NURSING ENGLISH 2

KELOMPOK 3 :

Noor Hadijah 1914201110041 Regita Pramesty 1914201110054

Nur Eka Agustina Putri 1914201110045 Santi 1914201110058
Nurul Assyifa Ridha Amilin 1914201110048 Syamsodinor 1914201110063
Rahmawati Hidayah 1914201110053 Wendi 1914201110065
 Case 6
Child M, 4 years old was taken to the
hospital for seizures while at home. The
client’s mother says “My child is fever
till right now”. Assessment data: The
child has a history of febrile seizures,
fever has been 3 days, cough, runny
nose, the child looks weak, body tem-
perature is 39 degress Celsius, respira-
tory rate is 35 breaths/minute.
 Assessment

Subjective Data
-Client’s mother said the child had a fever

Objective Data
- Skin feels hot
- (+) Restless-ness
- (+) Takipnea
 Nursing Diagnosis

Hyperthermia (rt) excessive

activity as evidenced by lethargy
 Goals and Outcomes

After the hyperthermia nursing action 1x24 hours the client

will

- Normal body temperature T: 37’ C

- Skin is not hot anymore
- Not restless
- Breath is not fast anymore
 Nursing Intervention

- Monitor TTV
- Give oxygen as needed
- Stop physical activity
- Keep the client’s away from heat sources move a cooler
envirounment
- Loosen or undress
- Wet body surface
Rationale
- Vital signs are a reference to determine
the general condition of the client’s
- Vital sign is a desire to know the general
condition of the client’s
- To keep the client’s comfortable, and thin
clothing worn to help evaporate the body
- Warm compress helps to lower body
temperature
- To find out the Client’s progress, warm
compresses can reduce the patient's body
temperature to return to normal
Rationale

- Early monitoring can be done earlier to

avoid complications that may occur.
- For the familly to know increase in body
temperature that occurs and to reduce
anxiety
 Implementation
- Monitoring ttv T: 37’C ; N: 80x/minute ; Bp: 110/75 ;
Rr: 20-30x/minute
- The client’s doesn’t have a fever anymore
- Client is not restless
- Giving oxygen as needed
- The client’s breathing is not fast or returns to normal as
before
- Stoping physical activity
 Implementation

- Keeping the patient away from heat sources, move to a

cooler environment
- Loosening or undress
- Weting body surface
1. Warming compress to the axilla and groin
- Skin is not warm anymore
 Evalution

S : The client’s doesn’t have a fever anymore

O : - The client’s is not restless
- The client’s breathing is not fast or returns to normal as before
- The client’s skin does not feel hot anymore
A : Hyperthermi related to excessive activity
P : Stop Intervention
Client’s goes Home
Thanks!