ASSESSMENT NURSING

DIAGNOSIS
SCIENTIFIC
EXPLANATION
PLANNING INTERVENTION RATIONALE EVALUATION
Subjective:
duwa nga aldaw
nga agsak-sakit diay
buksit na, as
verbalized by the
patients mother
.
Objective:
expre
ssive behavior
(crying, irritability
and restlessness)
muscle
pain(myalg
ia)
presence
of facial
grimace
presence
of guarding
behavior,
hands
placed on
the
abdomen
presence
of facial
tension
Looks
irritable
Vital signs
taken
T=3.!
Acute Abdomi!"
P!i #$t i%ectiou&
'#oce&&
"engue virus
introduction to
susceptible host
#
$nvasion to the liver
#
$n%lammatory
response
#
&elease o% chemical
mediators
#
'asodilation
#
(apilliary
permeabiity
)
*lood +lo, to the
area
#
$mpingement to
abdominal nerve
endings
#
-bdominal .ain
-%ter /03 hours o%
nursing
intervention, the
patient ,ill be
relieved %rom pain
as evidenced by1
good %acial
expression
# negative
expressive
behavior
such as
crying,
irritability
and
restlessness
demonstrat
e use o%
diversion2
relaxation
activities
vital signs
,ithin
normal
range

3. 4stablish rapport.
/. .rovide com%ort
measures1
a. place in a le%t
side lying position
b. provide a 5uiet
environment
conducive %or
resting
c. %acilitate
diversion activities0
use puppets, play
cards, etc.
3. 4ncourage
verbalization o%
%eelings2 response
6. 7onitor vital
signs.
8. encourage rest to
patient
9.per%orm pain
assessment every
time the pain ,ill
occur
(ollaborative1
3. -dministered
antipyretics as
ordered by the
physician
to provide a
%oundation %or
a good nurse0
patient
relationship
relieves
tension
promotes non0
pharmacologi
c pain
management
enhances
understanding
and reduces
level o% %ear
and anxiety
determines
%urther
intervention
indication o%
pain: usually
altered during
acute pain
in a ,ay, rest
helps to
reduce pain,
and there
to rule out
,orsening o%
underlying
conditions2de
velopment o%
complication
To decrease
temperature
;oals ,ere met as
evidenced by1
<o resistance
to nursing
interventions
# negative
expressive
behavior
.atient is
com%ortably
lying on bed
"ecreased
irritability
and did not
cry
.atient does
not loo=
restless
normalized
vital signs
ASSESSMENT NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATION
PLANNING INTERVENTION RATIONALE EVALUATION
Subjective:
>;rabe ti gurigor na,
madi metten
bumabbaba ti
gurigorna as
verbalized by the
mother.
Objective:
increased body
temperature
above normal
range (%ebrile
at 3.!?()
%lushed s=in
s=in ,arm to
touch
teary0eyed
lac= o% appetite
,ea= in
appearance
(0) chilling
noted
@ears extra
clothing
Auly /6,/BB1
,ith
hematology
test done ,ith
a result o%
neutrophils=B.
C9(B.880B.!B)
)
lymphocytes=
B.B6(B./B0B.6B)
()'e#t*e#mi!
#$t &)&temic
i%ectio
&ecod!#) to
De+ue %eve#
&)d#ome
$n%ection
#
&elease o% pyrogen
#
$rritation o% the
hypothalamus
#
-lteration in
thermoregulating center
#
+ever (hyperthermia)
DEF&T T4&7
;F-G1
-%ter /03 hours o%
intervention, the
patient ,ill be
exhibit1
normal
temperature
%rom
3.!H( to
39.8H(0
3!H(
%lushed
s=in to
normal
GF<; T4&7
;F-G1
-%ter 9 days o%
nursing
intervention1
the patient ,ill
maintain his
normal body
temperature
<o episodes o%
hyperthermia
throughout the
hospitalization

$ndependent1
3. 7onitor
temperature.
/.-dminister tepid
sponge bath.
3. 4ncourage to
lessen clothing.
6. $ncrease %luid
inta=e.
8. .rovide high0
calorie diet li=e rice
and meat, bread.
9. 7aintain bed rest
%or baseline
data
To lessen heat
by
conduction.
To lo,er
do,n the
temperature.
To avoid
additional
heat
to replace lost
%luids in the
body
to meet
increased
metabolic
demands
To reduce
oxygen
consumption
to provide
com%ort %or
the patient
;oals ,ere met as
evidenced by1
normalized
temperature
at 3!? (
absence o%
%lushed s=in
s=in not
,arm to
touch
patient ,ears
a com%ortable
cotton shirt
and
shortpants
DF
rein%orced
same
activities
,ith regards
to the
maintenance
o% ade5uate
%luid inta=es
patient eats
burger and
loa% bread
DF rein%orces
bedrest to the
patient