Nurses Diagnosis (Focus) Elevated Body Temperature

Nurses Progress Notes (Data/Assessment/Action/Response) D: Warm to touch, temperature 38.5 C A: Tepid sponge bath rendered Encouraged to increase oral fluid intake R: Temperature rechecked 37.9 C A: Continue cooling measures Kept well ventilated PRN medication given R: Latest Temperature 36.8 C D: Nilalamig siya as verbalized by the mother Temperature 35.2 C, chills noted A: Placed under droplight Extra blanket given Instructed mother to use thick clothes R: Latest Temperature 36.5 C D: Increased respiratory rate to 40 No cyanosis, no difficulty of breathing noted Non-productive cough noted A: Positioned on moderate high back rest Referred to Pedia Resident on Duty Dr. _______ responded and seen patient Informed pulmo staff Due nebulization given by pulmo staff Instructed mother to do chest and back tapping after nebulization R: Respiratory rate 28, patient seemed comfortable on bed D: Complain of persistent cough Respiratory rate 35 No cyanosis and difficulty of breathing With crackles upon auscultation Non productive cough noted A: Positioned patient on high back rest Referred to Pedia Resident on Duty Dr. _______ responded and seen patient Due nebulization given by pulmo staff Instructed relative to do chest and

Ineffective Thermoregulation

Increased Breathing Pattern

Ineffective Airway Clearance

back tapping after nebulization Encouraged to increase oral fluid intake R: Patient able to sleep, no further complaints made Nurses Diagnosis (Focus) Impaired Gas Exchange

Impaired Urinary Elimination

Nurses Progress Notes (Data/Assessment/Action/Response) D: Nahihirapan siya huminga, as verbalized by the mother Respiratory rate 40s Positive cyanosis on lips and fingernails O2 Saturation = 78% A: Positioned on high back rest Referred to Pedia Resident on Duty Dr. _______ responded and seen patient Hooked to oxygen via nasal cannula at 3-4 liters per minute Hooked to pulse oximeter For ABG informed pulmo staff, done and relayed result to Pedia Resident on Duty Dr. _______ Medicated with NaHCO3 ______ meqs given via slow IV push by Dr. _______ R: Hindi na sya nahihirapan huminga, as verbalized by the mother O2 Saturation = 95-98% Respiratory rate = 32 D: Masakit lumunok Loss of appetite noted, inflamed tonsil noted Irritability noted A: Stressed proper oral hygiene Referred to Pedia Resident on Duty Dr. _______ responded and seen patient

Impaired swallowing

Impaired Skin Integrity

Instructed mother to feed on soft cold diet Encouraged to increase oral fluid intake R: Decreased sensation of pain upon swallowing D: Bed sore on buttocks area Redness of the skin area noted A: Turned patient every 2 hours Kept patient always clean and dry Washed wound with plain NSS Observed for signs of infection like inflammation, pus R: No inflammation or pus noted on the affected area D: No urine output for 6 hours Distended bladder noted A: Warm and cold compress applied on hypogastric area alternately Nurses Diagnosis (Focus) Nurses Progress Notes (Data/Assessment/Action/Response) A: Referred to Pedia Resident on Duty Dr. _______ responded and seen patient Stimulated to urinate, accompanied to comfort room R: Voided freely approximately 200cc Risk for Fluid Volume Deficit D: 3x loss bowel stools, greenish, moderate in amount Pale in appearance No abdominal pain noted A: Encouraged patient to increase oral fluid intake Regulated intravenous fluid as ordered fluid rate Referred to Pedia Resident on Duty Dr. _______ responded and seen patient Instructed patient on BRAT diet, no oily and milk products

Infiltration

Impaired Oral Mucous Membrane

Observed for signs of fluid volume deficit R: No sunken eyes noted, adequate urine output for the whole 8 hours shift Admission Assessment D: Oral thrush white patches noted on oral cavity Irritability noted, loss of appetite A: Stressed proper oral hygiene Referred to Pedia Resident on Duty Dr. _______ responded and seen patient Instructed relative to feed patient on soft cold diet Medicated Daktarin oral gel as ordered R: Patient able to eat

Risk for Infection

D: Swelling, cold on palpation at intravenous IVT Therapy site, decreased intravenous flow rate, minimal pain of 2/10 A: Checked back flow Referred to Pedia Intern on Duty for reassessement Discontinued intravenous line as ordered Warm compress applied at site R: Verbalized feeling better after warm compress

Nurses Diagnosis (Focus) Alteration in Comfort

Nurses Progress Notes (Data/Assessment/Action/Response) D: Masakit ang tiyan ko, Pain scale of 8/10, facial grimace noted, crying noted A: Assessed abdomen for tenderness, swelling Warm compress applied over epigastric area Referred to Pedia Intern on Duty for reassessment

Medicated by Ranitidine 25mg/IVT as stat dose as ordered R: Verbalized pain was lessened with pain scale of 2/10 D: Admitted a 2 year old male, conscious and crying cuddle by mother per wheelchair, with a chief complain of fever, direct to room With written order from AMD A: Assisted patient to room of choice Initial vital signs checked and recorded Oriented to room and hospital policies Informed Pedia Resident on Duty of admission R: Mother amenable to instruction D: 3 days fever, decreased milk formula intake, pale and weak in appearance A: For Complete Blood Count as ordered requested and done Perineal wash done and placed wee wee bag for urinalysis specimen sent R: Waiting for laboratory result D: Seen by Pedia Resident on Duty Dr. _______ and assessed with order A: D5 0.3 NaCl 500cc started as venoclysis by Pedia Resident, inserted at left hand using neoflon and secured properly, regulated at 70 ugtts/min R: IVF infusing well