Nursing Analysis Goal and Interventions Rationale Evaluation

Diagnosis/ Objectives
Cues
ONGOING
ASSESSMENT
ONGOING
ASSESSMENT
Goal:
Goal: After 1
Hyperther Increase in the After 1 hour hour of
mia related temperature results in of nursing nursing
to infection. response to the intervention interventio
infectious process s, the client ns, the
experienced by the body. will be able client was
to have able to
SCIENTIFIC: body have body
temperature temperature
Cues: Stimulation of the at normal at normal
thermoregulatory center range. range.
in the hypothalamus by
Objective:
endogenous pyrogens Objectives: Objectives:
- Skin feels resulting to the increase After 1 hour After 1
warm to temperature in the body. of nursing hour of
touch intervention nursing
IMMEDIATE CAUSE: , the client interventio
- Client will be able Provide tepid TSB helps in n, the
wrapped Different mechanisms to: sponge bath lowering the client was
on blanket occur in response to
(TSB) body be able to:
interruption of the
temperature
normal processes of the Lower body
September and
body. Increase in temperatur Lower body
22 2010 alcohol cools
temperature or e by temperatur
VS as taken the
Hyperthermia is the enhancing e by
and skin too
body’s way to defend heat loss by enhancing
recorded: rapidly,
T – 38.9 c itself with the evaporation heat loss
causing
RR – 26 bcm interruption.
and by
shivering.
PR – 130 INTERMEDIATE CAUSE: conduction. Shivering evaporatio
bpm increases n and
Infection is one of the metabolic conduction.
causes of hyperthermia. rate and
High body temperatures Promote bed body
signal infection-fighting rest. temperature
cells of the immune
system such as Resting will
phagocytes, neutrophils, reduce body
and lymphocytes to Provide cool heat
production.
defend and help fight off circulating
infections. air using
a fan. Circulation Maintain a
ROOT CAUSE: well
of air may
Maintain a promote ventilated
 Infection
well clear area.
- URTI ventilated flow of air in
area. the
Reference: patient’s
Promote area. One
http://bodyandhealth.can ventilation of way of
ada.com/ skin by promoting
means of heat loss. Provide
http://www.docstoc.com undressing . comfort
These
decrease
Provide warmth and
comfort Assist increase
patient in evaporative
changing cooling.
into dry
clothing.
 Dry clothing
increases
Monitor vital client’s
signs comfort.
especially
temperature.

Vital signs
Maintain provide
body more
temperatur accurate
e at normal indication
range of core
temperature.
To know the
effectivenes
s of
nursing
THERAPEUTI intervention
C s done
INTERVENTIO and to know
NS the
progress of
Immediate patient’s
response to condition.
fever.

Prompt
responses to
complaints
may result in
 decreased
anxiety in
the patient.
Demonstrate
d concern
Notify for patient’s
physician if welfare and
interventions comfort
are fosters the
unsuccessful development
. of a trusting
relationship.

Patients who
request pain
medications
at more
frequent
DEPENDENT intervals
INTERVENTIO than
NS prescribed
may actually
Give require
antipyretics higher doses
as ordered, or more
evaluating potent
effectiveness analgesics.
and
observing for
any signs
and These drugs
symptoms of inhibit the
untoward prostaglandi
effects. n that
serve as
mediators
of pain and
fever.

TEACHING
POINTS

Explain
cause of
fever, if
known.
Provide
instructions Teaching the
and Support
appropriate system the
interventions right way to
do
TSB will help
in
knowing
what to
do in case
the
patient’s
temperature
increase
Sources:
Medical-
Surgical
Nursing by
Joyce Black

Doenges, M.
E.,
Moorhouse,
M. F., &
Murr, A.
(2008).
Nurse's
Pocket
Guide (11
ed.). F. A
Davis
Company.