CUES NURSING DIAGNOSIS SCIENTIFIC RATIONALE OBJECTIVE INTERVENTION RATIONALE EVALUATION

Subject: Altered body temperature Bacterial microorganisms After 2 hours of nursing Independent:
- “An akon anak kay related to bacterial (e.g. pulmonary pathogens) intervention, the child’s - Monitor patient’s - To determine if the
mapasupaso gad hiya invasion in the lungs as enter the airway. These temperature will decrease temperature every patient’s
tas maluya it iya lawas manifested by body bacteria/ viruses infects the from 39C to normal range hour. temperature is
yana,” as vferbalized temperature higher than lung/s resulting to (36.5-37.2C). above the normal
by the mother normal inflammation in the lungs range.
- “Diri gud hiya nakaka- and causes the signs and - Encourage patient - Allows the patient
ka-on hin tuhay, symptoms of pneumonia to take rest. to recuperate
tuman la it iya (e.g. temperature may be physical strength.
nakaka-on...nagkukuri greater than 37.5C), - Encourage patient - To maintain
man gud hiya pag tachypnea, coughs with to increase fluid hydration status
hinga,” as verbalized greenish secretions. intake. and increase fluid
by the mother intake helps lessen
febrility.
Objectifve: SOURCE: - Encourage the - Sponge bath with
- Febrile; 39C patient’s guardian to warm water
temperature (36.5- do tepid sponge evaporates off his
37.2C) http://nursingcrib.com/wp- bath. skin, thus cooling
- Moist skin content/uploads/case off the patient.
- Tachypnea; study/NCPpneumonia.pdf - If patient is lying on - This may help to
RR=52cpm (20- bed, frequent reduce discomfort.
40cpm) changing position
and linen.
- Frequently change - Because of
patient’s clothing. increased in
sweating.
DBVGIUgqeiufgQIUF - If patient feels cold - To conserve body
HGCqiugfcyqFE provide blanket. heat or to reduce
JVYqfd heat loss.
Dependent:

- Acetaminophen
elixir 120mg every 4
hours PRN for
temperature >101F,
as ordered by the
physician
- Ampicillin
100mg/kg/day in
divided doses every
6 hours.