Mark jayson Barcelona ASSESMENT NURSING DIAGNOSIS Subjective: Madalas Hyperthermia siya s tulog related to at impaired CNS kinukumbul

infection syon As verbalized by mother of the patient. OBJECTIVE: Vital signs as follow: BP: 90/60 T: 38.2 P: 110 R: 28 Spacity of muscle. Shivering BACKGROUND KNOWLEDGE
A CNS infection is an infection which involves the central nervous system in some way. Meningitis is one of the most common and well known types, involving the meninges, the coverings of the brain and spinal cord. Other types of infections involve the brain or spinal cord directly. For example, a cerebral abscess is a bacterial brain infection and encephalitis is typically a viral infection of the brain.

EXPECTED OUTCOME After 8 hours of nursing intervention the patient will demonstrate comfort and decrease in body temperature

INTEVENTION
Provide tepid sponge baths; avoid use of alcohol.

RATIONALE May help reduce fever. Note: Use of ice water/alcohol may cause chills, actually elevating temperature. In addition, alcohol is very drying to skin
To support circulating volume and tissue perfusion.

EVALUATION After 8 hours of nursing intervention the patient will M a i n t ai n a normal temperature and demonstrate temperature

Administer replacement fluids and electrolytes such as water.

Promote adequate nutritional food intake.

Helps in maintaining the bodys defenses against infection. This will also facilitate faster recovery.

Remove excess clothing or blankets to promote heat loss. Encourage wearing loose cotton clothing.

Heat loss by radiation and conduction. Adding clothes or blanket inhibits the bodys natural ability to reduce body temperature;

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where cold is conducted from the air to the skin and from the skin to the blood vessel. Maintain bed rest Decreases stress and promotes earlier recovery.

Monitor patients temperature (degree and pattern); note shaking chills/profuse diaphoresis. Promote clients safety by means of maintaining patent airway and raised side rails.

Temperature of 102F-106F (38.9C-41.1C) suggests acute infectious disease process.

Hyperthermia can lead to seizure and convulsion. Thus, patent airway and raising the side rails is important.