ASSESSMENT

DIAGNOSIS

RATIONALE

GOALS AND OBJECTIVES

INTERVENTION

RATIONALE

EVALUATION

SUBJECTIVE: May lagnat ako ngayon eh as verbalized by the patient OBJECTIVE: Temp: 38.4 Skin is warm to touch Dry Lips Loss of appetite

Hyperthermia related to stimulation of the thermoregulatory center in the hypothalamus by endogenous pyrogens that are released in an inflammatory process as evidenced by the increase in body temp than normal range

Pyrogens are exogenous or endogenous substances that produce fever. Exogenous pyrogens are derived from outside the body and include such substances as bacterial products, bacterial toxins, or whole microorganisms. Exogenous pyrogens induce host cells to produce feverproducing mediators called endogenous pyrogens
Temperature is ultimately regulated in the hypothalamus. A trigger of the fever, called a pyrogen, causes a release of prostaglandin E2(PGE2). PGE2 then in turn acts on the

After 3 hours of nursing intervention the client will -Reach a temperature of 37.5 or lower

-Take temp q1/q4

-To obtain an accurate core temperature -Antipyretics act on hypothalamus to regulate temperature

After of nursing intervention client was able to: - Reach a temperature of 37.4

-Administer antipyretics as ,prescribed, record effectiveness

-experience no associated complications

-Provide tepid sponge baths; avoid use of alcohol

-May help reduce fever .note. use of ice water/ alcohol may cause chills, actually elevating temperature. In addition, alcohol is very drying to the skin

-Experience no associated complications with hyperthermia

The goal was : Met

-Use a hypeothermia blanket if patients temperature rises above 103F. Monitor vital signs every 15minutes for 1 hour and as indicated.

-Shivering increases metabolic rate, increasing temperature.

-Monitor heart rate and rhythm, blood pressure, respiratory rate, LOC and level of

-To evaluate effectiveness of interventions and monitor for