ASSESSMENT BACKGROUN NURSING OBJECTIVE NURSING RATIONALE EXPECTED

D DIAGNOSI S INTERVENTION OUTCOME

S
Subjective: Short Term: Independent: Vital signs provide Short term:
Hyperthermia is Hyperthermia Monitor vital signs more precise
“Hindi nga elevated body related to After six hours q4, while indication of core After six hours
nababa lagnat bacterial of nursing temperature every temperature of appropriate
temperature due
niya, limang infection intervention, hour until it become nursing
araw na” to a break in the patient Fluid resuscitation intervention, the
stable
thermoregulation temperature may be required to patient
Objective: that arises when a will lower Monitor fluid intake correct dehydration. temperature was
Patient looks body produces or down to normal and output lower down to
weak, less absorbs more heat range 37.4 ° C
active, lack of than it dissipates. Adjust Room temperature
interest to play Long Term: environmental may be accustomed Long Term:
It is a sustained
and irritable factors; room to near normal
core temperature After one week temperature and put body temperature After one week
Warm to touch beyond the of nursing pillow in the side and side rails of appropriate
normal variance, intervention rails nursing
usually greater patient’s intervention, the
Vital sign: than 39° C overall Dependent: patient will
(102.2° F). condition will maintain normal
PR:160 RR: 30 return to Maintain IV fluids To prevent temperature of
normal state. as ordered by dehydration. 36.5 – 37.5 ° C
Temp: 39.3 If the baby has a
physician
fever, in most Be alert and
instances it means D5 IMB 500mL 47- responsive
he/she has 48cc/hour that will
probably picked run to 10-11 hours
up a cold or other
Administer anti To reduce fever and
viral infection. pyretic as ordered. pain

Tempra

Client: SILVA, L. 10 months old | Care Plan by: BON HAROLD BACOL BSN 2 | Date Initiated: March 4. 2020
 Paracetamol

PRN for 37.8° C

Client: SILVA, L. 10 months old | Care Plan by: BON HAROLD BACOL BSN 2 | Date Initiated: March 4. 2020