ASSESSMENT SUBJECTIVE Mainit ang pakaradam ko as verbalized by the patient OBJECTIVE: T: 37.

6 P: 84 R: 23 BP: 110/80

DIAGNOSIS Hyperthermia related to dehydration

INFERENCE Infectous Agents

PLANNING After 6 hrs of nursing intervention the patients temperature will subside to normal temperature

INTERVENTION INDEPENDENT Monitor heart rate and rhythm

RATIONALE

EVALUATION

Monocytes

Pyrogenic Cytokines

Anterior Hypothalamus

After 6 hrs of nursing Dysryhthm interventions, ias changes the patient was are commonly able to to due to maintain core electrolyte temperature imbalances within normal and range dehydration and direct effect of hyperthermia on blood and cardiac tissues To monitor fluid and electrolyte losses To decrease temperature by means through evaporation and

Elevated Thermoregulator y set point

Record all fluid

Increased heat conservation Promote surface cooling by means of TSB

Increased heat production

conduction Wrap extremeties with blankets Administer replacement fluids and electrolytes To minimize shivering

Fever

To support circulating volume and tissue perfusion

Maintain bed rest

To reduce metabolic demands and oxygen consumption

Provide high calorie diet, tube feedings, or parenteral nutrition Administer

To increase metabolic demands

To facilitate fast

antipyretics as prescribed by the physician ASSESSMENT SUBJECTIVE Mabilis ang kanyang paghinga nya as verbalized by the care taker OBJECTIVE: T: 36.5 P: 88 R: 22 BP: 120/90 DIAGNOSIS Impaired Gas Exchange related to altered oxygen supply (obstruction of airways by secretion) as evidenced by wheezes upon auscultation INFERENCE Entry of particles or gases to the lungs Abnormal inflammation of the lungs Chronic inflammation Scar tissue formation Narrowing of airway lumen Airflow limitations Impaired gas PLANNING After 3 days of nursing intervention the client: -Attain normal breathing pattern of 20 cpm -Demonstrate improved ventilation INTERVENTION Independent: -Monitor skin and mucous membrane color -Elevate head of the bed, assist patient to semi fowlers or high fowlers position -Provide quiet environment to allow the patient to relax Collaborative: -Monitor pulse oximetry and ABGs -Administer antianxiety,

recovery

RATIONALE -Duskiness and central cyanosis indicate advanced hypoxemia -Oxygen delivery may be improved

EVALUATION

-External stimuli may prevent relaxation or inhibit sleep -to identify if hypoxia is present -to reduce dyspnea by controlling the

exchange

sedative, or narcotic agents as indicated

anxiety and restlessness