DATA/CUES NURSING SCIENTIFIC GOAL/OBJECTIVES NURSING RATIONALE EVALUATION

DIAGNOSIS BACKGROUND INTERVENTIONS

Subjective: Hyperthermia Entry of pathogens Short Term: Independent: Short Term:
“He’s been also as evidence by in the systemic After 8 hours of nursing Monitor vital signs. Notes progress & After 8 hours of
having a high body circulation interventions, the changes of condition. nursing
↓ patient will be able to: interventions, the
temperature” as temperature
Regulations of  Maintain body Encourage ample fluid If the patient is patient has been
verbalized by the above the toxins in the body intake by mouth dehydrated or able to:
temperature within
patient. normal range ↓ normal range diaphoretic, fluid loss  Maintain body
Release of pyrogen Long Term: contributes to fever. temperature
Objective: ↓ After 2 days of nursing within normal
 V.S.: Stimulation of the interventions, the Provide tepid sponge Enhances heat loss by range
o PR: 130 hypothalamus patient will be able to: bath (TSB) evaporation & Long Term:
↓  The patient will conduction. After 2 days of
bpm Increase alteration of maintain optimal nursing
o RR: 27 thermoregulation fluid balance Assess fluid loss & Increases metabolic rate interventions, the
cpm ↓  Reports no facilitate oral intake. & diaphoresis. patient has been
o TEMP: Increase body elevation of able to:
38°C temperature temperature or Provide bed rest. Reduces body heat  Reports no
↓ recurrence of pain production. elevation of
 Diarrhea hyperthermia temperature or
 vomiting Adjust and monitor Room temperature may recurrence of
 abdominal environmental factors be accustomed to near pain
pain like room temperature normal body temperature The goal is met.
 watery, and bed linens as and blankets and linens
indicated. may be adjusted as
yellow-
indicated to regulate
colored stool temperature of the
 sunken eyes patient.
 dry lips
 irritable Raise the side rails at This is to ensure patient’s
all times. safety even without the
 dry mucosal presence of seizure
membrane activity.
noted Dependent:
Maintain IV fluids as Prevents dehydration
 Capillary ordered
refill is 2
seconds Give antipyretic Antipyretic medications
 11kg and 109 medications as lower body temperature
cm in height prescribed. by blocking the synthesis
(underweight, of prostaglandins that act
in the hypothalamus.
BMI - 9.3)
 Hands and
feet are cold
to touch.
 Tachycardia