Assessment Diagnosis Planning Implementation/Intervention Evaluation

Subjective Data: - Hyperthermia - After 4 hours of Independent: - After 6 hours of

- Patient related to effective nursing - Instructed the patient effective nursing
complained of potential infection intervention, to change into loose intervention,
headache upon process as patient will clothing. patient has been
waking up this manifested by a relieve of fever - Rendered tepid relieved of fever as
morning which recorded with a decrease sponge bath to the manifested by
was accompanied temperature of in temperature patient. patient’s
by body 39.1 C from 39.1 C to - Gave the patient 1 liter statement: “I am
weakness - Acute pain on the 37.5 C. of water to be not chilly anymore”
- Patient started frontal area - After 4 hours of consumed for 3 hours. and patient’s latest
having chills after related to effective nursing temperature is
her first class. potential infection intervention, Dependent: 37.4 C, thus the
- Patient process as patient will - Gave a tablet of goal was met.
Verbalized: “I am manifested by a relieve of Paracetamol (500mg) - After 6 hours of
not feeling well” VAS of 6/10 headache with a as ordered by the effective nursing
decrease in VAS school physician. intervention,
Objective Data: from 6/10 to patient has been
- Temperature: 2/10. Collaborative: relieved of
39.1C - Regulated the clinic’s headache as
- VAS: 6/10 air conditioner as manifested by
- Patient was warm tolerated by the patient’s
to touch patient. statement: “My
headache has
greatly decreased”
and patient’s latest
VAS is 2/10, thus
the goal was met.