Assessment S- Mainit ang pakiramdam ko O- Temp.-38.

5 BP- 110/ 70 PR- 106 RR- 24 >flushed skin and warm to touch

Nursing Diagnosis Hyperthermia r/t infection process Scientific basis: Pyrogens cause a rise in the body temperature,it also acts as an antigen triggering immune system responses. The hypothalamus reacts to raise the set point and the body respond by producing heat

Nursing goal After 2 hours of nursing intervention the patient temperature will lower down to normal levels : Temp.-36.5- 37.5 C

Nursing intervention Independent: >provide TSB

Rationale

>enhances heat loss by evaporation and conduction >Assess fluid loss > increases and facilitate oral metabolic rate and intake diaphoresis >Promote bed rest > reduces body heat production >Be free of >Provide > dissipates heat by dehydration circulating air using convection >Maintain normal fan vital signs at >assisting patient in >increases comfort normal levels changing into dry clothing > Be alert and >Provide oral > Prevents herpetic responsive hygiene lesions of the mouth >Be comfortable in >monitor vital >Notes progress bed signs and changes of condition Dependent: >Maintain body >Prevents fluids as ordered by dehydration physicians >Administer anti>Reduces fever pyretic as ordered >Administer >Treats underlying antibiotic as cause

Outcome Evaluation After 2 hours of nursing interventions the patient will: > Maintain normal temperature of 37.5 C

ordered

HYPERTHERMIA-NURSING CARE PLAN Assessment Subjective: May manifest: Irritability Weakness Objective: The patient may manifest one or more of the following:

NursingDiagnosis Hyperthermiarelated to inflammatoryprocess/ hypermetabolic state as evidenced by an increase in bodytemperature, warm skinand tachycardia

Planning Short-term:After 30 minutes of nursingintervention the patient will maintain normal core temperature as evidenced by vitalsigns within normal limits and normal WBC level

Intervention

Rationale

Temperature above normal level (36 oC) Skin warm to touch Presence of tachycardia (above 160 bpm) Presence of tachypnea (above 60 bpm) WBC elevated

Independent1. 1. To determine Monitorneonates the need for condition. interventionand the effectiveness of therapy.2. 2. To have a MonitorVitalsigns baseline data 3. Provide TSB 3. Helps in lowering down Interdependent the temperature Long Term: 4. Ensure that all 4. this would equipment used for After 3 days of NI, infant is sterile, prevent the pt will still spread of scrupulously clean. maintain normal pathogens to the Do not share core temperature as equipment with other infant from evidenced by equipment infants normal vitalsignsand 5. aids in Dependent normal laboratory lowering down results. temperature 5. Administer Anti-pyretics as ordered

Expected Outcome The patient shall maintain normal core temperature as evidenced by normal vitalsignsand normal laboratory results.