CUES/CLUES Subjective: Yung anak ko nahihirapan gumalaw, hindi niya magalaw ng maayos leeg niya at nainigas yung mga

kamay at paa niya minsan. as verbalized by the patient s mother. !bjective: "resence o# nuchal rigidity, di##iculty in per#orming activities which re$uire a large rom, posture instability, di##iculty turning.

NURSING DIAGNOSIS %mpaired physical mobility related to neuromuscular impairment as evidenced by sti##ening o# upper and lower e&tremities

SCIENTIFIC RATIONALE 'euromuscular disorders a##ect the nerves that control your voluntary muscles. (oluntary muscles are the ones you can control, like in your arms and legs. Your nerve cells, also called neurons, send the messages that control these muscles. )hen the neurons become unhealthy or die, communication between your nervous system and muscles breaks down. *s a result, your muscles weaken and waste away. +he weakness can lead to twitching, cramps, aches and pains, and joint and movement problems. Sometimes it also a##ects heart #unction and your ability to breathe.

OBJECTIVE Short +erm !bjective: *#ter , hours o# giving e##ective nursing interventions, the patient will be able to understand the situation o# her current condition as evidenced by verbalization and be able to maintain skin integrity as evidenced by absence o# contractures, #ootdrop, decubitus and other complications. -ong +erm !bjective: *#ter . days o# giving e##ective nursing interventions, the patient will be able to: increase strength and #unction as evidenced by

NURSING INTERVENTION %ndependent 'ursing %nterventions: /. 0evelop therapeutic relationship with the patient. 1eing attentive to the patient s needs, encourageme nt #or e##orts and maintaining open communicatio n 2. *ssist the patient in repositioning on a regular schedule. .. %nstruct the use o# siderails, overhead trapeze and roller pads. ,. Support a##ected body parts or joints using pillow rolls, #oot supports or shoes 3. Schedule

RATIONALE %ndependent 'ursing %nterventions: /. +o promote trust situation in which client is #ree to be open and honest with sel# and therapist. 4'urse s "ocket 5uide6

EVALUATION *#ter , hours o# giving e##ective nursing interventions, the patient was able to understand the situation o# her current condition as evidenced by verbalization and the patient was able to maintain skin integrity as evidenced by absence o# contractures and other complications. *#ter . days o# giving e##ective nursing interventions, the patient was able to increase strength and #unction as evidenced by participating in desired activities and was able to per#orm *0-S7 the patient was able to demonstrate techni$ues or behaviors that enable resumption o# activities as

2. +o prevent #urther complications such as decubitus ulcer. 4'urse s "ocket 5uide6 .. +o promote sa#ety and #or position changes and trans#ers. 4'urse s "ocket 5uide6 ,. +o maintain position and to be able to decrease the risk o# pressure ulcers 4'urse s

4S!89:;: http:<<www.nlm .nih.gov< medlineplus< neuromuscular disorders.html6

participating in desired activities and per#orming *0-s able to demonstrat e techni$ues or behaviors that enable resumption o# activities as evidenced by ease o# movement o# e&tremities.

activities with ade$uate rest periods during the day. =. "roviding regular skin care.

"ocket 5uide6 3. +o be able to promote rest at night and reduce #atigue. 4'urse s "ocket 5uide6 =. +o promote proper hygiene and to monitor #or signs o# pressure ulcers 4'urse s "ocket 5uide6 0ependent 'ursing %nterventions: /. +o alleviate the patient s condition and prevent e&acerbation o# symptoms as e&hibited by the patient. :ollaborative 'ursing %nterventions: /. +o develop individual e&ercise and mobility program, and identi#y appropriate

evidenced by ease o# movement o# e&tremities.

0ependent 'ursing %nterventions: /. *dministration o# medication as prescribed by the physician in charge. :ollaborative 'ursing %nterventions: /. :onsulting with physical or occupational therapist as indicated

mobility devices. 4'urse s "ocket 5uide6

CUES/CLUES Subjective: Yung anak ko nanginginig at sobrang nilalamig tapos ang init init niya pa. as verbalized by the patient s mother. !bjective: >+ ? .@ : > Alushed skin >"resence o# seizures and convulsions 4muscle rigidity6

NURSING DIAGNOSIS Bypethermia related to illness as evidenced by elevated body temperature.

SCIENTIFIC RATIONALE Byperthermia is de#ined as a temperature greater than .C.3? .@.. D: 4/EE?/E/ DA6, depending on the re#erence used, that occurs without a change in the bodyFs temperature set point.G,HG3H +he normal human body temperature in health can be as high as .C.C D: 4II.I DA6 in the late a#ternoon.G@H Byperthermia re$uires an elevation #rom the temperature that would otherwise be e&pected. Such elevations range #rom mild to e&treme7 body temperatures above ,E D: 4/E, DA6 can be li#e threatening 4Source: http:<<en.wikipedia .org<wiki< Byperthermia6

OBJECTIVE Short +erm !bjective: *#ter , hours o# giving e##ective nursing interventions, the patient will be able to: >maintain core temperature within normal range as evidenced by decrease body temperature. -ong +erm !bjective: *#ter 2 days o# giving e##ective nursing interventions, the patient will be able to: 0emonstrate behaviors to monitor and promote normotherm ia as evidenced by absence o# complication s such as seizures and

NURSING INTERVENTION %ndependent 'ursing %nterventions: /. Jonitor core temperature regularly.

