ASSESSMENT Subjective Nurse, parang mainit ung nanay ko as verbalized by the relative of the patient. Objective Temperature: 38.

.6C RR: 26cycle per minute Hot, flushed skin Increased respiratory rate Diaphoresis Warm to touch

NURSING DIAGNOSIS

PLANNING

NURSING INTERVENTION Independent 1. Monitor vital signs.

RATIONALE

Evaluation Short Term After 1 hour of appropriate nursing intervention the patients temperature decreased to 37.5oC. Long Term After 4 hours of appropriate nursing intervention the patients vital signsl return to normal range; with a temperature of 36.537.5oC,pulse rate of 60-100bpm and respiratory rate of 12-20 cycles per min.

Hyperthermia Short Term related to bacterial After 1 hour of infection. appropriate nursing Definition: intervention the Body temperature patients elevated above temperature will normal range. decrease to 37.5oC.

TSB helps in lowering the body Long Term temperature and After 4 hours of alcohol cools the appropriate skin too rapidly, nursing causing intervention the shivering. patients vital Shivering signs will return to increases normal range; with metabolic rate a temperature of 3. Remove excess and body 36.5-37.5oC,pulse clothing and temperature rate of 60-100bpm covers. and respiratory These decrease rate of 12-20 warmth and cycles per min. increase 4. Promote a wellevaporative ventilated area cooling. to patient. To promote clear flow of air in the patients area. One way of promoting heat loss. Additional fluids help prevent elevated temperature associated with

2. Provide tepid sponge bath. Do not use alcohol.

Vital signs provide more accurate indication of core temperature.

5. Advise patient to increase oral fluid intake.

6. Maintain bed rest.

ASSESSMENT

NURSING DIAGNOSIS
Hyperthermia related to dehydration

PLANNING

NURSING INTERVENTIONS
Independent: Monitor heart rate and rhythm.

RATIONALE

EVALUATION

Subjective: Mainit ang pakiramdam ko as verbalized by the patient. Objective: Flushed skin, warm to touch. Restlessness . V/S taken as follows: T: 38.1 P: 70 R: 19 BP: 110/90

After 4 hrs. Of nursing interventions, the patient will maintain core temperature within normal range.

Record all sources of fluid loss such as urine, vomiting and diarrhea. Promote surface cooling by means of

Dysrhythmias and ECG changes are common due to electrolyte imbalance and dehydration and direct effect of hyperthermia on blood and cardiac tissues. To monitor or potentiates fluid and electrolyte loses. To decrease temperature by means

After 4 hrs. Of nursing intervention s, the patient was able maintain core temperature within normal range.

tepid sponge bath.

through evaporation and conduction. To minimize shivering. To offset increased oxygen demands and Consumption. To support circulating volume and tissue perfusion. To reduce metabolic demands and oxygen consumption To increased metabolic demands. To facilitate fast recovery

Wrap extremities with cotton blankets. Provide supplemental oxygen.

Administer replacement fluids and electrolytes. Maintain bed rest. Provide high calorie diet, tube feedings, or parenteral nutrition. Administer antipyretics orally or rectally as prescribed by the physician.

ASSESSTMENT

NURSING DAIGNOSIS

PLANNING

NURSING INTERVENTION

RATIONALE

eVALUATION

Subjective: Parang mainit ang pakiramdam ko as verbalized by the patient. Objectives: BP- 120/80mmhg PR- 90bpm RR19cpm Pallor

Increased risk of infection related to post CS as manifested by increased body temperature.

After 8 hours of nursing intervention the patients body temperature will become stable.

Establish rapport Perform TSB Provide health teaching such as:

To promote trust. To minimize body temperature.

After 8 hours of nursing intervention the patients body temperature become stable.

1. avoid evcessive 1. to give comport clothing that to the patient covers the and feel more body. comfortable. 2. maintain proper 2. To avoid hygiene infection