NURSING BACKGROUND

CUES PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS KNOWLEDGE
SUBJECTIVE Hyperthermia as Activated immune After 2 hrs of 1. Assess the 1. To obtain baseline Goal met.
manifested by cell (macrophage, Nursing child’s vital signs data.
“Nilalagnat po abnormal body lymphocytes) intervention, the After 2 hrs of
closely.
sya at giniginaw temperature as client will nursing
noong isang araw evidenced by regain and 2. Elevated body intervention, the
2. Assess for signs of
pa” as verbalized temperature of temperature client regained
maintain body dehydration such as
by the guardian. Endogenous increases the and maintained
38.5°c temperature dry mouth, sunken
pyrogen metabolic rate,
within a eyes, sunken body
OBJECTIVE hence increases the
fontanelle, low temperature of
normal range. insensible fluid
concentrated urine 36.5°c.
Flushed skin loss.
output.
Abnormal Circulation
posturing
Skin warm to 3. To decrease
touch 3. Perform tepid temperature by
VS: Anterior sponge. liberating heat by
Temp: 38.5 hypothalamus conduction and
(Chemical convection.
mediators- 4. Maintain
prostaglandins) adequate fluid 4. To prevent
intake as dehydration; Avoid
fluid overload
tolerated. because of the risk
Increased “set of cerebral edema.
point”
5. Administer 5. Antipyretics
antipyretics as decrease fever
indicated. and lessen brain
Fever
oxygen demand
as fever
increases
cerebral
metabolic
demand