1.

Nursing Diagnosis: Hypertermia related to the infection process

Goal: The temperature within normal limits

Expected outcomes are:

1. Free from cold

2. Stable body temperature 36-37 C

Intervention:

1. Monitor the temperature of the client (the degree and pattern) note the chills / diaphoresis
2. Monitor the temperature of the environment, limit / add the bed linen as indicated
3. Give a warm compress to avoid the use of alcohol
4. Give the drink as needed
5. Collaboration for the provision of antipyretics

2. Nursing Diagnosis: Risk for Injury related to repetitive strain

Goal: free from injury

Expected outcomes are:

1. shows the homeostatic

2. no mucosal bleeding and free from other complications

Intervention:

1. Review the signs of complications

2. Assess the status of cardiopulmonary
3. Collaboration for laboratory monitoring: monitor routine blood
4. Collaboration for the administration of antibiotics

3. Nursing Diagnosis: Fluid Volume Deficit related to the intake of less

Goal: Adequate fluid volume

Expected outcomes are:

1. vital signs within normal limits

2. strong peripheral pulses palpable
3. adequate urine output
4. there are no signs of dehydration
Intervention:

1. Measure / record the urine output and specific gravity. Record the input and output
cumulative imbalance
2. Monitor blood pressure and heart rate
3. Palpation of peripheral pulses
4. Review of dry mucous membranes, poor skin tugor and refined taste
5. Collaboration for the administration of IV fluids as indicated
6. Monitor laboratory values

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Fever Control

 Monitor temperature at least every 2 hours.

 Monitors in continuous basal temperature.
 Monitor blood pressure, pulse, and respiration.
 Monitor skin color and temperature.
 Monitor level of consciousness.
 Monitor WBC, Hb, Hct.
 Monitor intake and output.
 Give antipyretic.
 Provide treatment to overcome the cause of fever.
 Provide intra-venous fluids.
 Compress the patient, on the thigh fold, axila and neck.
 Increase air circulation.
 Provide treatment to prevent shivering.

Temperature Regulation

 Monitor signs of hyperthermia

 Increase fluid intake and nutrition
  Teach the patient how to prevent fatigue due to heat
 Discuss and clarify the importance of temperature regulation and possible negative
effects of cold
 Provide appropriate antipyretic medication as needed
 Use the mattress cool and warm water bath to overcome the interference fit the needs of
the body temperature
 Release of excess clothing and covered the patient with only a piece of clothing.

Vital Sign Monitoring

 Monitor blood pressure, pulse, temperature, and respiration

 Record the blood pressure fluctuates
 Monitor the patient’s vital signs while standing, sitting and lying
 Auscultation of blood pressure in both arms and compare
 Monitor blood pressure, pulse, and respiration before, during, and after activity
 Monitor the quality of the pulse
 Monitor breathing frequency and cadence
 Monitor the voice of the lungs
 Monitor abnormal breathing patterns
 Monitors temperature, humidity and skin color
 Monitor peripheral cyanosis
 Monitor the availability of a widened pulse pressure, bradycardia, increase in systolic
(Chusing Triad)
 Identify the cause of the change in vital signs.