ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective Data: Hyperthermia related After 4 hours of Independent: After 4 hours of

“ang taas nga ng to inflammatory nursing interventions, nursing interventions,
lagnat niya eh... di process secondary to patient’s temperature Monitored vital signs Monitor vital signs to patient’s temperature
bumamababa... TB Meningitis. will be decreased to assess patient’s assess effectiveness has decreased
tinutuloy na nga lang from 38.1 C to 37. 6 response to nursing of nursing from 38.1 C to 37. 6
naming ung pagpunas interventions done. interventions.
sa kanya...” After 1 day of nursing After 1 day of nursing
interventions, the Maintained a Position while interventions, the
Objective Data: patient will be free of comfortable position sleeping increases the patient was free of
complications such as while sleeping or patient’s feeling of complications such as
 T: 38.7 oC irreversible brain or resting. relaxation and irreversible brain or
 CR: 139 bpm neurological damage. comfort. neurological damage.
 (+) Flushed skin
 (+) diaphoresis Performed Continuous tepid
 Skin that is warm continuous tepid sponge bath
to touch sponge bath (TSB) to decreases body
 RR of 50 breaths the patient. temperature.
per minute
Watch out for febrile Continuous elevation
seizures. of body temperature
can predispose
seizure attack.

Encouraged bed rest. To reduce metabolic

demands and oxygen
consumption.

Dependent:

Administered Treatment of mild to

antipyretics as moderate pain; fever;
prescribed by the various inflammatory
 physician. conditions.

Provided To offset increased

supplemental oxygen. oxygen demands and
consumption.

Administered To support circulating

replacement of fluids volume and tissue
and electrolytes. perfusion.

Provided high calorie To metabolic

diet and tube demands.
feedings.

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective: Ineffective airway After 8 hours of Independent: After 8 hours of

clearance related to nursing intervention, nursing intervention,
“Nahihirapan siya retained secretions the patient will be Monitored It is an indication of the patient was able
huminga dahil sa secondary to TB able to display respiratory rate and respiratory distress to display decreasing
plema.” As verbalized Meningitis. decreasing amount of breath sounds. and/or accumulation amount of secretions
secretions (less than of secretions. (less than 40 cc), allay
by the patient’s 40 cc), allay restlessness, and
mother. restlessness, and Noted use of It may occur in sustain respiratory
sustain respiratory accessory muscles response to rate within normal
rate within normal during respiration. ineffective range.
Objective: range. ventilation.
After 2 days of
After 2 days of Maintained patient Positioning helps nursing intervention,
nursing intervention, on moderate high maximize lung the patient was able
the patient will be back rest. expansion. to maintain patent
able to maintain Assisted on chest To loosen up airway as evidenced
patent airway as physiotheraphy. secretions. by normal respiration,
evidenced by normal absence of dyspnea
respiration, absence Dependent: and adventitious
of dyspnea and breath sounds,
adventitious breath Administered To offset increased absence of bronchial
sounds, absence of supplemental oxygen oxygen demands and secretions, and allay
bronchial secretions, as prescribed by consumption. restlessness.
and allay restlessness. physician.

Administered To mobilize
bronchodilators as secretions.
prescribed by the
physician.

Suctioned the patient To clear airway.

prn as ordered by the
physician.