CUES

NURSING
DIAGNOSIS

SCIENTIFIC
RATIONALE

Subjective:
May haranat niya as
verbalized by the
patients mother.

Thermoregulation
ineffective related to
disease process
(presence of bacterial
infection) as
manifested by elevated
temperature.

Pyrogens cause a rise

in body temperature; it
also acts as an antigen
triggering immune
system responses. The
hypothalamus reacts to
raise the set point and
the body responds by
producing heat.

Objective:
- Flushed skin
- WBC count:
24.3x10^10g/L
- Hematocrit: 0.64 L/L
- Hemoglobin: 206 g/L
Vital Signs:
HR: 153 bpm
RR: 63 cpm
Temp: 38.3c
Wt.: 2.3 Kg

GOAL

Long-term:
After 2 weeks of
interventions, the
Newborn will be able
to sustain normal selfthermoregulation.

Short term:
After 4 hours of
comprehensive nursing
intervention, the
newborns temperature
will lower down to
normal levels: 36.5c
37.5c.

INTERVENTION
PLAN

INDEPENDENT:
1. Provide tepid
sponge bath
2. Assess fluid
loss and
facilitate oral
intake.

RATIONALE

- enhances heat loss by

evaporating and
conduction.
- Increases metabolic

- reduces body heat

4. Promote cool
circulating air
using a fan.

- dissipates heat by
convection.

5. Monitor vital
signs.

-Notes progress and

changes of condition.

production

-prevents dehydration

- reduces fever

-treats underlying
cause

COLLABORATIVE:

Monitor hematologic
test and other pertinent

Long-term:
After 2 weeks of
interventions, the
Newborn have been
able to sustain normal
self-thermoregulation.

rate and diaphoresis.

3. Promote bed
rest.

DEPENDENT:
1. Maintain IV fluids
as ordered by the
physician.
2. Administer
antipyretic as
ordered.
3. Administer
antibiotic as
ordered.

EVALUATION

-indicates presence of

Short term:
After 4 hours of
comprehensive nursing
intervention, the
newborns temperature
has lower down to
normal levels: 36.5c
37.5c.

lab records.

PATIENTS NAME: DELUTE, CHLOE LIANNE

infection and
dehydration.

STUDENTs NAME: NEW CHUA, CEASAR JAY T.