Assessment Nursing Inference Planning Nursing Rationale Evaluation

Diagnosis Intervention

Subjective: Hyperthermia Infectious Agent After 4 hours of Independent: After 4 hours of

“Apat na araw na related to (pyrogen) nursing nursing
akong nilalagnat inflammatory ↓ interventions,  Monitor vital  Regular interventions,
at sumusuka ” process Stimulates Clients signs temperature Clients
secondary to Monocytes temperature will monitoring will temperature
Objective: urinary tract ↓ be decreased identify adequate was decreased
infection as from 39.2 oC to thermoregulation from 39.2 oC to
Release Pyrogenic
Conscious & manifested by T: 36.5 oC & 36.5 oC &
cystokines
coherent 38.1 maintain body  Provide tepid  To promote maintains body
↓ temperature at a temperature at
sponge bath cooling of body
Vital Signs of: Stimulate Anterior normal range a normal range.
surface
BP – 100/60 Hypothalamus
PR – 115 ↓  Promote
RR – 24 Elevated ventilation of  To maintain stable
T – 39.2 Thermoregulatory skin by means body temperature
set point of undressing and decrease the
↓ (heat loss by possibility of
Increased Heat radiation and complication
conservation conduction) (dehydration)
(Vasoconstriction)
↓  Wrap  To minimize
Increased Heat extremities shivering
production with cotton
(involuntary blanket
muscle
contractions)
↓
Fever
Collaborative:
 Treatment of mild
 Administer to moderate pain;
antipyretics w/ fever; various
correct inflammatory
pediatric conditions
dose(as
ordered)