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7 C • R: 29 bpm • Sweating noted
Nursing Diagnosis Hyperthermia related to increased metabolic rate as evidenced by a temperature of 39.7 C
Inference Infectious agent (filterable virus of measles) ↓ Stimulate monocytes ↓ Release pyrogenic cytokines ↓ Stimulate anterior hypothalamus ↓ Results in elevated thermoregulator y set point ↓ Leads to ↑ heart conservation And ↑ heat production ↓ fever
Planning Short-term: After 1-3 hours of nursing intervention the patient will be able to: Decreased body temperature to normal range from 39.7C to 37.5-36.5C Long term: After 8 hours of nursing intervention the patient will be able to: Maintain core temperature within normal range of 37.5C-36.5C Free from any complication or infection
Intervention Assess pt.’s condition VS monitor and record (especially temperature) Observe/Record for the intake and output of the patient Promote surface cooling by means of tepid sponge bath. Wrap extremities with cotton blankets Maintain bed rest Encourage increase in fluid intake Collaborative: Check for the results of diagnostic exam or laboratory exam Administer medication as prescribed by the doctor: Paracetamol
Rationale To obtain baseline data Serve to track important changes To monitor possible fluid and electrolyte imbalances To decrease body temperature To minimize shivering. To reduce metabolic and oxygen demand To prevent fatigue. To monitor for any complication or further infection. Anti-pyretic
Evaluation Goal partially met. The patient still have high temperature from 39.7C to 39.1C.