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NCP - hyperthermia

NCP - hyperthermia

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Published by giadda

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Published by: giadda on Feb 02, 2010
Copyright:Attribution Non-commercial

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08/19/2013

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NURSING CARE PLAN
AssessmentNursingDiagnosisNursingGoalNursingInterventionRationaleOutcomeCriteriaActualEvaluation
Subjective:“Gihilantanmana siya”,as verbalizedby the S.O.Objective:
Skinwarm totouch withatemperature of 39.1°C
↑RR:28cpm
↑HR:102bpm
Weaknessobserved
Drymucousmembranes
Flushed SkinHyperthermiarelated to theinfectiousprocess orcerebraledema
ScientificBasis:
Pyrogenscause a rise inbodytemperature,it also acts asan antigentriggeringimmunesystemresponses. Thehypothalamusreacts to raisethe set pointand the bodyrespond byproducingheat.
Reference:
Fundamentalsof Nursing-Harry & PerryAfter 2 hoursof comprehensive nursingintervention,the patienttemperaturewill lowerdown tonormallevels: T:36.5°C –37.5°CINDEPENDENT:
Provide tepidsponge bath.
Assess fluid loss &facilitate oral intake.
Promote bed rest.
Provide coolcirculating air usinga fan.
Assist patient inchanging into dryclothing.
Provide oralhygiene.
Monitor vital signs.DEPENDENT:
Maintain IV fluids asordered byphysician.
Administer anti-pyretic as ordered.
Administerantibiotic asordered.COLLABORATIVE:
Monitor hematologictest & otherpertinent labrecords.
Enhances heat lossby evaporation &conduction.
Increases metabolicrate & diaphoresis.
Reduces body heatproduction.
Dissipates heat byconvection.
Increases comfort.
Prevents herpeticlesions of themouth.
Notes progress &changes of condition.
Preventsdehydration.
Reduces fever.
 Treats underlyingcause.
Indicates presenceof infection &dehydration.
Ensures continuousAfter 2 hours of comprehensivenursingintervention,the patient will:
Maintainnormaltemperatureof 37.5°C
Be free of dehydration
Maintain vitalsigns atnormal levels
Be alert andresponsive
Becomfortablein bed.

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