ASSESSMENT
Subjective data:
“Lain kayo akong paminaw
sa akong lawas nurse, sakit
akong ulo unya init kayo
akong lawas” as verbalized
by the patient
objective:
Flushed skin with a body
temperature of 38.1ᴼC per
axilla
Respiratory rate of : 21
breaths per minute
Pulse rate of: 89 beats per
minute
Unstable blood pressure
Muscle rigidity; chills
DIAGNOSIS PLANNING INTERVENTION EVALUATION
Hyperthermia related to After 4 hrs of nursing Assess and monitor The patient s body
intervention the patient client’s temperature and temperature is at normal
Inability or decreased will: note for presence of chills/ range 37.2 C
ability to perspire profuse diaphoresis; also
Patient maintains body note for degree and The patients skin return in
temperature below 39° C pattern of occurrence. normal shape at 3
(102.2° F) R- Temperature 38.9ᴼC – seconds.
41ᴼC may suggest acute
infectious disease process. “Nurse, dili na kayo luya
Patient’s skin turgor will A sustained fever may be akong gibati” as verbalized
be less than 5 seconds due to pneumonia or by the patient
within 24 hours of typhoid fever while a
hospitalization. remittent fever may be Goal met.
due to pulmonary
Patient will report increase infections; and an
in energy within 72 hours intermittent fever may be
of hospitalization. caused by sepsis or
tuberculosis.
Adjust and monitor
environmental factors like
room temperature and
bed linens as indicated
r- Room temperature may
be accustomed to near
normal body temperature
and blankets and linens
may be adjusted as
indicated to regulate
temperature of client
Apply tipid sponge bath
sponge bath, Giving a
Patient a Bed Bath
r-It could help in reducing
hyperthermia; avoid using
alcohol and iced water
which may even produce
chills and increase client’s
temperature.

Encourage the client to

increase fluid intake.
R- Water regulates body
temperature.

Educate client of signs and

symptoms of
hyperthermia and help
him identify factors
related to the occurrence
of fever; discuss the
importance of increased
fluid intake to avoid
dehydration.
R-Providing health
teachings to client could
help client cope with
disease condition and
could help prevent further
complications of
hyperthermia
GENERIC BRAND CLASSIFICATION INDICATION MECHANISM DOSAGE AND ADVERSE EFFECT NURSING
NAME NAME OF ACTION FREQUENCY CONSIDERATION
Ceftriaxone Rocephin Ceftriaxone is Susceptible Ceftriaxone 2g IVTT Q rash. bloody, or watery Assess patient’s
used to treat a bacterial works by 12hrs ANST stools, stomach previous sensitivity
wide variety of infections of inhibiting the cramps, or fever during reaction to penicillin
bacterial the lower mucopeptide treatment or for up to or other
infections. This respiratory synthesis in two or more months cephalosphorins.
medication tract, skin and the bacterial after stopping
belongs to a skin structure, cell wall. The treatment. stomach Assess patient for
class of drugs bone and beta-lactam tenderness, pain or signs and symptoms of
known joint, acute moiety of bloating. nausea and infection before and
as cephalospori otitis media, ceftriaxone vomiting. during the treatment.
n antibiotics. UTIs, binds to
septicemia, carboxypeptid Watch for seizures;
pelvic ases, notify physician
inflammatory endopeptidas immediately if patient
disease (PID), es, and develops or increases
intraabdomin transpeptidas seizure activity.
al infections, es in the
meningitis, bacterial Monitor signs of
uncomplicate cytoplasmic pseudomembranous
d gonorrhea. membrane. colitis, including
These diarrhea, abdominal
enzymes are pain, fever, pus or
involved in mucus in stools, and
cell-wall other severe or
synthesis and prolonged GI
cell division. problems (nausea,
vomiting, heartburn).