Date/ Cues Need Nursing Diagnosis Objective of Care Nursing Interventions Evaluation

Time

SUBJECTIVE: N Hyperthermia r/t After 2 hours span of my a.) perform tepid sponge bath July 28, 2010 @ 5:00 PM
J “medyo init akong paminaw U inflammatory response 2 o nursing interventions, the
U maam” T post Extra Capsular Cataract patient will be able to ® heat is loss by evaporation and “GOAL MET”
L R Extraction demonstrate improvement conduction After 2 hours span of my
Y OBJECTIVE: T in maintaining body’s nursing interventions, the
I temperature within the b.) encourage to increase oral fluid patient was able to
2 Flushed skin O ®Inflammation is a normal range as evidenced intake demonstrate improvement in
8 N defensive reaction intended by: maintaining body’s
Dry lips A to neutralize, control, or ®hydration helps in regulating body temperature within the
2 L eliminate the offending agent a.) temperature within the temperature and it replaces fluid loss normal range as evidenced
0 Slightly febrile and to prepare the site for normal range preventing dehydration by:
1 T=37.8 oC M repair. Fever is the most (35.5 – 37.5 oC)
0 E common sign of a systemic c.) recheck temperature a.)T=37.2 oC
T response to injury and it is b.) (-)flushed skin
@ A most likely caused by ®to evaluate the effectiveness of the b.) (-)flushed skin
3PM B endogenous pyrogens c.) (-) dry lips interventions
O (internal substances that c.) (-) dry lips
L cause fever) released from d.) Encourage to wear loose clothing
I neutrophils and macrophages
C (specialized forms of ®Excessive clothing and covering can
leukocytes). These result to a temperature elevation
P substances reset the
A hypothalamic thermostat e.) provide cool environment and
T which controls body adequate ventilation
T temperature and produces
E fever. ®heat is loss by convection
R
N f.) encourage adequate rest and sleep
Reference:
Smeltzer, S., Bare, B., Hinkle, ®to decrease metabolic demand and
J., Cheever, K. (2010). O2 consumption
Brunner and
Suddarth’s Textbook g.)administer paracetamol as ordered
of Medeical-Surgical
Nursing. (12th Ed.). ®antipyretic med reduces fever by
Philadelphia: Wolters acting on the hypothalamic heat-
Kluwer/ Lippincott regulating center to cause vasodilation
Williams & Wilkins and sweating which helps dissipate
heat

Reference:
Doenges, M. E., Moorehouse, M. F.,
Murr, A. C. (2008). Nurse’s
Pocket Guide Diagnoises,
Prioritized Interventions and
Rationales. (11th Ed.).
Philadelphia: F. A. Davis
Company