Assessment Nursing Scientific Planning Nursing Rationale

Diagnosis Explanation Intervention

S= patient may Hyperthermia CAP is the Short Term : > Monitor body core >To have a baselin
verbalize inflammation of the temperature
“Mapali ku lung parenchyma due After 4 hours >Evaporation is
panandman .” to offending of Nursing >Note presence or decreased by
organisms, Interventions, absence of sweating environmental fac
inflammatory lung the patient’s as body attempts to high humidity and
O=Patient response will be body increase heat loss by ambient temperatu
Manifested the stimulated leading to temperature evaporation, well as the body fa
following : the release of will decrease conduction, diffusion producing loss of
chemical mediators from 38oC to to sweat
>flushed skin that would increase 37oC.
blood flow to the >Promote heat los
>skin is warm to lung tissues leading > promote surface radiation, conduct
touch to erythema, cooling by means of evaporation
swelling, pain, and loose clothing; cool
> increased RR increased body Long Term : environment/fan;
temperature that cool/tepid sponge
> Diaphoresis would reset the After 24 hours bath local icepack
hypothalamus which of Nursing especially in the
Patient may is the major center for Interventions, axilla and groin
manifest the regulation of body the patient will
following : temperature maintain a > Review signs and >indicates need fo
normal body symptoms of prompt interventi
>Convulsions temperature hyperthermia
during
> Hypotension
hospitalizations >Encourage the > to increase resis
>Fluid and
and be free patient to take
electrolyte
imbalance from any vitamin C in the diet
complications such as citrus fruits,
of pneumonia. etc.
> To prevent dehy
>Discuss importance
of adequate fluid
intake
>To reduce metab
>Maintain bed rest demands/ oxygen
consumption

>Provide high- > to meet increase

calorie diet metabolic demand

>Provide >To offset increas

supplemental oxygen oxygen demand an
consumption
>administer anti-
pyretics as ordered >To control shiver
seizure