DATE CUES NEED NURSING PATIENT INTERVENTION IMPLEMEN EVALUATION

/ DIAGNOSIS OUTCOME TATION

TIME
Objective: N Hyperthermia After 8 hours of  Monitor the patient’s HR,
- Body U related to nursing RR, and especially the
temperature T dehydration as intervention, the tympanic or rectal
above normal R evidenced by client will be able temperature.
- Hot, flushed I increase in body to: R: HR and RR increase as
skin T temperature higher hyperthermia progresses.
- Increase I than normal range Tympanic or rectal

heart rate O temperature gives a more

- Increase N accurate indication of core

respiratory A temperature.

rate L  Determine the patient’s

- Loss of - age and weight.

M R: Extremes of age or weight
appetite
E increase the risk for the
- Malaise or
T inability to control body
weakness
A temperature.
- Seizures
B  Monitor fluid intake
O and urine output. If the
L patient is unconscious,
I central venous pressure
C or pulmonary artery
pressure should be
P measured to monitor fluid
A status.
T R: Fluid resuscitation may be
T required to
E correct dehydration. The
R patient who is significantly
N dehydrated is no longer able
to sweat, which is necessary
for evaporative cooling.
 Eliminate excess clothing
and covers.
R: Exposing skin to room air
decreases warmth and
increases evaporative
cooling.
 Encourage ample fluid
intake by mouth.
R: If the patient is dehydrated
or diaphoretic, fluid loss
contributes to fever.
 Raise the side rails at all
times.
R: This is to ensure patient’s
safety even without the
presence of seizure activity.
 Start intravenous normal
saline solutions or as
indicated.
R: Intravenous normal saline
solution replenishes fluid
losses during shivering chills.
 Provide high caloric diet
or as indicated by the
physician.
R: Appropriate diet is
necessary to meet the
metabolic demand of the
patient.