Assessment Objective Temp 37.

8C Skin warm to touch

Diagnosis Hyperthermia r/t inflammatory response of the body as evidence by increase in core temperature

Planning

Intervention

Rationale > for baseline data > to facilitate heat loss through evaporation and conduction > to provide proper knowledge and to empower the SO in taking care of the patient To slow down the patient metabolism > aid in lowering down the temperature

Evaluation Goal met as evidenced by lowered temperature from 37.8-37.0 C

After 30 minutes of > monitored V/S nursing interventions the > Performed tepid patient will have sponge bath lowered temperature from 37.8-37.0 C > demonstrated proper performance of TSB

> instructed the SO to keep the patient rested

Assessment SUBJECTIVE: nahihirapan akong gumalaw kaya nakahiga na lang ako as verbalized by the pt. OBJECTIVES: Impaired ability to turn side to side Cannot eat without support Slowed movement Irritable Limited ROM

Nursing Diagnosis Impaired mobility related to bodt weakness

Planning After 4 hours of nursing intervention the pt will be able to move safely and independently.

Intervention Provide activities with adequate rest. Encouraged adequate intake of fluids.

Rationale To reduce the fatigue

Evaluation After 4 hours of nursing intervention the pt was able to move safely with assistive device

Promotes well being and maximize energy production To exercise/mo bilization of body parts and develop muscle strength

Advise to move hands and legs slowly

Encourage participatio n in self care.

Enhance self concept and sense of indepenence

Assessment

Nursing Diagnosis S:masakit yung era ko Risk for as verbalized by the pt. infection r/t post O: debridement Weak in appearance Poor muscle tone With wound dressing on left foot with elactic bandage and soiled by pus

Planning After 8 hours of nursing intervention the pt will understand ways on preventing infection and to reduce further complication

Intervention v/s taken and recorded

Rationale *to get baseline data

Evaluation Patient verbalized understand ways on preventing infection and ways to reduce further complication. Able to demonstrate proper colostomy care and hand washing Verbalized understanding the importance of proper hygiene and identified s/sx of infection. Still weak in appearance

Maintain clean *to avoid invasion technique in cleaning of microorganisms and changing the wound dressing. Instructed to perform passive ROM Instructed client to limit visitors *To promote proper circulation

* This reduces the number of organisms in patients environment and restricts visitation by individuals with any type of infection to reduce the transmission of pathogens to the patient at risk for infection. *to assess the signs of infection

Observed for any untoward s/sx such as redness, swelling, increased pain.

Encourage intake of protein- and calorie-

*This maintains optimal nutritional

rich foods.

status. *These measures reduce stasis of secretions in the lungs and bronchial tree. When stasis occurs, pathogens can cause upper respiratory infections, including pneumonia.

Encourage coughing and deep breathing; consider use of incentive spirometer.

Health teaching given: Teach patient and significant others to wash hands often, especially after toileting, before meals, and before and after administering self-care. Teach patient the signs and symptoms of infection, and when to

*To lessen microorganisms; Patients and caregivers can spread infection from one part of the body to another, as well as pick up surface pathogens; hand washing reduces these risks.

*To give immediate intervention

report these to the physician or nurse. * To lessen microorganisms Reviewed importance of proper hygiene