Assessment Nursing Diagnosis Objective Intervention Rationale Evaluation

Subjective
Data:

Init ako
paminaw, gi
hilantan ko ug
lain ako gibati
as verbalized

Objective Data:

Febrile,
T=37.8 C in bo
th axilla;warm
to touchwith
flushing

PR=65 bpm

RR=28cpm

Patient
looks pale and
weak in
appearance

HYPERTHERMIA
R/TINFLAMMATORY
RESPONSEAEBINCREASE
INBODYTEMPERATUR E
GREATER THAN
THE NORMALRANGE,FLUSHEDS
KIN; WARMTO TOUCH
After 2 hours of effective
nursing intervention,
the patients
temperature will
decrease AEB:

Demonstrate
temperature within
normal range, from38.1
C to 36.5C-37.5C

Demonstrate behaviors
to monitor and promote
normothermia.

Skin is cool to touch and
less flushness

Identify underlying
cause/contributing
factors and importance
of treatment, as well
as signs/symptomsrequir
ing further interventions.

Verbalized

understanding of specific
interventions to prevent
hyperthermia

Independent
Monitor core
temperature q 30
mins.

Note presence
or absence of
sweating as body
attempts to increase
heat loss by
evaporation.

Increase oral fluid
intake.

Promote bed rest,
encourage relaxation
skills and diversional
activities.

Provide TSB as
needed

Promote surface
cooling, loosen
clothing and cool
environment

Review specific
risk factors/causes,
signs and symptoms
with the
interventions
Temperature
of 38.9-41.1C
suggest acute
infectious
disease
process.

Evaporation is
decreased by
environmental
factors of high
humidity and
high ambient
temperature as
well as body
factors produci
ng loss of
ability to
sweat.

To support
circulating
volume and
tissue
perfusion.

To reduce
metabolic
demands/oxyg
en
consumption.

Heat is loss by
After 2 hours
of effective nursing
intervention, goal is
met.

Patients temperature
is already in the
normal range; T=37.1
C

Demonstrated behavi
ors to monitor
and promote
normothermia.

Skin is cool, absence
of flushing.

The patient, together
with his significant
other, understands
causes of the disease
and is ready
to practice specific
interventions
to prevent
hyperthermia

required

Discuss importance
of adequate fluid
intake and protein
diet

Collaborative:

Administer medicatio
ns as indicated to
treat underlying
cause, such as:-
Paracetamol
325mg/tab 1 tab q 6

Administer replacem
ent fluids and
electrolytes to
support circulating
volume and tissue
perfusion


evaporation
and conduction
Heat is loss by
convection
radiation and
conduction.

To promote
wellness

To prevent
dehydration

To treat
underlying
causes

To support
circulating
volume and
tissue
perfusion