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;“taas lage iya hilanat” as verbalized by SO 
Objective Cues: 
 Skin warm to touch 
 On O2 Inhalation at 2-4 L/min 
 On Intravenous Fluid at 60-70 microgtts/min 
 Flushed skin upon inspection 
 Heart rate of 72 bpm 
 Respiratory rate of 28 cpm 
 Body Temperature of 39.5 0C 
 Glasgow Coma Scale of 6 
• Eye opening – no response – 2 
• Motor response – extends abnormally – 2 
• Verbal response – no response – 2 
Nsg. Dx 
 hyperthermia r/t Increased basal metabolic rate secondary to meningitis 
Planning 
 After 8 hrs of duty patient’s temperature will be able to decrease from 39.50C to normal range(36.50C-37.50C). 
Intervention 
Independent: 
 V/S monitored and recorded 
Rationale- for baseline data 
 Performed TSB 
Rationale - to facilitate the release of heat through the skin 
 Provided tube feedings 
Rationale- to meet increased metabolic demand. 
Dependent 
 Administered antipyretic drug (Paracetamol) per doctor’s order 
Rationale- Used to reduce fever by its central action on the hypothalamus. 
 Administered antibiotic (Cefimax) per doctor’s order 
Rationale- To treat underlying cause 
Evaluation 
 Goal partially met. After 8 hours of duty patients temperature have been reduced from 39.50C to 38.50C. 
Date: 
Subjective Cues 
 “Murag nagniwang lage siya ug perme ra siya tulog” as verbalized by the SO 
Objective cues 
 Vital Signs: 
 Weight 
 Flaccid extremeties upon inspection 
 Dry lips upon inspection 
 Dry skin upon inspection 
 Patient is on NGT feeding 
 Glasgow Coma Scale of 6 
• Eye opening – no response – 2 
• Motor response – extends abnormally – 2 
• Verbal response – no response – 2 
 Generalized weakness 
 On Intravenous Fluid at 60-70 microgtts/min 
Nsg. Dx 
 Imbalance nutrition: less than body requirements r/t decrease level of consciousness 
Planning 
 After 3 days of duty, the patient’s weight will be back to her usual weight (25 kgs). 
Intervention 
Independent: 
 Provided feeding safety; 
- elevated head while eating or during the feeding 
Rationale – reduces risk of regurgitation and/or aspiration 
Dependent: 
 Administered feedings by appropriate means; e.g. IV/Tube feeding, oral feeding with soft foods and thick liquids. 
Rationale – Choice of route depends on client’s needs/ capabilities. Tube feedings may be required initially, or parental route may be indicated in presence of gastric / intestinal pathology. If client is able to swallow, soft foods or semi liquid foods may be more easily swallowed w/out aspiration. 
Evaluation 
> Goal not met. After 3 days of duty, patient still have some potential signs of ma本论文由英语论文网提供整理，提供论文代写，英语论文代写，代写论文，代写英语论文，代写留学生论文，代写英文论文，留学生论文代写相关核心关键词搜索。