Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Sleep deprivation After 2 hours of nursing -provide cold compress -to promote constriction After 2 hours of nursing
related to pain intervention, the client to the site. of the vein and relief to intervention the client
“iyak sya ng iyak secondary to removal of sleep pattern will return the site sleep pattern had return
pagkatapos tanggalin the intravenous fluid to normal. -provide a silent to normal. Goal met.
nung nasa kamay line. environment that is -to promote comfort
nya,hindi tuloy siya comfortable for the
makatulog“, as patient
verbalized by the -the baby has its own
mother. -teach parents to
comfort the baby after way to comfort and calm
Objective: 5-10 minutes of crying herself

-loud lust cry

-facial grimace

-irritability

-bleeding in the IV
Assessment
Subjective: “nilalagnat
siya dahilsa inpeksyon
nya” as verbalized by
the mother.
Objective:
-T: 38.7 °C
-flushed skin, warm to
touch, red cheecks
-loud lust cry, irritability
Diagnosis Planning Intervention Rationale Evaluation
Hyperthermia related to After 30 minutes of -monitor temperature, -to acquire base line After 30 minutes of
infection. nursing intervention, the heart rate, and rhythm data nursing intervention, the
patient core patient core
temperature will - administer medication - to decrease temperature had
decrease within normal given by the physician temperature by means decreased within normal
range. of medication range.
- promote surface
cooling by means of -to decrease
tepid sponge bath temperature through
evaporation and
conduction