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Assessment Subjective: Patients mother verbalized mainit palagi siya kapag hinahawakan. Siguro dahil sa mainit ditto sa ward.

Objective: Body Temperature = 38 C Warm to touch skin RR = 45 bpm HR = 110 bpm Body sweating Seizure precaution Convulsion

Diagnosis

Inference

Planning

Intervention Apply tepid sponge bath Assess body temperature from time to time Dont do alcohol TSB

Rationale To help decrease body temperature To know what is the response of client to TSB Alcohol increases peripheral vascular constriction & CNS depression To prevent chills Hot environment promotes further increase in temperature and so much stimulus to patient may trigger seizure To prevent injury To reduce temperature

Evaluation Short Term goal met: Temperature is normal

Hyperthermia related Hot environment Short term: to exposure to hot contributes to body At the end of the environment temperature of any shift, patient will be: individual. If the environment is hot, Normal in expect that the temperature temperature of an individual also Decreased increased. seizure activity

No seizure activity at the end of the shift

Long term: Upon discharge, the patient as well as the family members will: Know and demonstrate how to promote normothermia Nomal body temperature Skin is not warm to touch Be free from seizure activity

Dont use cold water in TSB Apply cool and quiet environment

Long term goal partially met: Relative know to promote normothermia

Normal in temperature

Increase siderails of bed Administer antipyretic drug as ordered

Still recurrence of seizure

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