DATE: July 17, 2009 TIME: 10:15am

ASSESSMENT: Received pt lying on bed, conscious and coherent, with ongoing IVF of D5LR at 660cc level in 40gtts/min regulation intact and infusing well on the left arm.

CUES NX DIAGNOSIS SCI-EXP PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: @ Fever r/t increase Lipopolysaccharides After 30min to 1hr > Monitored vs >For baseline data After 30min to
pyrogens associated LPS (exogenous of nursing > Provided TSB > To lessen fever -1hr of nursing
Objective: with increase in pyrogens) intervention the pt > Encouraged pt to > to facilitate heat loss intervention the pt
> teary eyes lymhocytes as to ↓ will be able lessen loosen clothes by convection will be able to
>dry mucous immunoresponse LPS binds to her fever > Encouraged pt to drink >H20 plays an lessen her fever as
membrane Lipopolysaccharide- lots of h2o 1-2L/day if important role in evidenced by:
>flashy face binding protein LBS tolerated maintaining the > Temp from 38 to
> warm to touch ↓ homeostasis of heat 37.4
>Temp: 38 LPS-LBP complex >Applied moisturizer > to prevent mucous
binds to such as cotton with h2o breakdown resulting to
Laboratory macrophage on lips bleeding tendencies
Analysis: receptors > Removed blankets > to facilitate heat loss
>Lymphocytes: ↓ through convection
Increased Release of > Changed position q2hrs > to facilitate heat loss
Interleukin 1 and 6 at the back
(endogenous > Put pillows along the > This areas are highly
pyrogens) axilla and inguinal area warm and needs to
↓ lessen heat by not
Activate touching both skin to
arachidonic lessen heat
pathway > Encouraged pt to > to prevent pulmonary
↓ change clothes when effectation
Release of moistened
Prostaglandin E2 > Provided cooling > to lessen heat thereby
(PGE2) techniques such as light- minimizing fever
↓ cold blankets
Initiates > Encouraged pt to eat > Immunoboosters
hypothalamus foods rich in Vit C such
↓ as pineapple, grapes juice
Generates sytem without artificial color
response > Administered
↓ Paracetamol 1amp IV > Antipyretic
fever q6hrs