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    Ncp. Hyper

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    Zmia
    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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    Ncp. Hyper

    Uploaded by

    Zmia
    148 views2 pages
    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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    ncp. hyper

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    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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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    148 views2 pages

    Ncp. Hyper

    Uploaded by

    Zmia
    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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    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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