RATIONALE %ndependent 'ursing %nterventions: /. +o be able to evaluate the e##ects or degree o# hyperthermia 4'urse s "ocket 5uide6 2. +o be able to monitor #or any signs o# neurological damage. 4'urse s "ocket 5uide6 .. +o be able to monitor #or any signs o# sweat gland dys#unction. 4'urse s "ocket 5uide6 ,. +o be able to monitor #or dehydration that might lead to shock. 4'urse s "ocket 5uide6 3. +o be able to loss heat by means o# conduction, convection and evaporation and

EVALUATION *#ter , hours o# giving e##ective nursing interventions, the patient was amenable to the interventions as evidenced by decreased in body temperature. *#ter 2 days o# giving e##ective nursing interventions, the patient was able to demonstrate behaviors to promote and monitor normothermia as evidenced by absence o# complications such as seizures and neurological damage7 and was able to return to normal #unction as evidenced by demonstrating and per#orming basic *0-s.

2. *ssess neurological response and note #or the level o# consciousness .. 'ote the presence or absence o# sweating. ,. Jonitor sources o# #luid loss such as urine.

3. "romote sur#ace cooling by means o# undressing, cool environment, tepid sponge bath and

neurological damage. 9eturn to normal #unction as evidenced by demonstrati ng or per#orming basic *0-s.

applying local ice packs.

can decrease temperature. 4'urse s "ocket 5uide6 0ependent 'ursing %nterventions: /. +o alleviate patient s illness and to prevent #urther e&acerbation o# symptoms as e&hibited by the patient. :ollaborative 'ursing %nterventions: /. +o be able to know the current condition o# the patient and to per#orm appropriate intervention i# any complications occur.

0ependent 'ursing %nterventions: /. *dminister medications such as antiKpyretics as prescribed by the physician in charge. :ollaborative 'ursing %nterventions: /. *id in gathering laboratory test 4such as :1:6 and monitor the results.

CUES/CLUES Subjective: Yung anak ko nanginginig at sobrang nilalamig tapos ang init init niya pa. as verbalized by the patient s mother. !bjective: >+ ? .@ : > Alushed skin >"resence o# seizures and convulsions 4muscle rigidity6

NURSING DIAGNOSIS Bypethermia related to illness as evidenced by elevated body temperature.

SCIENTIFIC RATIONALE Byperthermia is de#ined as a temperature greater than .C.3? .@.. D: 4/EE?/E/ DA6, depending on the re#erence used, that occurs without a change in the bodyFs temperature set point.G,HG3H +he normal human body temperature in health can be as high as .C.C D: 4II.I DA6 in the late a#ternoon.G@H Byperthermia re$uires an elevation #rom the temperature that would otherwise be e&pected. Such elevations range #rom mild to e&treme7 body temperatures above ,E D: 4/E, DA6 can be li#e threatening 4Source: http:<<en.wikipedia .org<wiki< Byperthermia6

OBJECTIVE Short +erm !bjective: *#ter , hours o# giving e##ective nursing interventions, the patient will be able to: >maintain core temperature within normal range as evidenced by decrease body temperature. -ong +erm !bjective: *#ter 2 days o# giving e##ective nursing interventions, the patient will be able to: 0emonstrate behaviors to monitor and promote normotherm ia as evidenced by absence o# complication s such as seizures and

NURSING INTERVENTION %ndependent 'ursing %nterventions: /. Jonitor core temperature regularly.

RATIONALE %ndependent 'ursing %nterventions: /. +o be able to evaluate the e##ects or degree o# hyperthermia 4'urse s "ocket 5uide6 2. +o be able to monitor #or any signs o# neurological damage. 4'urse s "ocket 5uide6 .. +o be able to monitor #or any signs o# sweat gland dys#unction. 4'urse s "ocket 5uide6 ,. +o be able to monitor #or dehydration that might lead to shock. 4'urse s "ocket 5uide6 3. +o be able to loss heat by means o# conduction, convection and evaporation and

EVALUATION *#ter , hours o# giving e##ective nursing interventions, the patient was amenable to the interventions as evidenced by decreased in body temperature. *#ter 2 days o# giving e##ective nursing interventions, the patient was able to demonstrate behaviors to promote and monitor normothermia as evidenced by absence o# complications such as seizures and neurological damage7 and was able to return to normal #unction as evidenced by demonstrating and per#orming basic *0-s.

2. *ssess neurological response and note #or the level o# consciousness .. 'ote the presence or absence o# sweating. ,. Jonitor sources o# #luid loss such as urine.

3. "romote sur#ace cooling by means o# undressing, cool environment, tepid sponge bath and

neurological damage. 9eturn to normal #unction as evidenced by demonstrati ng or per#orming basic *0-s.

applying local ice packs.

can decrease temperature. 4'urse s "ocket 5uide6 0ependent 'ursing %nterventions: 2. +o alleviate patient s illness and to prevent #urther e&acerbation o# symptoms as e&hibited by the patient. :ollaborative 'ursing %nterventions: /. +o be able to know the current condition o# the patient and to per#orm appropriate intervention i# any complications occur.

0ependent 'ursing %nterventions: 2. *dminister medications such as antiKpyretics as prescribed by the physician in charge. :ollaborative 'ursing %nterventions: /. *id in gathering laboratory test 4such as :1:6 and monitor the results.