A 3-month-old child presents to the emergency room with her mother.

The mother reports that the baby is not acting

like herself and she is having a hard time arousing the baby. Upon inspection the baby is wrapped in blankets in her
car seat sleeping. The nurse unwraps the baby and feels heat radiating off the child.
The vital signs are as follows: Temp 104°F Rectally HR 150 bpm RR 32 bpm SpO2 99% BP 66/32 mmHg (54
MAP)
Assessment Diagnosis Goal Nursing Rationale Evaluation
Interventions
S: The Hyperthermia After 2 hours  Monitor  Enhances  After 2 hours
mother related to of nurse vital signs heat loss by of nurse
reports that exposure to interventions every 1 means of interventions
the baby is hot the baby’s hour. evaporation the baby’s
not acting environment. fever will  Promote and fever will
like herself subside and surface conduction subside and
and she is decrease its cooling  To assist in decrease its
having a temperature environment creating an temperature
hard time from 40 by means of accurate from 40
arousing the degrees tepid sponge diagnosis and degrees
baby Celsius to 37 bath using monitor Celsius to 37
degrees lukewarm effectiveness degrees
O: Temp Celsius. water. of medical Celsius.
104°F  Remove treatment,
Rectally excessive particularly
HR 150 clothing, the
bpm RR 32 blankets antibiotics
bpm SpO2 and linens. and fever-
99% BP  Administer reducing
66/32 the drugs
mmHg (54 prescribed administered.
MAP) antibiotic/  To regulate
antiviral or the
antiparasitic temperature
and anti- of the
pyretic
environment
medications
and make it
.
more
comfortable
for the
patient.
 To facilitate
the body in
cooling down
and provide
comfort.