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Goals and Evaluation of Goals
Planning: Nursing orders with rationales
Nursing diagnosis: Hyperthermia Related to Statement R/t infection AEB increased WBC to 15.3k/ul and temp of 101.3 F. Subjective assessment -Family member c/o: ³my mom been having fever up to 103 F since last night´ Objective assessment Vital Signs: -T: 101.3 F -P: 70 -R: 19 BP: 130/75 WBC: 15.3K/ul Flushed skin and feels warm to touch. Restlessness. System Assessment: Please see the Nurses Notes.
Short term goal #1: After 4 hours, of providing the nursing interventions the patient will have decreased core temperature to at least 99F. 02/01/2011. Evaluation of goal #2: Goal met, By 1200, the patient¶s temperature when down to 98.8 F.
Intervention # 1 Take an oral or axillary temperature every 1 to 4 hours, and 1 hour after administration of antipyretics Rationale To obtain an accurate core temperature and to monitor thermoregulation. Source Sparks and Taylor, Nursing Diagnosis Reference Manual. Pg #: 441 Intervention #2 Administer antipyretics medication as ordered. Rationale Antipyretics act on the hypothalamus to regulate temperature. Source Sparks and Taylor, Nursing Diagnosis Reference Manual. Pg #: 441 Intervention # 3 Remove excess clothing, sheets and blankets and place cool clothes on axillae or groins or tepid water sponges Rationale These nonpharmacological measures reduce body temperature and promote comfort, and tepid water reduces chances of chills or shivering because cold water cause shivering which increases body temperature Source Sparks and Taylor, Nursing Diagnosis Reference Manual. Pg #: 442 Intervention # 4 Monitor heart rate, Blood Pressure, respiratory rate, LOC, responsiveness, and capillary refill every 1-4 hours. Rationale To evaluate effectiveness of interventions and monitor for any complications such as seizures Source Sparks and Taylor, Nursing Diagnosis Reference Manual. Pg #: 442 Intervention # 5
Implementation of Intervention # 1 Took oral temperature every two hours. Evaluation of patient response to intervention -10:00-Temp went down to 99.2 F -12:00- Temp went down to 98.9 Implementation of Intervention # 2: 08:00 administered antipyretic (Tylenol) medication as per Doctor¶s order. Evaluation of patient response to intervention After 1 hour of administering antipyretic the temperature went down to 100.1F. Implementation of Intervention # 3: 10:00Explained to patient about removing extra blanket and clothing, and how sponge with tepid water will lower body temperature. Evaluation of patient response to intervention 10:05 Patient removed extra clothing¶s but refused to put on any cool or tepid water sponge. Implementation of Intervention # 4: 08:00, 10:00, 12:00 Monitored HR, BP, Resp. rate, LOC, and Capillary refill every 2 hours. Evaluation of patient response to intervention The findings were within the normal, and patient was alert and responded. Implementation of Intervention # 5:
Rationale To prevent dehydration Source Sparks and Taylor. Evaluation of patient response to intervention Patient and family were okay to take in fluids.Encourage the patient to drink as much fluids as possible unless contraindicated. such as dehydration and febrile seizures. Source Sparks and Taylor. but had to be careful because the patient was on dialysis therapy. Nursing Diagnosis Reference Manual. Rationale Early recognition and treatment of fever reduces the risk of further complications. . asked the family if they have any more questions. Implementation of Intervention # 6: 12:00 Provided family and patient about what S & S needs to be reported to prevent further complications verbally and written. Evaluation of patient response to intervention To make sure they understand. and explain which signs and symptoms they need to report to a physician. Nursing Diagnosis Reference Manual. Pg #: 442 11:00 Explained to the patient and family how drinking fluids will prevent dehydration. Pg #: 442 Intervention # 6 Describe the complications of fever to the patient and family.