Name: Ginmarie A.

Fabillar Year&Section: BSN-3B

Assessment Nursing Pathophysiology Planning Nursing Rationale Evaluation

Problem Intervention
Subjective •Hyperthermi Fever results •After 4 hrs. Independent: •After 4 hrs.
Data: a related to when something Of nursing Of nursing
dehydration raises the interventions, 1.Monitor 1.Dysrhythmia interventions,
“Mapaso hypothalamic the patient heartrate ands and ECG the patient
ako” as set point, will maintain rhythm. changes are was able to
verbalized triggering core common due to maintain core
by the vasoconstriction temperature electrolyte temperature
patient. and shunting of within 2.Record all imbalance and with in
blood from the normal sources of dehydration normal
Objective periphery to range. fluid loss and direct range.
Cues: decrease heat such as effect of
loss; sometimes urine, hyperthermia
shivering, which vomiting and on blood and
Vital signs: increases heat diarrhea. cardiac tissues.
T- 38.7 production, is
P- 94bpm induced. 3.Promote 2.To monitor
RR- 20cpm surface or potentiates
BP- 140/70 Footnote: Text cooling by fluid and
Author: Larry means of electrolyte
M. Bush tepid sponge loses.
bath.
3.To decrease
4.Wrap temperature by
extremities means through
with cotton evaporation
blankets. and
conduction.
 5.Provide
supplemental 4.To minimize
oxygen. shivering.

6.Administer 5.To offset

replacement increased
fluids and oxygen
electrolytes. demands and
consumption
7.Maintain
bedrest. 6.To support
circulating
8.Provide volume and
high calorie tissue
diet, tube perfusion.
feedings, or
parenteral 7.To reduce
nutrition. metabolic
demands and
9.Administer oxygen
antipyretics consumption
orally or
rectally as 8.To increased
prescribed metabolic
by the demands.
physician
9.To facilitate
fast recovery

Assessment Nursing Pathophysiology Planning Nursing Rationale Evaluation

Problem Intervention
Subjective Actvity The reflex of After 4 1.Independent: 1.Establishes After 4
Data: intolerance coughing is hours of Evaluate patient's hours of
related to initiated with a nursing patient's capabilities or nursing
“Gin- exhaustion chemical interventions response to needs and interventions
iinubo ako” associated irritation at the patient activity. facilitates the patient
as with peripheral nerve will choice of was able to
verbalized interruptio receptors within demonstrate 2.Provide a interventions demonstrate
by the n in usual the trachea, a quiet Reduces A
patient. sleep main carina, measurable environment stress and measurable
pattern branching points increase in and limit excess increase in
because of of large airways, tolerance in visitors during stimulation, tolerance in
discomfort, and more distal activity with acute phase. promoting activity with
Objective excessive smaller airways. absence of Elevate head rest. absence of
Cues: coughing They are also dyspnea. and encourage dyspnea and
and present in the frequent 2.These excessive
• Dyspnea. dyspnea. pharynx. position measures fatigue.
Laryngeal and changes, deep promotes
V/S taken breathing and maximal
tracheobronchial
as follows: effective inspiration,
receptors
respond to coughing. enhance
T- 37.6
mechanical and expectoratio n
P- 85bpm 3.Encourage
chemical of secretions
RR- 20cpm adequate rest
stimuli. to improve
BP- 110/60 balanced with ventilation.
Footnote: Text moderate
Author: activity. 3.Facilitates
1.Sandeep Promote healing
Sharma adequate process and
2.Muhammad F. nutritional enhances
Hashmi intake. natural
3.Mohamed S. resistance.
Alhajjaj 4. Force fluids 4.Force fluids
to at least to at least
3000 ml per 3000 ml per
day and offer day and offer
warm, rather warm, rather
than cold than cold
fluids. fluids.

Collaborative: Collaborative:

Administer Administer
medications as medications
prescribe: as prescribe:
mucolytics or mucolytics or
expectorants expectorants