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Nursing Background

Assessment Planning Intervention Rationale Evaluation


Diagnosis Knowledge

Hyperthermia The metabolic Short term: Independent: Short-term: Goal met


Subjective:
related to effects of increased
increased levels of thyroid After 2 hours of Monitored vital signs To evaluate degree of After 2 hours of
metabolic rate hormones cause nursing especially temperature. hyperthermia. nursing intervention,
“Pakipatay yung
secondary to clinical symptoms. intervention, the the client:
exhaust fan, mainit disease process Metabolic rate client will: Monitored and recorded To evaluate effects of
increases with heat all sources of fluid loss hyperthermia.  Achieved
kasi...ok lang, TSB
intolerance and  Achi such as urine and noted body
mo ulit ako?,” as hyperthermia. eve body presence of sweating temperature
written by the temperature within normal
within normal Promoted surface cooling To assist with range; 37.5°C
patient. range by means of minimizing measures to reduce
the number of dressing, body temperature with  Demonstrate
 Be providing cool heat loss by radiation, d behaviors to
Objective: able to environment. conduction, and monitor and
demonstrate convection promote
behaviors to normothermia
 Presence of monitor and Rendered continuous To assist with as the client
promote cool sponge bath, measures to reduce participated in
sweating especially in groin and body temperature with
normothermi every
 Flushed skin a axillae. heat loss by intervention and
evaporation and regularly asks
 Palmar Long term: conduction for her
erythema temperature.
Within the shift, Provided supplemental To offset increased
 Warm to the client will: oxygen via mechanical oxygen demands and Long-term: goal met
touch ventilation consumptions
 Maintain Within the shift, the
 V/S: temperature Provided high-caloric To meet increased client:
within normal tube feedings. metabolic demands.
Temp.: 38.2 °C
range  Had a
PR: 110 beats Dependent: maintained
per minute  Be free temperature
of Administered antipyretics, To assist with within normal
BP: 148/85 complication as ordered. measures to reduce range
s such as body temperature
mmHg
dehydration  Was free of
Administered medications To treat underlying complications
such as propylthiouracil, cause, hyperactive such as
as indicated thyroid dehydration