Assessment Subjective: Medyo nanghihina ako, as verbalized by the patient:

Nursing Diagnosis

Planning Short Term: After 4 hours of nursing intervention, the patient will demonstrate behaviors to improve circulation. Long Term: After 4 days of nursing intervention the patientt will demonstrate increased perfusion as appropriate

Nursing Interventions Establish Rapport Monitor Vital Signs Assess patients condition

Rationale To gain patients trust To obtain baseline data To assess contributing factors

Evaluation The patient was able to demonstrate behaviors to improve circulation. The patient shall have demonstrated increased perfusion as appropriate

Ineffective tissue perfusion related to decreased Hemoglobin Objective: Decreased WBC concentration Decreased platelet in the blood Decreased HgB secondary to Decreased capillary DHF 1 refill time Dysrhythmias Altered LOC Fever Chills Diaphoresis

Note customary baseline data For comparison with current findings Determine presence of dysrhythmias To identify alterations Perform blanch test Check for Homans sign Note presence of bleeding Elevate HOB Encourage quiet & restful atmosphere Instruct to avoid tiring activities Encourage light ambulation Encourage use of relaxation techniques from normal To identify / determine adequate perfusion To determine presence of thrombus formation To determine risk of anemia To promote circulation To promote comfort & decrease tissue O2 demand To decrease cardiac workload

Assessment Subjective: Mainit ang paki ramdam ko, as verbalized by the patient. Objective: Temp of 39.8 > Flushed skin > Skin warm to touch > Chills

Nursing Diagnosis

Objectives

Nursing Interventions Establish Rapport Monitor Vital Signs Assess neurologic response, note LOC & orientation, reaction to stimuli, papillary reactions & presence of seizures Note presence / absence of sweating Provide TSB q 15 minutes

Rationale To gain patients trust To obtain baseline data To evaluate effects & extent of hyperthermia

Expected Outcome The patient was able to decrease body temperature from 39.8 to 37.

Hyperthermia Short Term: After 4 hours of nursing intervention, patients temperature will decrease from 39.8 to 37. Long Term: After 3 days of nursing intervention, the patient will identify underlying factors & importance of treatment as well as signs and symptoms requiring further evaluation or intervention

To monitor heat & fluid loss To reduce body temperature

Instruct client to have bed rest To reduce metabolic demands / oxygen consumption Administer replacement fluids To prevent dehydration To support circulating blood volume and tissue perfusion Administer antipyretics To restore normal body temperature