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Ncp. Hyper

The patient presented with hyperthermia related to increased metabolic rate and dehydration as evidenced by an elevated body temperature of 39°C. The short term goal was to reduce the patient's temperature to 38°C within 30 minutes using a tepid sponge bath. The long term goal was to reduce the temperature to the normal range of 37.5-39°C within 4 hours through monitoring vital signs, fluid intake/output, neurologic status and administering antipyretics and IV fluids as ordered.

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184 views2 pages

Ncp. Hyper

The patient presented with hyperthermia related to increased metabolic rate and dehydration as evidenced by an elevated body temperature of 39°C. The short term goal was to reduce the patient's temperature to 38°C within 30 minutes using a tepid sponge bath. The long term goal was to reduce the temperature to the normal range of 37.5-39°C within 4 hours through monitoring vital signs, fluid intake/output, neurologic status and administering antipyretics and IV fluids as ordered.

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Zmia
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ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Hyperthermia Actual or potential tissue Short Term INDEPENDENT: Short term goal:
Subjective related to damage Objective Applied tepid sponge To decrease warmth Goal met.
Cues increased bath.
“ Mainit pa rin po metabolic increase pressure Within 30 minutes Encouraged increase fluid To decrease warmth and Within 30 minutes of
yung rate and of nursing intake promote hydration nursing intervention the
pakiramdam ko dehydration Increase metabolic rate intervention , the client’s body temperature
at palagi po as evidenced client’s body Monitored vital signs To obtain baseline and was decreased from 39 to
akong by elevated Insufficient fluid temperature will be compare the following 38 ℃
nauuhaw.” body reduced from 39 to data.
- as verbalized temperature. Vasoconstriction of 38 degree Celcius Monitored core For most closely
by the patient blood vessel temperature approximate core Long term goal:
temperature; Rectal and Goal met.
Failure to Long Term tympanic temperatures
Objective thermoregulation Objective Assessed neurologic Within 4 hours of nursing
Cues response, noting level of To watch out for seizures intervention temperature
Elevated body Within 4 hours of consciousness and was within normal range
T: 39 ℃ temperature nursing orientation, reaction to To watch out for effects of from 39℃ to 37.5 ℃
Warm to touch intervention the stimuli, reaction to pupils elevated body temperature
Chills client’s to blood and cardiac tissue
Flushed skin temperature will be Monitored heart rate and
within normal rhythm To watch out for potential
range from 39 to fluid and electrolyte losses
37.5 degree Monitored and record To decrease warmth
celcius input and output

Removed excess clothing To decrease warmth and


if patient is feeling chills be comfortable
Encouraged to wear loose
cotton clothes To promote rest and
Encouraged to bed rest decrease fatigue

Provided with warm and To minimize shivering


friendly environment
Documented each and As evidence for legal
every procedure done purposes

DEPENDENT: .
Administered antipyretic To decrease body
(Paracetamol) as ordered temperature
by the physician

Administered IV fluid as To keep the patient


ordered by the doctor. hydrated

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