Assessment Subjective: Mainit ang pakiramdam ko as verbalized by the patient. Objective: -Flushed skin, warm to touch. -Temp 38.

3 C

Diagnosis Imbalanced body temperature related to dehydration/ excessive fluid loss. Infectious agents (Pyrogens) (Stimulate) Monocytes (release) Pyrogenic cytokines (Stimulate) Anterior hypothalamus (result in) Elevated thermoregulatory set point (leads to) Increased Heat conservation (Vasoconstriction/behavior Changes) Increased heat problem (involuntary muscular contraction) (result in) FEVER

Planning After 2 hours of nursing intervention The patient will able to maintain temperature w/in normal range from (38.3 C to 36.5 37.5 C)

Intervention Independent: -Monitor heart rate.

Rationale

Evaluation After 2 hours of nursing intervention The patient was maintain core temperature w/in normal range 37.5

-Dysrhythmias is a changes are common due to electrolyte imbalance and dehydration and direct effect of hyperthermia on blood and cardiac tissues. -to monitor or potentiates fluid and electrolyte loses.

Goal met

-Record all sources of fluid loss such as urine, vomiting and diarrhea. -Promote surface cooling by means of tepid sponge bath.

-To decrease temperature by means through evaporation and conduction. -To minimize shivering. -To reduce metabolic demands and oxygen consumption.

-wrap extremities with cotton blankets. -maintain bed rest.

Dependent . -Administer IV Fluids. -Administer antipyretics orally or rectally as prescribed by the attending physiscian. -To support circulating volume and tissue perfusion.