Recorded all sources of fluid loss such as urine vomiting and diarrhea. Therapeutic: Maintained bedside care. Promoted surface cooling by means of tepid sponge bath(TSB). Wrapped extremities with cotton blankets. Administered Paracetamol as ordered. Educative: Instructed the parent to increase the fluid intake of the patient. Educated the parent of the patient of signs and symptoms of

To determine any unusual manifestation from normal. To monitor or potentiates fluid and electrolyte loses. To provide comfort. To decrease temperature by means through evaporation. To minimize shivering. To facilitate fast recovery.

LTO: Water regulates Goal met: the body After 24 hours of nursing temperature. intervention, the mother Providing health reported improvement teachings to with regards to the client could help patients condition as

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evidenced by: >stop manifestation of shivering.

hyperthermia and help them identify factors related to occurrence of fever; discuss importance of increased fluid intake to avoid dehydration.

client cope with disease condition and could help prevent further complications of hyperthermia.

evidenced by: >stop manifestation of shivering.

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2. Actual Problem: Abdominal pain related to infectious process secondary to diarrhea. EXPLANATION OF THE OBJECTIVE NURSING ASSESSMENT PROBLEM INTERVENTION The patient is 6 years STO: Diagnosis Subjective: old.He is experiencing After 1 hour of nursing Monitored intake and "Mansakit eges abdominal pain and intervention,the output, character, na asin pag LBM.According to the patient will feel better and amount of mantinae ."(He father of the patient,their as manifested by: stools; estimate has abdominal water supply is come >restlessness will insensible fluid pain and severe from spring .These is a diminished losses. diarrhea).As contributing factor that >no irritability will be verbalized by can cause parasitic noted the father. infection of the large >No facial grimace intestine and will be noted characterized by non >No guarding specific diarrhea with behaviour will be Assessed vital signs Objective: loose semi formed,foul noted (BP, pulse, Restlessness stools.Often there is an > Abdominal pain will temperature). Irritability ineffectual urge to decrease from scale Facial grimace defecate again and of 7/10 to 4/10 Guarding again with very little stool behaviour actually being passed. Poor skin turgor LTO: Pain scale After 2 days of Therapeutic: 7/10 nursing Administered Vital signs interventions, parenteral fluids as taken as follows: the patient will indicated. maintain T:37C adequate fluid CR:120 volume as RR:30 evidenced by Admistered Hyoscinegood skin N-butyl bromide turgor and (HNBB) as ordered.

RATIONALE Provides information about overall fluid balance, renal function, and bowel disease control, as well as guidelines for fluid replacement. Hypotension (including postural), tachycardia, fever can indicate response to or effect of fluid loss.

EVALUATION STO: Goal met: After 1 hour of effective nursing intervention,the patient will feel better as manifested by: >restlessness is diminished >no presence of irritabilitynoted >No facial grimace is noted >No guarding behaviour is noted > Abdominal pain decreases from scale of 7/10 to 4/10

LTO: Goal met: Maintenance of After 2 days of bowel rest nursing requires interventions, alternative fluid the patient replacement to maintained correct losses adequate fluid Relieve cramps volume as or spasms of the evidenced by stomach, good skin

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Nursing Diagnosis:
Abdominal pain related to infectious process secondary to diarrhea.

balance intake and output. Administered Metronidazole as ordered. Educative: Encouraged adequate rest period. Instructed and encouraged use of relaxation techniques such as breathing exercise.

intestines, and bladder. Disturbs DNA synthesis in susceptible bacterial organisms. To prevent fatigue. To distract attention and reduce tension.

turgor and balance intake and output.

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3. Actual Problem: Disturbed sleep pattern r/t abdominal pain secondary to diarrhea. EXPLANATION OF THE OBJECTIVE NURSING ASSESSMENT PROBLEM INTERVENTION When you obtained an STO: Diagnosis: Subjective: After 30 minutes of Monitored vital signs. "Adi makaseyep inadequate amount of total sleep time,you may nursing si kusto."(He suffer sleep intervention,the cant sleep deprivation.This may mother will report well)As result in decreased improvements in Observed for physical verbalized by allertness,excessive rest/sleep pattern of signs of the patients daytime sleep their child as fatigue,restlessness, father. manifested by: irritability and >actively playing in disorientation. Objective: the morning Restlessness > no irritability will be Therapeutic: noted Provided quiet Irritability >sleep well at night environment. Sleepy in the

RATIONALE To determine any unusual manifestations from normal. To assess degree of impairment.

EVALUATION STO: Goal met: After 30 minutes of nursing intervention,the mother reported improvements in rest/sleep pattern of their child as manifested by: >actively playing in the morning > no irritability noted >sleep well at night . LTO: Goal met: After 2 days of nursing intervention the mother demonstrates the appropriate interventions to promote sleep for their child.

morning Nursing Diagnosis: Disturbed sleep pattern r/t abdominal pain secondary to diarrhea.

LTO: After 2 days of nursing intervention the mother will be demonstrate the appropriate interventions to promote sleep for their child.

To promote relaxation and promotes continuation of sleep without disturbances. Provide comparative baseline. To build trust

Determined clients usual sleep pattern and expectations. Established rapport Educative: Instructed the parent to give the patient a glass of milk before

Help getting proper sleep because it

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sleeping. Taught the patient proper deep breathing excercise.

contains Tryptophan. To divert attention from abdominal pain.