NURSING CARE PLAN PROPER PROBLEM #1: Hyperthermia related to altered thermoregulation ASSESSMENT S > Mainit pa rin kasi

ako. Ilang araw na akong nilalagnat. Sumasakit din ulo ko. > rated pain as 7/10, characterized as shooting pain, localized at head area, intermittent, and non-radiating OBJECTIVES LTO: After 48 hours of nursing interventions, the patient will experience no associated complications such as seizures, etc. NURSING INTERVENTIONS > Assess vital signs and record > Monitor input and output > Record all sources of fluid loss such as urine, vomiting and diarrhea. > Note presence or absence of sweating as body attempts to increase heat by evaporation > Maintain bed rest to prevent fatigue > Promote surface cooling by means of tepid sponge bath. > Wrap extremities with cotton blankets > Provide supplemental oxygen > Provide surface cooling, loosen clothing, blanket and cool environment > Administer replacement fluids and electrolytes > Provide high calorie diet, tube feedings, or parenteral nutrition > Administer antipyretics orally or rectally as prescribed by the physician > Determine the childs preferences for oral fluids and encourage the child to drink as much as possible, unless contraindicated >Encourage to have relaxation skills such as DBE and diversion activities such as watching TV > Teach the parents and watchers how to effectively lower the temperature by rendering the tepid sponge bath > Emphasize to increase fluid intake to replace fluid loss > Reiterate food rich in Vitamin C to fight for further infection EVALUATION Goal fully met if patient will be able to: demonstrate temperature within normal range from 39.5 to 36.5-37.5, have cool skin to touch and less flushness, identify underlying cause/contributing factors and importance of treatment, as well as signs and symptoms requiring further interventions, and verbalized understanding of specific interventions to prevent hyperthermia such as performing Tepid sponge bath Goal partially met if patient will be able to: demonstrate temperature within normal range from 39.5 to 36.5-37.5, and have cool skin to touch and less flushness Goal not met if patient will not be able to meet any of the said objectives.

STO: Within 8 hours of nursing interventions, patient will be able O > vital signs of: BP= to: 130/80mmHg, RR= 23cpm, PR= 95bpm, T= 39.5  Demonstrate temperature > flushed skin within normal range from > warm to touch 39.5 to 36.5-37.5 > dry lips and skin  Have cool skin to touch > malaise/weakness and less flushness > loss of appetite consuming  Identify underlying only of food served cause/contributing factors > good capillary refill of 1-2sec and importance of > shivering treatment, as well as signs and symptoms requiring further interventions  Verbalized understanding of specific interventions to prevent hyperthermia such as performing Tepid sponge bath