hyperthermia ncp

ASSESSMENT

NURSING

PLAN PLANNI NING NG

INTE INTERV RVEN ENTI TION ON

RATI RATION ONAL ALE E

EVAL EVALUA UATI TION ON

DIAGNOSIS

Subjective ”Nurse, parang mainit ung nanay ko” as verbalized by the relative of the patient. Objective Flushed skin • Increased respiratory rate • Diaphoresis • Warm to touch •

VS: -BP: 120/90 -PR: 72 -RR: 26 -T: 38.6

Hyperthermia related to  bacterial infection as manifested by flushed skin, increased respiratory rate of 26cpm, diaphoresis, warm to touch with a temperature of  38.6C .

Short term After 1 hour of  appropriate nursing intervention intervention the  patient’s temperature will decrease from 38.6C to 37.5 oC. Long term After 4 hours or  appropriate nursing intervention intervention the  patient’s vital signs will return to normal range with a temperature of  36.537.5 oC,pulse rate of 60100bpm and respiratory rate of 12-20 cycles  per min.

Independent 1. Monitor Monitor vital vital signs. 2. Provide Provide tepid tepid sponge bath. Do not use alcohol.

3. Remove Remove excess excess clothing and covers.

After 1 hour of  1.Vital signs  provide more accurate indication of core temperature. 2.TSB helps in lowering the body temperature and alcohol cools the skin too rapidly, causing shivering. Shivering increases metabolic rate and  body temperature

4. Promote Promote a wellwellventilated area to patient. 3.These decrease 5. Advise Advise patien patientt to increase oral fluid intake. 6. Maintain Maintain bed rest. 7. Provide Provide highhighcalorie diet.

8. Educate Educate and advise support

warmth and increase evaporative cooling. 4.To promote clear  flow of air in the  patient’s area. One way of promoting heat loss.

nursing intervention, the client’s temperature decreased from 38.6C to 37.7C as evidenced by decreased diaphoresis and calm breathing.

After 4 hours of  nursing intervention intervention the  patient’s vital signs returned to

5.Additional fluids help prevent elevated temperature associated with dehydration.

normal range.

system (relative) to do TSB when  patient feels hot. - Luke warm water only. - Make sure that armpits and groins were included in doing TSB. 9. Monitored VS and recheck. Dependent 10. Provide antipyretic medications as indicated.

6.Reduce metabolic demands/ oxygen consumption 7.To meet increased metabolic demands.

8.Teaching the Support system the right way to do TSB will help in knowing what to do in case the  patient’s temperature increases 9.To know the effectiveness of  nursing interventions done and to know the  progress of   patient’s condition. 10.These drugs inhibit the  prostaglandin that serve as mediators of pain and fever.