ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Hyperthermia related Within 2hr.of nursing Goal met, after 2hr.of
“Nanghihina ako tapos to the Infectious interventions, the patient’s INDEPENDENT: effective nursing
madalas akong Process as evidenced temperature will be interventions, the
lagnatin” as verbalized by Lethargy, Flushed alleviated from 39℃ to  Provide cool circulating air using  Dissipates heat by convection. patient’s temperature was
by the patient. skin, Warm to Touch normal levels. (36.5℃- a fan. alleviated from 39℃ to
with a Temperature 37.5℃)  Emphasize the importance of self-  Serves as first line of defense 37.3 ℃.
Objective: of 39℃ care in reducing risk for infection. against infection
 Lethargic  Monitor for signs of infection.  To promote body wellness.
 Flushed skin  Provide tepid sponge bath.  Enhances heat loss heat loss by
 Warm to touch evaporation and conduction.
 Vital Signs:  Keep the patient comfortable in  To promote safety
-BP: 110/70 bed.
mmHg  Provide safe and quiet  To provide to place to rest
-PR: 112 bpm environment.  Prevents herpetic lesions of the
-RR: 30 cpm  Provide oral hygiene. mouth.
-TEMP.: 39℃
DEPENDENT:

 Maintain IV fluids as ordered.  Prevents dehydration.

 Administer antipyretic as ordered.  To reduce fever.
 Administer antibiotic as ordered.  Treats underlying cause.