ASSESMENT NURSING SCIENTIFIC NURSING GOAL NURSING RATIONALE OF THE EVALUATION

DIAGNOSIS EXPLANATION INTERVENTION NURSING ACTION

• “Tatlong araw HYPERTHERM ENTRY OF After 2 hours of effective • Monitor core • Temperature of After 2 hours of
ng pabalik- IA R/T PATHOGENS IN THE nursing intervention, the temperature q 1 °. 38.9-41.1°C effective nursing
balik ang INFLAMMATO SYSTEMIC patient’s temperature will suggest acute intervention, goal is
lagnat ng apo RY RESPONSE CIRCULATION decrease AEB: infectious met.
ko, hindi AEB disease process.
maganda ang INCREASE IN • Demonstrate • Note presence or • Patient’s
pakiramdam BODY temperature within absence of sweating • Evaporation is temperature is
nya kaya TEMPERATUR REGULATION OF normal range, from as body attempts to decreased by already in the
pinunta ko na E GREATER TOXINS IN THE 38.1 °C to 36.5°C increase heat loss environmental normal range;
siya dito” THAN THE BODY -37.5°C by evaporation. factors of high T=37.1 °C
AVB the NORMAL humidity and
grandmother. RANGE, • Demonstrate high ambient • Demonstrated
FLUSHED behaviors to temperature as behaviors to
Objective Data: SKIN; WARM RELEASE OF monitor and well as body monitor and
TO TOUCH PYROGEN promote factors promote
• Febrile, T= normothermia. normothermia.
• Increase oral fluid producing loss
38.1 °C in of ability to
• Skin is cool to intake.
both axilla; sweat. • Skin is cool,
warm to touch STIMULATION OF touch and less absence of
with flushing THE flushness
• To support flushing.
HYPOTHALAMUS
• PR=65 bpm • Identify underlying circulating
volume and
cause/contributing
• RR=28cpm factors and • Promote bed rest, tissue perfusion.
importance of encourage • To reduce
INCREASE OR • The patient,
• Patient looks ALTERATION OF treatment, as well relaxation skills and metabolic
together with
pale and weak THERMOREGULATIO as signs/symptoms diversional demands/oxygen
his significant
in appearance N requiring further activities. consumption.
others
interventions. understands
• Provide TSB as causes of the
• Verbalized needed disease and is
INCREASE IN BODY ready to
TEMPERATURE • understanding of practice
specific • Promote specific
interventions to surface cooling, • Heat is loss by interventions to
prevent loosen clothing evaporation and prevent
hyperthermia and cool conduction. hyperthermia.
environment
• Heat is loss by
• Review specific convection,
 risk radiation and
HYPERTHERMIA factors/causes, conduction.
signs and
symptoms with
the
interventions • To promote
required wellness

• Discuss
importance of
adequate fluid
intake and • To prevent
protein diet dehydration

Collaborative:
• Administer
medications as
indicated to • To treat
treat underlying underlying
cause, such as: causes
-Paracetamol
325mg/tab 1 tab q 6°

• Administer
replacement
fluids and
electrolytes to
• To support
support
circulating
circulating
volume and
volume and
tissue perfusion.
tissue perfusion