ASSESSMENT NURSING INFERENCE OBJECTIVES NURSING RATIONALE EVALUATION

INTERVENTIONS
DIAGNOSIS
Subjective: Hypertermia Hypothalamus is After 30 mins. of  Identified  To obtain After 30 mins on
“Opo nilalagnat anak ko. related to the nursing underlying factors of effective nursing
Mainit po cia” as increase thermoregulatio intervention the factors that may increase body interventions the
verbalized by the mother metabolic rate n center of a client will cause alterations tempearature. client was able to
( illness) human body maintain core of body maintain core
temperature temperature temperature
Objective: within normal within normal
 Flushed skin presence of range of 37.5 range of 37.5.
 Warm to touch infection fr0m 38.1  Monitored Goal met
 Temperature of temperature  To obtain an Latest temp: 37.2
38.2 trigger of the every 30 accurate core
 Respiratory rate fever, called a minutes. temperature
of 27 pyrogen and detect for
 Pulse rate of 125 further
development.
release of
prostaglandin
E2 (PGE2).
PGE2 then in  Monitored pulse
turn acts on the rate and
hypothalamus respiratory rate  To evaluate
effectiveness
of
causing heat- independent
creating effects nursing
increase heat regimen
conservation
and production  Provided surface
resulting cooling such as
TSB and
removing of extra  To promote
increase body clothing. core cooling
temperature by helping
reduce body
temperature.
hyperthermia.

 Promoted rest
and comfort
providing bed
rest
  To detect
further
existing
 Encouraged discomforts
increase in fluid and level,
intake. whether
increased or
decreased.

 To prevent
Dependent dehydration
function: because
increase in
 Administered body
paracetamol as temperature
ordered. causes fluid
loss such as
sweating

 Paracetamol
are classified
as analgesics
and
antipyretic
which acts on
the
hypothalamus
to regulate
normal body
temperature.