CUES NURSING DIAGNOSIS SCIENTIFIC RATIONALE OBJECTIVE INTERVENTION RATIONALE EVALUATION

Subject: Altered body temperature Bacterial microorganisms After 2 hours of nursing Independent:
- “An akon anak kay related to bacterial (e.g. pulmonary pathogens) intervention, the child’s - Monitor patient’s - To determine if the
mapasupaso gad invasion in the lungs as enter the airway. These temperature will decrease temperature every patient’s
hiya tas maluya it manifested by body bacteria/ viruses infects the from 39C to normal range hour. temperature is
iya lawas yana,” as temperature higher than lung/s resulting to (36.5-37.2C). above the normal
vferbalized by the normal inflammation in the lungs range.
mother and causes the signs and - Encourage patient - Allows the patient
- “Diri gud hiya symptoms of pneumonia to take rest. to recuperate
nakaka-ka-on hin (e.g. temperature may be physical strength.
tuhay, tuman la it greater than 37.5C), - Encourage patient - To maintain
iya nakaka- tachypnea, coughs with to increase fluid hydration status and
on...nagkukuri man greenish secretions. intake. increase fluid intake
gud hiya pag hinga,” helps lessen
as verbalized by the febrility.
mother SOURCE: - Encourage the - Sponge bath with
patient’s guardian to warm water
Objectifve: do tepid sponge evaporates off his
- Febrile; 39C http://nursingcrib.com/wp- bath. skin, thus cooling off
temperature (36.5- content/uploads/case the patient.
37.2C) study/NCPpneumonia.pdf - If patient is lying on - This may help to
- Moist skin bed, frequent reduce discomfort.
- Tachypnea; changing position
RR=52cpm (20- and linen.
40cpm) - Frequently change - Because of
patient’s clothing. increased in
sweating.
- If patient feels cold - To conserve body
provide blanket. heat or to reduce
heat loss.
Dependent:

- Acetaminophen
elixir 120mg every 4
hours PRN for
temperature >101F,
as ordered by the
physician
- Ampicillin
100mg/kg/day in
divided doses every
6 hours.