NURSING CARE PLAN ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION Independent: Subjective: • Hyperthermia Infectious agents • After 4 hrs. Of • Monitor heart • Dysrhythmias • After 4 hrs. related to (Pyrogens) nursing rate and and ECG Of nursing “Mainit ang dehydration. stimulate interventions, rhythm. changes are intervention pakiramdam ko” Monocytes the patient will common due s, the as verbalized by maintain core to electrolyte patient was release the patient. temperature imbalance able Pyrogenic cytokines within normal and maintain Objective: stimulate range. dehydration core Anterior hypothalamus and direct temperature • Flushed skin, effect of within results in warm to Elevated thermoregulatory set point hyperthermia normal touch. on blood and range. leads to cardiac • Restlessness Increased Heat conservation tissues. . (Vasoconstriction/behaviour changes) • Record all • To monitor or Increased Heat production sources of fluid potentiates (involuntary muscular contractions) • V/S taken as loss such as fluid and result in urine, vomiting electrolyte follows: FEVER and diarrhea. loses. T: 38.1 • Promote • To decrease P: 70 surface cooling temperature R: 19 by means of by means BP: 110/90 tepid sponge through bath. evaporation and conduction. • Wrap • To minimize extremities with shivering. cotton blankets. • Provide • To offset supplemental increased oxygen. oxygen demands and consumption. • Administer • To support replacement circulating fluids and volume and electrolytes. tissue perfusion. • Maintain bed • To reduce rest. metabolic demands and oxygen consumption • Provide high • To increased calorie diet, metabolic tube feedings, demands. or parenteral nutrition. • Administer • To facilitate antipyretics fast recovery. orally or rectally as prescribed by the physician.
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