Date/

Time
Nov.
30,
2015
@
6 pm

Cues
Sub.
init kayo akong
anak nurse. As
verbalized by the
mother.
Obj.
Temp: 39.1c
RR:32 cpm
PR: 127 bpm
-pallor
-flushed skin
-dry mucous
membranes
-muscle rigidity
-chills
-body malaise
-profuse
diaphoresis
-skin warm to
touch
-droopy eyes

Needs
N
U
T
R
I
T
I
O
N
A
L
M
E
T
A
B
O
L
I
C
P
A
T
T
E
R
N

Nursing
Diagnosis
Hyperthermia
related to
inflammatory
process

Scientific
Basis
Pyrogens cause a
rise in body
temperature, it
also acts as
antigen triggering
immune system
responses. The
hypothalamus
reacts to raise the
set point and the
body respond by
producing heat.
Fundamentals of
Nursing
-Harry & Perry

Goals
Objectives
Criteria
Within 4 hours of
nursing
interventions,
client will be able
to report and show
manifestations that
fever is relieved as
evidenced by:

Nursing
Interventions
-Establish
rapport with
the client and
parents.
-Monitor vital
signs

-Promotes cooperation in
the nursing care.
-vital signs provide more
accurate indication of core
temperature.
-To reduce body temperature through
the process of conduction

Verbalization of
feeling well
VS within normal
range

Rationale

-Provide TSB
-Water regulates body
temp.

Absence of
muscular
rigidity/chills

-Encourage to
increase OFI

Absence of
flushing

-Promote bed
rest

-To promote relaxation

Evaluation
Within 4 hours of
nursing
interventions,
client was able to
report and show
manifestations that
fever was relieved
as evidenced by:
Verbalization of
the client:
dili na init akong
pamati ate nurse.
VS of:
Temp= 36.7c
RR= 25 cpm
PR= 92

-To replenish fluid losses

during shivering chills

Absence of
muscular
rigidity/chills

-Maintain IVF
as indicated
by physician

-To treat underlying causes

Normal
complexion of skin

-Administer
medications as
order by
physician such
as

-To know the fluid balance

of the body.

paracetamol
or any
antipyretic
drugs
-Monitor I & O
-remove
excess
clothing and
covers

-Promotes heat loss