RUFINO, LESLIE KRIZTEL S.

BSN 3-2 GROUP 1

NCP # 1
NCP # 2
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE: Increased body Within 7-8 hours  Adjust and  To help regulate After 8 hours of
“Mataas ang lagnat temperature of nursing monitor room body temperature. nursing intervention
niya, mainit siya” related to interventions the temperature and  The patient’s
as verbalized by inflammatory patient will: bed linens as temperature has
the patient’s process as  Decreased indicated. decreased from
mother. evidenced by temperature  Instruct mother to  Exposure of skin to 39.8C to 37.4C
temperature of from 39.8C eliminate excess room air decreases
39.8C to 37.4C clothing and warmth and
OBJECTIVE: covers. increase evaporative
 Listlessness cooling.
 Lethargic and  Position the  To promote optimal
irritable patient in a patient comfort.
 Sleepiness comfortable Head elevation
 Bulged position and helps improve lung
fontanelle elevate the head of expansion, enabling
 Sunken eyes the patient. for effective
 Depressed breathing.
level of
 Instruct mother to  Replenish fluid loss
consciousness
increased fluid and prevent severe
 Pale oral dehydration.
intake of the
mucosa
patient.
V/S taken as  Monitor input and
follows: output of the
 Temp: 39.8C patient.
 PR: 166 bpm  Instruct mother to
 RR: 34 bpm provide tepid bath  Promotes cooling
 Pulse O2: 95% using lukewarm and lowers body
 Ht./Wt.: 65 water. temperature.
percentiles  Administer
 antipyretic and
antibiotics
medications as
prescribed by the
physician.
 Monitor the
patient’s vital
signs and signs of
convulsions.
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE: Ineffective Within 7-8 hours  Restrict  Produces relaxation After 8 hours of
“Lagi siyang tissue perfusion of nursing environmental effects to decrease nursing intervention
pagod, tapos related to intervention the stimuli, especially adverse physiologic the patient:
madalas lang siya cerebral edema patient will: during planned response and • Gradually
matulog” As as evidenced by  Gradually times for rest and promotes rest. maintained normal
verbalized by the listlessness, maintain sleep. vital signs range.
patient’s mother. lethargy, normal vital • Has increased
sleepiness, and signs range.  Monitor ABGs,  To determine energy and
depressed level  Increase and oxygen hypoxia. concentration as
OBJECTIVE: of energy and saturation. evidenced by
 Listlessness consciousness. concentration demonstrating more
 Lethargic and as evidence  Promote sufficient  Properly balanced positive and happier
irritable by nutritional food intake of nutrients attitude.
demonstrating intake of the provides energy • Has been more
 Sleepiness
more positive patient. resources. active and oriented
 Neck stiffness as evidenced by
and happier
 Sensitivity to attitude. playing with his
light  Be more  To promote optimal mother and reduced
 Position the
 Depressed active and patient in a patient comfort and crying.
level of oriented as comfortable to avoid increasing
consciousness evidenced by position. Maintain of ICP.
playing with the head or neck
V/S taken as his mother in midline
follows: and reduce position, provide
 Temp: 39.8C crying. soft pillows
 PR: 166 bpm .
 RR: 34 bpm  Administer
 Pulse O2: 95% oxygen and
 Ht./Wt.: 65 medication as
percentiles prescribed by the
physician.