ASSESMENT Subjective Data: • “Tatlong araw ng pabalikbalik ang lagnat ng apo ko, hindi maganda ang pakiramdam nya kaya

pinunta ko na siya dito” AVB the grandmother.

NURSING DIAGNOSIS HYPERTHERM IA R/T INFLAMMATO RY RESPONSE AEB INCREASE IN BODY TEMPERATUR E GREATER THAN THE NORMAL RANGE, FLUSHED SKIN; WARM TO TOUCH

SCIENTIFIC EXPLANATION ENTRY OF PATHOGENS IN THE SYSTEMIC CIRCULATION

NURSING GOAL

NURSING INTERVENTION Independent: • Monitor core temperature q 1 °.

RATIONALE OF THE NURSING ACTION • Temperature of 38.9-41.1°C suggest acute infectious disease process. Evaporation is decreased by environmental factors of high humidity and high ambient temperature as well as body factors producing loss of ability to sweat. To support circulating volume and tissue perfusion. To reduce metabolic demands/oxygen consumption.

EVALUATION

After 2 hours of effective nursing intervention, the patient’s temperature will decrease AEB: • Demonstrate temperature within normal range, from 38.1 °C to 36.5°C -37.5°C Demonstrate behaviors to monitor and promote normothermia. Skin is cool to touch and less flushness Identify underlying cause/contributing factors and importance of treatment, as well as signs/symptoms requiring further interventions. Verbalized understanding of specific interventions to prevent hyperthermia

After 2 hours of effective nursing intervention, goal is met. • Patient’s temperature is already in the normal range; T=37.1 °C Demonstrated behaviors to monitor and promote normothermia. Skin is cool, absence of flushing.

REGULATION OF TOXINS IN THE BODY • RELEASE OF PYROGEN • STIMULATION OF THE HYPOTHALAMUS

Note presence or absence of sweating as body attempts to increase heat loss by evaporation.

Objective Data: • Febrile, T= 38.1 °C in both axilla; warm to touch with flushing PR=65 bpm RR=28cpm Patient looks pale and weak in appearance

Increase oral fluid intake. •

• • •

INCREASE OR ALTERATION OF THERMOREGULATIO N • INCREASE IN BODY TEMPERATURE •

Promote bed rest, encourage relaxation skills and diversional activities. Provide TSB as needed • Promote surface cooling, loosen clothing and cool environment Review specific

Heat is loss by evaporation and conduction. Heat is loss by convection,

The patient, together with his significant others understands causes of the disease and is ready to practice specific interventions to prevent hyperthermia.

HYPERTHERMIA

risk factors/causes, signs and symptoms with the interventions required • Discuss importance of adequate fluid intake and protein diet

radiation and conduction.

To promote wellness

To prevent dehydration

Collaborative: • Administer medications as indicated to treat underlying cause, such as: -Paracetamol 325mg/tab 1 tab q 6° • Administer replacement fluids and electrolytes to support circulating volume and tissue perfusion

To treat underlying causes

To support circulating volume and tissue perfusion.

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