ASSESSMENT Subjective: May lagnat siya kanina pa.

Bumababa yung temperature niya tapos tumataas din as verbalized by the mother. Objective: Febrile (38.5C) Skin warm to touch Irritable PR of 142 bpm

DIAGNOSIS Ineffective thermoregula tion: Hyperthermia related to released pyrogens secondary to inflammatory response.

RATIONAL E Damaged tissues stimulate initial inflammato ry response that resulted to stimulation of hypothala mus, secreting pyrogens which are responsible for increasing bodys core temperatur e.

PLANNING

INTERVENTI ON

RATIONALE
To provide a baseline data of clients existing disease condition To determine the progress of clients condition. To promote heat loss by convection, evaporation and conduction.

EVALUATION After 4 hours of nursing intervention client was able to:

Decreased core body temperature from 38.5 to 37.C. Demonstrated behaviors to monitor and promote normothermia such as continuous tepid sponge bath, drinking plenty of water, and taking adequate rest.

After 4 hours Assessed clients of nursing condition. intervention client will be able to:

Monitored vital Decrease signs core body temperature especially the temperature. to 37 - 38.0 C. Promoted surface cooling Demonstrat through tepid e sponge bath behaviours and to monitor and promote maintaining a normotherm cool quiet environment ia. Encouraged increase fluid intake. Encouraged to take adequate rest. Aeknil given @6pm as ordered

To avoid dehydration and decrease clients temperature. To reduce metabolic demands and oxygen consumption. To provide pharmacologic effect on the patient

Goal met