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OBJECTIVES NURSING
INTERVENTIONS
RATIONALE EVALUATION
Subjective:
Opo nilalagnat anak ko.
Mainit po cia¨ as
verbalized by the mother


Objective:
Flushed skin
Warm to touch
Temperature of
38.2
Respiratory rate
of 27
Pulse rate of 125

ypertermia
related to
increase
metabolic rate
( illness)
ypothalamus is
the
thermoregulation
center of a
human body


presence of
infection

trigger of the
fever, called a
pyrogen


release of
prostaglandin E2
(PGE2). PGE2
then in turn acts
on the
hypothalamus


causing heat-
creating effects
increase heat
conservation
and production
resulting


increase body
temperature


hyperthermia.

After 30 mins. of
nursing
intervention the
client will
maintain core
temperature
within normal
range of 37.5
fr0m 38.1
Ìdentified
underlying
factors that may
cause alterations
of body
temperature

Monitored
temperature
every 30
minutes.



Monitored pulse
rate and
respiratory rate




Provided surface
cooling such as
TSB and
removing of extra
clothing.



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 promote
core cooling
by helping
reduce body
temperature.






After 30 mins on
effective nursing
interventions the
client was able to
maintain core
temperature
within normal
range of 37.5.
Goal met
Latest temp: 37.2
Promoted rest
and comfort
providing bed
rest


Encouraged
increase in fluid
intake.


Dependent
function:
Administered
paracetamol as
ordered.


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


Paracetamol
are classified
as analgesics
and
antipyretic
which acts on
the
hypothalamus
to regulate
normal body
temperature.

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