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NURSING DIAGNOSIS #2 _ Hyperthermia related to: Inflammation/infection of epiglotis as evidence by increase in body

temperature higher than normal range

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GOALS- NURSING INTERVENTIONS SCIENTIFIC EVALUATION


EXPECTED (Independent, dependent, collaborative) RATIONALE (Include revisions)
OUTCOMES (For each intervention-use
(Short-term/long- citations)
term goals specific
with time frames)
Independent Temperature of 102 F Return of body temperature to
Demonstrate Monitor client temperaturedegree and to106 F (38.9 C41.1 C) 97.0 C
temperature within pattern. Note shaking suggests acute infectious
normal range and be chills or profuse diaphoresis. disease process.
free of chills whint
the next 48 hours.

Monitor environmental temperature. Limit Room temperature and Return of body temperature to
or add bed linens, as indicated. linens should be altered to 97.0 C
maintain near-normal body
temperature.

Provide tepid sponge baths. Avoid use of Tepid sponge baths may Body temperature is less than
alcohol. help reduce fever. Note: 98.0 C
Use of ice water or alcohol
may cause chills, actually
elevating temperature.
Alcohol can also cause
skin dehydration.

Collaborative Antipyretics reduce fever Patient is free of fever


Administer antipyretics, such as by its central action on the
acetylsalicylic acid (ASA) (aspirin) or hypothal- amus; fever
acetaminophen (Tylenol). should be controlled in
clients who are neu-
tropenic or asplenic.
However, fever may be
beneficial in limiting
growth of organisms and
enhancing autodestruc-
tion of infected cells.

Provide cooling blanket, or hypothermia Used to reduce fever, Patient is free of fever
therapy, as indicated. especially when higher
than 104 F to 105 F (39.5
C40 C), and when
seizures or brain damage
are likely to occur.

Teach parents to take oral and axillary Allows parents to monitor Parents ar able to take childs
temperature and allow for return temperature temperature correctly.
demonstration; instruct in use of digital for elevation when child
thermometers and plastic strips. feels warm.