Assessment Diagnose Planning Intervention Rationale Evaluation

Objectives: Hyperthermia Short term: Independent: 1. Vital signs After 1 hour of

-Flushed skin related to bacterial After 1 hour 1.Monitor vital provide intervention the
-Increase infection as of signs more patient
respiratory manifested by intervention accurate temperature
rate flushed skin, the patient’s indication of decreased from
-Diaphoresis increase temperature core 38.6c to 37.5c as
-Warm to respiratory rate 0f will decrease evidenced by
temperature
touch 26cpm,diaphoresis, from 38.6c to decreased
2. TSB help
Warm to touch 37.5c 2. Provide tepid diaphoresis and
Vital signs: with a temperature sponge bath. Do decreased calm breathing
BP-120/90 of 38.6c Long term: not use alcohol the body
PR-72 After 4 hours temperature
RR-26 of and alcohol After 4 hours of
T-38.6 intervention cools the intervention the
the patients skin too patients vital signs
vital signs will rapidly, returned to
return to causing normal range
normal range shivering.
with a Shivering
temperature increases
of 36.5-37.5,
metabolic
pulse rate of
rate and
60-100bpm
and body
respiratory 3. Remove temperature
rate of 12-20 excess clothing 3. These
cycles per and covers decrease
min. warmth and
4.promote well increase
ventilated area evaporative
to patient cooling
4. To promote
clear flow of
air in the
patient’s
area, and
also one way
5. Advise the of promoting
patient to heat loss.
increase fluid 5. Increase
intake fluid intake
help prevent
elevated
temperature
associated
6. Recheck the with
vital signs
dehydration
 6. To ensure
Interdependent: the
Provide effectiveness
antipyretic of
medication as intervention
indicated 7. This drugs
will reduce
the fever