Assessment

Explanation of the problem > Hyperthermia or fever is a normal defense mechanism of the body which is characterized by increased systemic inflammation causing increase in the core temperature above 37 degrees Celsius. This may be due to an infection which triggers pyrogens to be stimulated causing increase in temperature.

Objective

Intervention

Rationale

Evaluation

O> temperature: 37.8 C, with flushed skin noted, and skin is warm to touch, crying and irritability noted.

A> Hyperthermia due to natural defense mechanism of the body related to probable immune response to infection.

> STG: Within 15 Dx>Assess temperature. minutes of effective nursing > Assess any signs of interventions, the hyperthermia. temperature of the client will go Tx>Provide fresh air by back to normal opening the windows. rate. > Place client to > LTG: Within comfortable position. 24 hours of effective nursing >Remove excessive interventions, the clothings. client will not manifest any >Provide TSB. alteration or increase in >Administer analgesics as temperature. prescribe by the physician.

>To assess alteration. >data aside from temperature reading. >Promote evaporation. >To encourage rest.

> STG: Goal met. After 15 minutes of effective nursing interventions, the clients temperature goes back to normal rate. > LTG: Goal met. After 24 hours of nursing interventions, the client did not manifest any alteration or increase un temperature.

>To lessen heat. >To decrease temperature by evaporation. >To chemically decrease body temperature. > To cool down body temperature. >To boost immune system.

Edx>Encourage to increase fluid intake. > Encouraged to eat foods high in Vitamin C and vegetables.

Assessment

Explanation of the problem Cleft palate, a fairly common congenital deformity in which the palatal plates (in the roof of the mouth) fail to close during the second month of prenatal life. The resulting fissure may occur on the soft palate only, or it may extend forward through the hard palate, in which case the nasal cavity opens into the mouth and the nasal septum and its vomer bone are often absent. As a result of hole in the roof the mouth, pediatric client is at high risk for aspiration.

Objective

Intervention

Rationale

Evaluation

O>with cleft secondary palate and uvula upon inspection of the mouth; backflow of gastric juices in the nose during vomiting. A> Risk for Aspiration related to anatomic defect secondary to cleft palate

> STG: Within 20 minutes of effective nursing interventions, the mother will understand and demonstrate the following: a.)Proper ways to care for a child with cleft palate b)the importance of understanding and preventing aspiration.

Dx: >Asses secretion during vomiting episodes.

>to determine if there is backflow of vomitus in the nasal cavity. > Prevents aspiration of feedings. >Facilitates intake while minimizing risk of aspiration. >Helps to prevent regurgitation and aspiration. >Minimizes passage of feedings through cleft. >educating caregivers lessen the risk of having aspiration. >in order for the child to prevent speech defect or abnormality.

Tx: > Position on side after feedings. > Feed slowly and slow frequent feedings as needed. >Burp frequently.

> STG: Goal met. After 20 minutes of effective nursing interventions, the mother understands and demonstrates the following: a.)Proper ways to care for a child with cleft palate b)the importance of understanding and preventing aspiration. > LTG: Goal met. After 24 hours of nursing interventions, the client did not experience any aspiration when feeding and vomiting episodes.

>Position upright for every feedings.

Edx: >instruct and educate mother about the proper > LTG: Within 24 position in feeding the child hours of effective and importance of burping nursing the child every after interventions, the feeding. client will not > advise to consult the experience any doctor regarding the aspiration when surgical repair because the feeding and best time for it is vomiting between twelve to fourteen episodes. months of age.