ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective Hyperthermia Short term Independent After 1 hour of
”Nurse, parang mainit ung related to After 1 hour of 1. Monitor vital 1.Vital signs
provide more nursing
nanay ko” as verbalized by the bacterial appropriate signs.
accurate indication
relative of the patient. infection as nursing 2. Provide tepid of core
intervention,
manifested by intervention the sponge bath. temperature. the client’s
Objective flushed skin, patient’s Do not use
• Flushed skin increased temperature alcohol. 2.TSB helps in temperature
lowering the body
• Increased respiratory respiratory rate will decrease
decreased from
temperature and
rate of 26cpm, from 38.6C to 3. Remove excess alcohol cools the
• Diaphoresis diaphoresis, 37.5oC. clothing and skin too rapidly, 38.6C to 37.7C
• Warm to touch warm to touch covers. causing shivering.
as evidenced by
with a Long term Shivering increases
temperature of After 4 hours or metabolic rate and decreased
VS: 4. Promote a well- body temperature
-BP: 120/90 38.6C . appropriate ventilated area diaphoresis and
-PR: 72 nursing to patient. 3.These decrease
-RR: 26 intervention the warmth and calm breathing.
-T: 38.6 patient’s vital 5. Advise patient increase
signs will evaporative
to increase oral
cooling.
return to fluid intake. After 4 hours of
normal range 4.To promote clear nursing
with a 6. Maintain bed flow of air in the
temperature of rest. patient’s area. One intervention the
36.5- way of promoting
heat loss. patient’s vital
37.5oC,pulse 7. Provide high-
rate of 60- calorie diet. signs returned to
100bpm and 5.Additional fluids
help prevent
normal range.
respiratory rate
of 12-20 cycles elevated
temperature
per min. 8. Educate and associated with
advise support dehydration.
 system 6.Reduce
(relative) to do metabolic
demands/ oxygen
TSB when consumption
patient feels
hot. 7.To meet
- Luke warm increased
water only. metabolic
demands.
- Make sure
that armpits
and groins were 8.Teaching the
included in Support system the
right way to do
doing TSB.
TSB will help in
knowing what to
9. Monitored VS do in case the
and recheck. patient’s
temperature
Dependent increases
10. Provide 9.To know the
antipyretic effectiveness of
medications as nursing
indicated. interventions done
and to know the
progress of
patient’s
condition.

10.These drugs
inhibit the
prostaglandin that
serve as mediators
of pain and fever.