Cues/Needs Nursing Rationale Goals and Interventions Rationale Evaluation

Diagnosis Objectives

Independent:
Subjective:
Hyperthermi Body
After 3hrs -monitor After 3hrs of nursing
“ Mainit ang katawan ko” as a related to temperat hyperventilati
heart rate intervention the client
verbalized by the client. of nursing on may
infection ure and rhythm.
initially be was able to maintain
intervention
secondary to elevated present.
Objective: the client core temperature within
bronchial above - monitor use
Temp: 38.1°C to minimize
will of normal range.
asthma as normal shivering.
maintain hypothermia
Skin warm to touch.
manifested range (> blanket and
core extremities
by 36.5 to
temperatur w/bath towels.
temperature 37.5 °C).
e within
above Helps in
normal -perform TSB
normal lowering the
range. body
range. temperature.

Dependent:
to treat
-administer
underlying
medications
cause, such as
(Paracetamol
antibiotics
) as
 prescribed by
the physician

Reference
:Nurse’s
Pocket
Guide 11
th Edition
by
Marilynn
E.
Doenges .