UPPER RESPIRATORY TRACT INFECTION HYPERTHERMIA: Actual Nursing Care Plan
Assessment Subjective: “Agpaparaw ak” Objective: Flushed skin Warm to touch Temperature of 38.2 Respiratory rate of 27 Pulse rate of 125 Blood pressure of
EXPLANATION OF THE PROBLEM Hypothalamus is the thermoregulation center of a human body. In presence of infection, a trigger of the fever, called a pyrogen, causes a release of prostaglandin E2 (PGE2). PGE2 then in turn acts on the hypothalamus, which generates a systemic response back to the rest of the body, causing heat-creating effects increase heat conservation and production resulting to increase body temperature or hyperthermia.
EVALUATION After 4 hours on effective nursing interventions the client was able to maintain core temperature within normal range of 37.5.
After 4 hours of nursing intervention the client will maintain core temperature within normal range of 37.5 fr0m 38.1
Dx: Identified underlying factors that may cause alterations of body temperature Monitored temperature every 30 minutes. Monitored pulse rate and respiratory rate Assessed neurological response
To obtain factors of increase body tempearature. To obtain an accurate core temperature and detect for further development. To evaluate effectiveness of independent nursing regimen To obtain level of consciousness in response to increase body temperature. To promote core cooling by helping reduce body temperature. Paracetamol are classified as analgesics and antipyretic which acts on the hypothalamus to regulate normal body temperature. To reduce metabolic demands that may contribute to further complications.
Increase body temperature related to disturbance of the hypothalamus due to production of pyrogen, secondary to bacterial infection in the respiratory tract.
Provided surface cooling such as TSB and removing of extra clothing. Administered paracetamol as ordered.
Promoted rest and comfort providing bed rest.
Demonstrated to SO how to perform TSB
For SO.’s independent accurate action in response to the client’s condition of hyperthermia.
Encourage verbalization of feelings
To detect further existing discomforts and level, whether increased or decreased. To prevent dehydration because increase in body temperature causes fluid loss such as sweating.
Encouraged increase in fluid intake.