ASSESSMENT EXPLANATION OBJECTIVES NURSING RATIONALE EVALUATION

OF THE INTERVENTIONS
PROBLEM
Subjective: Bacterial STO: After 30 minutes to Independent
Complains of microorganisms (e.g. 1 hour of nursing 1. Monitor vital  Vital signs provide
coughing and fever pulmonary intervention, the patient signs. more accurate
as verbalized by the pathogens) will be able to: indication of core
patient a. participate in temperature.
recommended
Objective: Enter the airway treatment  TSB helps in
 with the program lowering the body
following vitals b. decrease 2. Provide tepid temperature and
signs of: Infects the lungs temperature from sponge bath. Do alcohol cools the
Temp- 38.6°C 38.6°C to 37.5°C not use alcohol. skin too rapidly,
BP- 110/73 Resulting to causing shivering.
O2 sat- 92% inflammation of the LTO: After 4-8 hours of Shivering increases
RR- 24 cycle per lungs nursing interventions, the metabolic rate and
minute patient will be able to: body temperature
 warm to touch a. return to normal
 generalized Causes the signs and temperature range  These decrease
discomfort with symptoms of of 36.5°C – warmth and
2/10 rating pneumonia (e.g. 37.5°C increase
 with slight SOB temperature may be b. return to normal evaporative
greater than 37.5°C, respiratory range cooling.
Nursing Diagnosis: tachypnea, coughs of 12-20 cycle per
Elevated body with greenish minute 3. Remove excess  To promote clear
temperature related secretions) clothing and flow of air in the
to bacterial invasion covers. patient’s area. One
as manifested by way of promoting
body temperature heat loss.
higher than normal 4. Promote a well-
range ventilated area to  Additional fluids
patient. help prevent
elevated
temperature
5. Advise patient to associated with
 increase oral fluid dehydration.
intake.
 Reduce metabolic
demands/ oxygen
consumption
6. Maintain bed rest.
 To meet increased
metabolic demands.

 Teaching the
7. Provide high- Support system the
calorie diet. right way to do
TSB will help in
knowing what to do
in case the patient’s
8. Educate and temperature
advise support increases
system (relative)
to do TSB when
patient feels hot.
- Luke warm
water only.
- Make sure that
armpits and  To know the
groins were effectiveness of
included in doing nursing
TSB. interventions done
and to know the
9. Monitored VS and progress of
recheck. patient’s
condition.

 These drugs
inhibit the
prostaglandin that
serve as
 mediators of pain
and fever.
Dependent
10. Provide
antipyretic
medications as
indicated.