Subjective: “Mainit ako, tatlong araw na akong nilalagnat,” as verbalized by the patient.
!ncreased *ter / hours Tetanus is body a disease o* nursing te"perature caused by a interventions, #+yperther"i toin the patient0s a( related to produced produced by body e**ects o* the bacteria te"perature toins called 'lostrid will subside #bactere"ia(. iu" tetani. within the -his toin can nor"al range. Objective: be *ound in in !ncrease in soils heavy in body "anure or te"perature other organic above the "aterial, nor"al range particularly particularly in #$%.& degree tropical or 'elsius( hu"id regions )ody is o* the war" to he"isphere. touch Once the Skin bacteria enters enters redness open wounds especially on or cuts it the in*ected generates area spores, which in turn creates neurotoins .
1Set the te"perature te"perature a co"*ortable environ"ent
1 Monitor body te"perature every 2 hours
-he environ"ent can 8O75-9M 5O8: a**ect the condition and te"perature o* *ter ; days o* individual body as a nursing, interventions process o* adaptation adaptation the patient able to through the process o* "aintained and< evaporation and i"proved sleep convection. pattern as evidenced evidenced by /= hours hours o* sleep !denti*y the sy"pto"s at night progress toward toward ehaustion shock. S+O--9M 5O8:
1 3rovide ade4uate 6luids help re*resh the hydration or ade4uate body and are a drinking co"pression body *ro" within. 1-ake action aseptic and antiseptic techni4ues in wound care.
7ursing wounds wounds eli"inate the possibility o* o* toins that are still located around the wound.
15ive cold co"press i* no seizures occur eternal sti"uli.
'old co"press is one way to lower body te"perature by "eans o* conduction process.
*ter / hours o* nursing intervention the patient relatives was able to verbalized understanding o* necessary intervention to i"prove sleep pattern.
1!"ple"ent progra"s and antipyretic antibiotic treat"ent as ordered.
-hese drugs can have broad spectru" antibacterial to treat gra"positive or gra" negative bacteria. ntipyretic worked as a process o* ther"oregulation to anticipate an increase in body te"perature.
1'ollaborative laboratory ea"inatio n o* leukocytes.
-est results leukocyte increased by "ore than >?,??? @ "" $ indicates in*ection and treat"ent or to *ollow the develop"ent o* the progra""ed.
CU ES
NUR SING
LONGTER
SHORTTER
NURSING
DIAGNOSI
M GOAL
M GOAL
INTERVENTION
RATIONALE
EVALUATION
S
S:”di nga siya pwedeng tu"ayo sabi ni Aok” verbalized by the husband o* the pt. O: #B( 8eg "uscle weakness 1!nability to per*or"ed A8 1eluctance to atte"pt "ove"ent 1 8i"ited range o* "otion 1Aoctors order o* '). #B( -racheosto" y
!"paired physical "obility r@t prescribed "ove"ent restriction. #6unctional level !C< Aependent, does not participate in activity.(
*ter ; days *ter % hrs o* 1Monitored v@s o* nursing nursing intervention intervention the the pt will be patient relatives able to will be able to "aintain verbalize 1ssessed patient position o* understanding signs o* *atigue, pain *unction and o* situation and and di**iculty o* skin integrity risk *actors and breathing as evidence by individual absence o* treat"ent and 1ssisted client in contractures, regi"en and repositioning every 2 *ootdrop, sa*ety hours or as needed decubitus and "easures. etc.. 1 3rovided patient daily scheduled o* eercise
-o note changes and possible signs o* co"plication and serves as baseline data !t "ay result in activity intolerance
Opti"izes circulation and to all tissue and relieves pressure.
-o enhance "ore his body "echanics
1 !nstruct patient@*a"ily regarding needs to "ake ho"e environ"ent sa*e
sa*e environ"ent is a prere4uisite to i"proved "obility.
1 3rovide sa*ety "easures as indicated in pt situation.
6or sa*ety o* the pt.
