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ASSESSMENTNURSING

DIAGNOSISPLANNING

NURSINGINTERVENTION

RATIONALEEvaluation

SubjectiveNurse, parangmainit ung nanayko as verbalizedby the relative ofthe patient.

Objective

Temperature:

38.6C

RR: 26cycle

per minute

Hot, flushed

skin

Increased

respiratoryrate

Diaphoresis

Warm to

touch

Hyperthermiarelated to bacterialinfection.

Definition:Body temperature

elevated abovenormal range.

Short TermAfter 1 hour ofappropriatenursingintervention thepatients

temperature willdecrease to37.5oC.

Long TermAfter 4 hours ofappropriatenursingintervention thepatients vital

signs will return tonormal range; witha temperature of36.5-37.5oC,pulserate of 60-100bpmand respiratoryrate of 12-20cycles per min.

Independent1. Monitor vital

signs.

2. Provide tepidsponge bath.Do not usealcohol.

3. Remove excessclothing andcovers.

4. Promote a well-ventilated area

to patient.

5. Advise patientto increase oralfluid intake.

6. Maintain bedrest.

Vital signs

provide moreaccurateindication of coretemperature.

TSB helps in

lowering thebodytemperature andalcohol cools theskin too rapidly,causingshivering.Shivering

increasesmetabolic rateand bodytemperature

These decrease

warmth andincreaseevaporativecooling.

To promote clear

flow of air in thepatients area.One way ofpromoting heatloss.

Additional fluids

help preventelevatedtemperatureassociated with

Short TermAfter 1 hour ofappropriatenursingintervention thepatients

temperaturedecreased to37.5oC.

Long TermAfter 4 hours ofappropriatenursingintervention thepatients vital

signsl return tonormal range;with atemperature of36.5-37.5oC,pulse rateof 60-100bpmand respiratoryrate of 12-20cycles per min.

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ASSESSMENT NURSING

DIAGNOSIS

PLANNING NURSING

INTERVENTIONS

RATIONALE EVALUATION

Subjective:Mainit angpakiramdam koas verbalized by

the patient.Objective:

Flushed skin,

warm totouch.

Restlessness

.

V/S taken as

follows:T: 38.1P: 70R: 19BP: 110/90

Hyperthermiarelated todehydration

After 4 hrs. Ofnursinginterventions,the patient will

maintain coretemperaturewithin normalrange.

Independent:

Monitor heart

rate andrhythm.

Record allsources of fluidloss such asurine, vomitingand diarrhea.

Promote

surface coolingby means of

Dysrhythmiasand ECGchanges are

common dueto electrolyteimbalanceanddehydrationand directeffect ofhyperthermiaon blood andcardiactissues.

To monitor orpotentiatesfluid andelectrolyteloses.

To decrease

temperatureby means

After 4 hrs.Of nursinginterventions, the

patient wasablemaintaincoretemperaturewithinnormalrange.

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tepid spongebath.

Wrap

extremities withcotton blankets.

Provide

supplementaloxygen.

Administer

replacement fluids

and electrolytes.

Maintain bed

rest.

Provide high

calorie diet,tube feedings,or parenteral

nutrition.Administer

antipyreticsorally or rectallyas prescribedby thephysician.

throughevaporationand

conduction.

To minimize

shivering.

To offset

increasedoxygendemands andConsumption.

To supportcirculatingvolume andtissueperfusion.

To reduce

metabolicdemands andoxygenconsumption

To increased

metabolicdemands.

To facilitate

fast recovery

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ASSESSTMENT NURSING

DAIGNOSIS

PLANNING NURSING

INTERVENTION

RATIONALE eVALUATION

Subjective:

Parang mainit

ang pakiramdam

ko as verbalizedby the patient.

Objectives:

BP- 120/80mmhg

PR- 90bpm

RR19cpm

Pallor

Increased risk of

infection related to

post CS as

manifested by

increased bodytemperature.

After 8 hours of

nursing

intervention the

patients body

temperature willbecome stable.

Establish rapport

Perform TSB

Provide healthteaching such as:

1. avoid evcessive

clothing that

covers the

body.

2. maintain proper

hygiene

To promote

trust.

To minimize

bodytemperature.

1. to give comport

to the patient

and feel more

comfortable.

2. To avoid

infection

After 8 hours of

nursing

intervention the

patients body

temperaturebecome stable.

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