Nursing Goal Intervention Rationale Evaluation

Diagnosis

Impaired After three Independent: Goal met. After 3

comfort days of 1.Establish rapport with the This is to allow days of effective
related to nursing pediatric patient communication and trust nursing
hyperthermia intervention, between the patient and interventions, the
as evidenced the patient nurse to easily provide patient was able
by crying, will interventions and carry to demonstrate an
irritable demonstrate out treatment plan as elevated level of
mood, an elevated necessary. comfort in both
elevated level of their physical and
Body comfort in emotional state.
Temperature both their 2.Monitor the patient’s vital signs Assess and record the Additionally, they
of 38C. physical and patient's vital signs. will be capable of
emotional Cooling measures should maintaining a
state. be implemented based on normal body
Additionally, the patient's response to temperature
they will be interventions. within the
capable of acceptable range
maintaining of at least 36.4°C.
a normal 3. Create a calm and quiet space by Reduce the amount of
body making sure there is enough unnecessary stimuli and
temperature airflow and ventilation and by work to make the
within the adjusting the temperature and environment more quiet.
acceptable humidity of the room.
range of at
least 36.4°C.

4. Apply Comfort Measures such Reduces the baby's body

as Cool Compresses and Tepid temperature and provides
Sponge Baths immediate relief from
discomfort.

5. In order to promote hydration, To avoid the baby

clear fluids such as water and broth becoming dehydrated and
should be encouraged. to assist the body in
maintaining a healthy
temperature, it is
important to encourage

6. Make sure the patient is
repositioned frequently and
encourage range-of-motion
activities like reaching, lifting the
head, and grasping textured baby
toys during tummy time.
7.Provide several relaxation
techniques such as music therapy
and guided imagery that may
decrease discomfort.
Dependent:
1.)Administer prescribed
antipyretic medications such as
Paracetamol 2.5 mL orally q4h for
body temperature of 37.8C and
above.
Interdependent:
1. Collaborate with the medical
technologist or laboratory
department for his laboratory
studies.
the child to drink fluids
that are clear.
Modifications in the
patient’s position
ameliorate stress and
tension and aid in pain
control. Furthermore,
initial treatment may
alleviate the discomfort
associated with bed rest.
Help shift the focus away
from the currently
experienced pain,
anxiety, and tension and
instead focus on more
pleasant experiences.
To alleviate symptoms of
fever and to provide
comfort for the child
1.To check any
significant changes in the
laboratory values which
include CBC, Complete
metabolic panel (CMP;
provides data on
electrolytes, glucose,
acid-base, renal, liver,
protein status) C-reactive
protein (CRP), and
Erythrocyte
sedimentation rate (ESR).