Cues Nursing Rationale Objective Expected Nursing Intervention Rationale Evaluation

Diagnoses Outcome

Subjective: Hyperthermia Infectious agents After 4 hrs. Of The patient was Promote To decrease
due to disease After 4 hrs.
(Pyrogens) able to maintain
“Mainit ang process nursing surface cooling temperature
normal body Of nursing
Stimulate
secondary to temperature
pakiramdam interventions, by means of by means
infection intervention
ko”
the patient will tepid sponge through
Monocytes s, the
as verbalized
by Release maintain core bath. evaporation
patient was
the patient. temperature and
able
Pyrogenic cytokines
within normal conduction.
Stimulate
maintain
Objective range.
core
Anterior hypothalamus temperature
Warm to touch results in Wrap To minimize
within
skin
extremities with shivering.
normal
Elevated
cotton blankets.
thermoregulatory set range.
Guarding point

behavior leads to
Maintain bed To reduce

Increased Heat
rest. metabolic
conservation
Shivering (Vasoconstriction/behaviour demands and
changes)

oxygen

Temperature of Increased Heat consumption

production
40ºC
(involuntary muscular
contractions)

Administer To facilitate
result in

FEVER
Antipyretics as prescribed fast recovery.

by the

physician.

Cues Nursing Rationale Objective Expected Nursing Intervention Rationale Evaluation

Diagnoses Outcome

Subjective: Ineffective Bronchial After 6 hours of The patient was Auscultate breath Some degree of
After 3 days of
asthma is able to
airway nursing demonstrate sounds. Note bronchospasm
nursing
a chronic behaviors to
“Nahihirapan
ako clearance inflammatory interventions, improve airway adventitious is present with interventions,
clearance
huminga” as related to disease of the the patient will breath sounds obstructions in the patient was

verbalized by increased airways, demonstrate like wheezes, airway and may able to
the associated
production of behaviors to crackles and or may not be demonstrate
patient. with recurrent,
secretions. improve airway rhonchi. manifested in behaviors to
reversible
clearance. adventitious improve airway
airway
Objective:
breath sounds. clearance.
obstruction Elevate head of
with
Use of the bed, have
intermittent Elevation of the
accessory patient lean on
episodes of bed facilitates
muscle. overbed table or
wheezing and respiratory
sit on edge of the
dyspnea. function by use
RR-25 bed.
Bronchial
of gravity.
hypersensitivity Encourage or
is
With Oxygen assist with
Theray caused by
abdominal or
various Provides patient
pursed lip
stimuli, which with some
breathing
innervate the means to cope
vagus exercises.
with or control
 nerve and beta dyspnea and

adrenergic reduce air

receptor
Administer tapping.
cells of the
bronchodilators
airways,
To reduce the
as prescribed.
leading to
viscosity of
bronchial
secretions.
smooth muscle

constriction,

hypersecretion
of

mucus, and

mucosal
edema.

Cues Nursing Rationale Objective Expected Nursing Intervention Rationale Evaluation

Diagnoses Outcome