CUES NURSING ANALYSIS GOAL NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION

Subjective: Hyperthermia Fever is a After 4 hrs. Of After 4 hrs. Of

frequent medical nursing nursing
sign that interventions, the Promote surface To decrease interventions, the
describes an patient will cooling by means temperature by patient was able
The client of tepid sponge means through
increase in maintain core maintain core
verbalized: bath. evaporation and
internal body temperature temperature
temperature to within normal conduction. within normal
“Mainit ang
pakiramdam ko” levels above range. range.
normal. Fever is
most accurately
characterized as
“Panagtlong araw a temporary To minimize
na ako nilalagnat elevation in the Wrap extremities shivering.
eh” body's with cotton
thermoregulatory blankets.
set-point, usually
by about 1–2 °C
(1.8-3.6 °F).

Fever is caused Provide To offset

Objective: by an elevation supplemental increased oxygen
in the oxygen. demands and
thermoregulatory consumption.
set-point, causing
Flushed skin
typical body
warm to touch. temperature
(generally and
Restless problematically
To facilitate fast
considered to be Administer
Diaphoretic recovery.
37 °C or 98.6 °F) antipyretics
to rise, and orally or rectally
Chills
effector as prescribed by
 mechanisms are the physician.
enacted as a
result. A feverish
individual has a
Measurement: Monitor Vital
general feeling of
signs
BP : 110/70 cold despite an To monitor the
increased body increase and
T : 38.5 oC temperature, and decreases in
increases in temperature.
heart rate,
muscle tone and
shivering, all of
which are caused
by the body's
attempts to
counteract the
newly perceived
hypothermia and
reach the new
thermoregulatory
set-point.
 CUES NURSING ANALYSIS GOAL NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTIO
N

Subjective: Decreased Constriction of At the end of Measure and Provides At the end of
tissue perfusion the peripheral the shift, the recorded blood objective data the shift, the
related to blood vessels client will pressure. for monitoring. client was able
peripheral will alter the maintain a to maintain a
The client
vasoconstriction flow of blood to blood pressure blood pressure
verbalized:
as manifested perfuse the within the within the
“matagal ng by high blood different cells of normal range normal range
mataas ang pressure. the body. Observed skin Presence of
presyon ng color, moisture, pallor: cool,
dugo ko.” temperature, moist skin; and
and capillary delays capillary
refill time. refill time may
be due to
“wala naman
peripheral
ako iniinum na
vasoconstriction
mga gamot
.
para bumababa
yung bp ko”

Reduces
Provided calm, physical stress
Objective:
restful and tension that
surroundings, affect blood
minimize pressure and
Cold clammy environmental the course of
skin activity/noise. hypertension.
Limit the
number of
Decreased visitors and
capillary refill length of stay.
Measurement:

BP : 160/100 Maintain activity Decreases

mmHg restrictions; discomfort and
such as bed may reduce
rest/chair rest; sympathetic
schedule stimulation
periods of
uninterrupted
rest; assisted
client with self-
care activities
as needed.

Administered
antihypertensiv
e medications
as prescribed Antihypertensiv
e medications
play a key role
in treatment of
hypertension
associated with
chronic renal
failure.

Encouraged Adherence to
compliance with diet and fluid
dietary and fluid restrictions and
restriction dialysis
therapy schedule
prevents excess
fluid and
sodium
accumulation