ASSESMENT Subjective: Masakit yung ulo ko as verbalized by the patient.

NURSING DIAGNOSIS Nursing Diagnosis: Altered comfort: Acute Pain related to inflammation and tissue necrosis as evidenced by verbal reports of the patient.

PLANNING Short term: After 30 minutes of nursing intervention patients pain will be relief with the pain scale of 2 out of 10.

INTERVENTION >Monitor patients Vital Signs. >Use pain rating scale appropriate for age and cognition. (0-10 pin scale) Note when pain occurs. Administer Analgesics, as indicated/ prescribed by doctors. Encourage adequate rest periods. Provide comfort measures.

RATIONALE >Usually Altered by Pain. >To assess severity of pain and to identify specific health care needs. To medicate prophylactically as appropriate. To maintain ACCEPTABLE level of pain.

EVALUATION Ate the end of nursing intervention, Patients pain was relieved and tolerable as evidenced by pain scale of 0 out of 10. The Parents also incorporated relaxation skills and diversional activities to alleviate patients pain.

Objective: > Non-healing wound > Swelling of the parietal area. > + Pus > + Fever > Guarding Behavior > Facial Grimace V/s taken as follows: T= 37.8 RR= 28 cpm PR= 98 bpm

Scientific Explanation: Unpleasant sensory and emotional experience arising from actual or potential tissue damage.

Long term: After 1 day of nursing intervention, the patient pain will be relief and tolerable with the pain scale of 0 out of 10. Patient will be provided relaxation skills and diversional activities to reduce pain.

To prevent fatigue. To promote nonpharmacological pain management.

ASSESSMENT Subjective: May sugat ako sa ulo, tinahi ng doctor as verbalized by the patient.

NURSING DIAGNOSIS Nursing Diagnosis: Impaired skin integrity related to disease condition as evidenced by non healing wound.

PLANNING Short term: After 1day of the nursing interventions, the patient will demonstrate behaviors/ techniques facilitate wound healing. Long term:

INTERVENTION Examine the skin for open wounds, foreign bodies and discoloration.

RATIONALE It provides information regarding skin circulation and problems that may require further medical intervention. To relief pain due to disease condition. Provides faster recovery and wound healing.

EVALUATION At the end of nursing intervention, the patient was able to display improve wound healing as evidenced by minimized presence of wound, absence of redness, intact skin, and absence of purulent discharge.

Administer prescribed analgesic. Explain the importance of proper and completing antibiotic medication. Discuss importance of adequate nutrition especially fluids, proteins, vitamins B and

Objective: > Disruption of the skin surface. > Possible suture line. > Swelling of the affected area. > Hair loss. > Redness > presence of pus > Non healing wound Scientific Explanation: Skin is the prima ry defense of the body; it protects the body against infections and disease brought about b y the invasion of microbes in the body. A normal skin is moist and intact.

After a 7 days of nursing intervention, the patient will able to display improvement in wound healing and minimized presence of wound.

These provide patient information how nutrition could elevate her chances of a faster

vitamin C. Demonstrate good skin hygiene.

recovery and wound healing. Maintaining a clean, dry skin provides a barrier to infection. This provides the patients guide towards a proper skin management technique. To avoid possible infection thus hindering the wound healing process. To provide the patients parents on the correct procedures and techniques of wound caring

Establish a turning or repositioning schedule.

Emphasize principles of asepsis especially hand washing and avoidance of touching wound with bare hands. Demonstrate wound care technique such as wound cleansing

ASSESSMENT Subjective: Nilalamig ako as verbalized by the patient.

NURSING DIAGNOSIS Nursing Diagnosis: Hyperthermia related to invasion of infection as evidenced by experiencing Chills.

PLANNING Short term: After 1 hour of nursing intervention, the patients temperature will decrease to normal range of body temperature.

INTERVENTION Establish Rapport to the patient Monitor Vital signs, especially temperature. Adjust and monitor environmental factors like room temperature and bed linens as indicated.

RATIONALE To gain trust from the patient. Notes progress and changes of condition. Room temperature may be accustomed to near normal body temperature and blankets and linens may be adjusted as indicated to regulate temperature of client. It could help in reducing hyperthermia; avoid using alcohol and iced water which may even produce chills and increase clients

EVALUATION At the end of nursing intervention, The patient was able to report and show manifestations that fever is relieved and controlled through body temperature of 36.7, RR and PR is stable, absence of Flushed skin, Chills and profuse diaphoresis.

Objective: >Skin warm to touch > With flushed skin > Profuse diaphoresis > Teary eyes > Tachycardia > Chills Vital signs: T= 38.8 RR= 26 PR= 118

Scientific Explanation: Increased body temperature caused by the presence of pyogenic microorganisms in the local circulation.

Long term: After 1 day of nursing intervention, the patient will be able to resume and maintain normal body temperature.

Apply tepid sponge bath

temperature. Administer antipyretics as prescribed by the physician. Antipyretics acts on the hypothalamus, reducing hyperthermia. Water regulates body temperature To replenish fluid losses during shivering chills To meet the metabolic demand of client. Providing health teachings to client could help client cope with disease condition and could help prevent further complications of

Encourage client to increase fluid intake. Start intravenous normal saline solutions or as indicated. Provide high caloric diet or as indicated by the physician. Educate patients parents of signs and symptoms of hyperthermia and help them identify factors related to occurrence of fever; discuss importance of

increased fluid intake to avoid dehydration.

hyperthermia.