ASSESSMENT
OBJECTIVE DATA
- Temp: 37.5 degrees
Celsius
- RR: 22 bpm
- Chills
- Warm to touch
- Redness o lips and eyes
- Head ache: pain scale:
6/10- 0 no pain/ 10-
severe pain.
- than (37.2 C), and
SUBJECTIVE DATA
“init akong lawas nurse unya
tugnaw, labad pud gamay
akong ulo.” As verbalized by
the client.
DIAGNOSIS PLANNING INTERVENTION EVAUATION
Hyperthermia r/t to After 8 hours of nursing Independent GOAL MET
inflammatory response intervention the patient will Monitor the patient’s temperature at After 8 hours of
secondary to infection be able to : designated times and as clinically indicated. nursing intervention
- The patient will Following a trend of the patient’s temperature patient was able to
maintain a core body helps determine the effectiveness of antipyretic have :
temperature within medications and antibiotics. - temperature of
normal limits as Obtain temperature measurements from the 36.5 degrees
evidenced by same site and with the same tool. Celsius,
consistent temperature Different sites and methods may skew - normal
measurements of less measurements and cause trends to be respiration with
inaccurate. RR of 18 bpm
normal respiration rate Remove warm clothing and adjust the room - No more chills
of less than 20 bpm. temperature. noted. Pain scale
- Relive chills and These external factors may affect the patient’s of 0.
maintain pain scale of body temperature. - Client verbalized
0. Provide temperature lowering measurements “gaan na akong
such as a fan or cold cloth to the forehead. paminaw nurse,
These measures may help lower body wala na ang
temperature. kalintura ugf
Offer tepid baths. labad sa ulo.
Using lukewarm water during baths instead of
hot water may help to keep the temperature
from rising.
Ask patient take rest
Rest may help client in healing process
Ask patient to increase fluid intake
Bodily fluids carry your immune cells
throughout your body and staying hydrated
helps them get where they need to go to fight
off infections
Dependent
Administer antipyretics as ordered.
Antipyretic medications may help reduce fever
 for a period of time.
CHRISTIAN CALAM,BA BSN 3B1