NURSING INTERVENTIO

ASSESSMENT INFERENCE PLANNING RATIONALE EVALUATION

DIAGNOSIS N

Subjective: Hyperthermia presence of an After 1 hour of Independent 1. To determine After 1 hour of nursing
The client related to infectious nursing the need for interventions the
manifested: inflammatory agents interventions 1. Monitor intervention and patient attained
- Irritability process as the patient will neonate’s the normal core
evidenced by stimulation of attain normal condition. effectiveness of temperature as
Objective: an increase in the monocytes core therapy. evidenced by vital
body temperature 2. Monitor Vital signs within normal
-Skin warm to temperature, release of the as evidenced signs 2. To have a limits:
touch warm skin pyrogenic by vital signs baseline data
-T: 37.8 C and cytokines within normal T: 36.3 C
3. Provide TSB
-HR: 173 bpm tachycardia limits 3. Helps in HR: 122 bpm
-RR: 73 cpm stimulation of lowering down RR: 55 cpm
anterior the temperature
hypothalamus
Dependent
elevated
thermoregulato 4. Administer
ry set point Anti-pyretics as 4. aids in
ordered lowering down
increased heat temperature
conservation Interdepende
(Vasoconstricti nt
on)
5. Ensure that 5. this would
increased heat all equipment prevent the
production used for infant spread of
is sterile, pathogens to
fever scrupulously the infant from
clean. Do not equipment
share
equipment with
other infants