*ter ; days o* nursing intervention the pt will be able to "aintain position o* *unction and skin integrity as evidence by absence o* contractures, *ootdrop, decubitus and etc.. S+O--9M 5O8: *ter % hrs o* nursing intervention the patient relatives will be able to verbalize understanding o* situation and risk *actors and individual treat"ent and regi"en and sa*ety "easures.
CUES
S:”Ai pa "agaling ung suagat niya gawa ng pag papaopera niya sa lala"unan” as verbalized by the husband o* the pt. O: #B( 6loppy skin D= yrs old #B( -racheosto"y
NURSING
LONGTERM
SHORTTERM
NURSING
DIAGNOSIS
GOAL
GOAL
INTERVENTION
!"paired skin *ter ; days *ter % hours o* integrity r@t o* nursing nursing "echanical intervention intervention the *actors the pt relatives patient relatives secondary to will be able to will be able to surgery. participate in verbalize prevention understanding "easures and o* how to treat"ent pro"ote early progra". healing o* wound.
1Monitored vital signs
1Monitored *luid intake and output. 1ssessed patient skin color, teture and turgor. 1!nstructed pt. relatives to keep area clean and dry 1!nstructed patient to apply lotion 1!nstructed patients 6a"ily to provide opti"u" nutrition including vita"ins and increase protein intake 19ncouraged patient to take "ultivita"ins
RATIONALE
-o note changes and possible signs o* co"plication and serves as a baseline data
EVALUATION
8O75-9M 5O8: *ter ; days o* nursing intervention the pt relatives was able to participate in -o note *luid retention prevention "easures and treat"ent -o assess etent o* progra". involve"ent S+O--9M 5O8: -o prevent *urther *ter % hours o* co"plication nursing intervention the patient relatives -o "aintain was able to "oisturize skin verbalized understanding o* -o provide a positive how to pro"ote nitrogen balance to early healing o* aid in skin healing wound.
-o increase i""unity
CUES
O: D= yrs old #B( -racheosto"y
NURSING
LONGTERM
SHORTTERM
NURSING
DIAGNOSIS
GOAL
GOAL
INTERVENTION
isk *or in*ection related to inade4uate pri"ary de*ense
*ter ; days o* *ter / hours o* nursing nursing intervention intervention the the patient will patient relatives be able to will be able to "aintain good identi*y hygiene intervention that will prevent@reduce risk o* in*ection o* the patient
RA TI ONAL E
1Monitored vital signs
-o note changes and possible signs o* co"plication and serve as baseline data
1ssessed patient nutritional status including history o* weight loss
3atients with poor nutritional status "ay be anergic, or unable to "uster a cellular i""une response to pathogens and are there*ore "ore susceptible to in*ection.
1!nstructed patient o* daily bathing and hand washing
-o reduce risk
19ncourage intake o* protein and calorie rich *oods.
-his "aintains opti"al nutritional status.
19ncouraged patient to take vita"ins such as vita"in '
-o increase and strengthen i""unity
E VA LU AT ION
8O75-9M 5O8: *ter ; days o* nursing intervention the patient was able to "aintained good hygiene S+O--9M 5O8: *ter / hours o* nursing intervention the patient relatives was able to identi*ied intervention that will prevent@reduce risk o* in*ection o* the pt.
CUES
S< “ !nuubo pa rin siya.” Cerbalized by the husband o* the pt.
!n ; days o* *ter rendering nursing i""ediate intervention nursing the patient will intervention the be able to pt will be able epectorate@ to "aintain clear airway patency secretions readily
RATIONALE
EVALUATION
1Suction endotracheal
-o clear airway when secretion are blocking airway.
8O75-9M 5O8: *ter rendering i""ediate nursing intervention the pt was able to "aintain airway patency
19levated head o* the bed, change position every 2 hours.
-o take advantage o* gravity decreasing pressure on the diaphrag" and enhancing drainage o* ventilation to di**erent lung seg"ent.
S+O--9M 5O8: !n ; days o* nursing intervention the patient was able to epectorate but not cleared the secretions readily
