NURSING NURSING

ASSESSMENT PLANNING RATIONALE

DIAGNOSIS INTERVENTION

Subjective Hyperthermia Short Term Independent

”Nurse, parang related to bacterial After 1 hour of 1. Monitor vital Vital signs provide
mainit ung nanay infection. appropriate nursing signs. more accurate
ko” as verbalized by intervention the indication of core
the relative of the Definition: patient’s temperature.
patient. Body temperature temperature will
elevated above decrease to 37.5oC. 2. Provide tepid TSB helps in
Objective normal range. sponge bath. Do lowering the body
 Temperature: Long Term not use alcohol. temperature and
38.6C After 4 hours of alcohol cools the
 RR: 26cycle appropriate nursing skin too rapidly,
per minute intervention the causing shivering.
 patient’s vital signs Shivering
 Hot, flushed will return to increases
skin normal range; with metabolic rate and
 Increased a temperature of body temperature
respiratory rate 36.5-37.5oC,pulse
 Diaphoresis rate of 60-100bpm 3. Remove excess These decrease
and respiratory rate clothing and warmth and
 Warm to touch
of 12-20 cycles per covers. increase
min. evaporative
cooling.

4. Promote a well- To promote clear

ventilated area to flow of air in the
patient. patient’s area. One
way of promoting
 heat loss.

5. Advise patient to
increase oral Additional fluids
fluid intake. help prevent
elevated
temperature
associated with
dehydration.
6. Maintain bed
rest. Reduce metabolic
demands/ oxygen
consumption
7. Provide high-
calorie diet. To meet increased
metabolic
demands.

8. Educate and
advise support Teaching the
system (relative) Support system the
to do TSB when right way to do
patient feels hot. TSB will help in
- Luke warm knowing what to
water only. do in case the
- Make sure that patient’s
armpits and temperature
groins were increases
included in doing
TSB.
9. Monitored VS
and recheck.  To know the
effectiveness of
nursing
interventions
done and to know
the progress of
patient’s
Dependent condition.
10. Provide
antipyretic  These drugs
medications as inhibit the
indicated. prostaglandin
that serve as
mediators of
pain and fever.