ASSESMENT NURSING SCIENTIFIC PLANNING NURSING RATIONALE OF THE EVALUATION

DIAGNOSIS EXPLANATION INTERVENTION NURSING ACTION

Subjective Data: Short Term: Independent: Short Term:

 “Ilang araw ng HYPERTHERMIA ENTRY OF PATHOGENS After 2 hours of nursing  Monitor core  Temperature of 38.9- After 2 hours of
nilalagnat ang anak R/T IN THE SYSTEMIC intervention, the patient’s temperature q 1 °. 41.1°C suggest acute effective nursing
ko, hindi maganda INFLAMMATOR CIRCULATION temperature will decrease infectious disease intervention, goal is
ang pakiramdam Y RESPONSE AS from 39.8C to 37.5C process. met.
nya kaya pinunta ko EVIDENCE BY
na siya dito” as INCREASE IN Long Term:  Note presence or  Evaporation is  Patient’s
verbalized by the BODY REGULATION OF TOXINS absence of sweating decreased by temperature is
After 4-6 hours of nursing already in the normal
mother TEMPERATURE IN THE BODY as body attempts to environmental
intervention the patient’s range; T=37.5°C
GREATER THAN increase heat loss by factors of high
Objective Data: vital sign will return to
THE NORMAL evaporation. humidity and high
normal range with a  Skin is cool, absence
RANGE, ambient temperature
 Eyes were RELEASE OF PYROGEN temperature of 36.5C- of flushing.
FLUSHED SKIN; as well as body
sunken and 37.5C.
WARM TO factors producing loss
jaundice
TOUCH of ability to sweat.
 Depressed level Long Term:
of STIMULATION OF THE
 Increase oral fluid  To support After 4-6 hours of
consciousness HYPOTHALAMUS
intake. circulating volume nursing intervention
 Lethargy
and tissue perfusion. the patient’s vital signs
 Dehydrated
 To reduce metabolic returned to normal
 Patient looks
INCREASE OR demands/oxygen range with a
pale and weak
ALTERATION OF consumption. temperature of 37.2C
in appearance
THERMOREGULATION
Vital signs taken as  Promote bed rest,
follow: encourage relaxation
skills and diversional
 Febrile, T= INCREASE IN BODY activities.
39.8 °C in both TEMPERATURE
axilla; warm to  Provide TSB as  Heat is loss by
touch with flushing needed evaporation and
conduction.
 PR=95 bpm
 Promote surface  Heat is loss by
 RR=34cpm
cooling, loosen convection, radiation
clothing and cool and conduction.
HYPERTHERMIA
environment

 Review specific risk

factors/causes, signs  To promote wellness
and symptoms with
the interventions
required